Exam 3 Renal Flashcards
1
Q
ROLE OF THE KIDNEY
A
- Balance solute and water
- Help control blood pressure
- Cleansing (filtering) of extracellular fluid (ECF) and maintenance
- of ECF volume and composition
- Excrete metabolic water-soluble wastes & foreign substances
- Convert nutrients
- Regulates acid/base
- Secretes renin and erythropoietin
- Help maintain red blood cell levels
- Converts vitamin D
- Calcifediol to calcitriol, the active form
2
Q
NEPHRONS
A
- Nephrons are the functional unit of the kidney
- Renal corpuscle (Glomerulus + Bowman capsule)
- Proximal convoluted tubule
- Loop of Henle
- Distal convoluted tubule
- Collecting duct
- All the components of the nephrons contribute to URINE formation
3
Q
GLOMERULAR FILTRATION RATE
(GFR)
A
- Filtration rate of plasma per unit per time
- 125 mL/minute
- Prostaglandins increases GFR
- Epinephinre and Endothelin decreases GFR
*
4
Q
HOW DO KIDNEYS AFFECT
BP
A
Blood Pressure
- Juxtaglomerular cells measure blood flow in the afferent arteriole and urine flow and composition.
- Release renin, to Angiotensin II to aldosterone (RAAS)
- Turns on Na/K ATPase
- Increases BP
- Vasoconstriction/thirst
- Does not change blood osmolarity
- Na and H2O reabsorbed
- Lowers K
5
Q
MICTURITION REFLEX
A
Micturition Reflex Begins when the bladder contains 150 to 250 mL of urine
Can be filled to ~500 ml, but pressure of detrusor muscle will overcome external sphincter
Bladder fills with urine stretch receptors sacral spinal cord stimulated Spinal reflex stimulated
Babies
6
Q
HYDROURETER
A
Dilation of the ureter
7
Q
HYDRONEPHROSIS
A
Expansion of the kidney with urine
- Increased pressure inside the renal capsule
- Compartment syndrome compresses blood vessels inside kidney; renal ischemia
8
Q
URINARY STASIS
A
Urinary Retention
- Risk of infection
- Stones
9
Q
POSTOBSTRUCTIVE DIURESIS
A
Polyuric state in which copious amounts of salt and water are eliminated after the relief of a urinary tract obstruction
10
Q
CAUSES OF
KIDNEY STONES
A
- Masses of crystals, protein or other substances that are a common cause of urinary tract infections
Saturation theory: Urine is supersaturated with stone components. Influenced by pH and temperature
- Alkaline urine > chance of Ca+ stone formation
- Acidic urine > of uric acid stone formation
Matrix theory: Organic materials act as a nidus for stone formation
Inhibitor theory: A deficiency of substances that inhibit stone formation
- Unilaterally located in the kidneys, ureters, bladder
- Renal tubules have many surfaces which attract a stone
- Stones < 5mm have a 50% chance of spontaneous passage
Risk factors:
- Race
- Age
- Gender
- Geographic location& seasonal factors
- Fluid intake
- Occupation
11
Q
SIGNS & SYMPTOMS OF
KIDNEY STONES
A
Flank pain (moderate to severe), may radiate to groin
If stone is obstructing, pt may experience urgency, frequent voiding
May or may not have hematuria
12
Q
TREATMENT OF
KIDNEY STONES
A
- Imaging needed to determine location of stone, severity of obstruction, size of stone
- Obtain a UA to determine pH of urine
- STRAIN urine to retrieve stone for further analysis
- Pain management
- Dietary modification PRN
- Nephrolithotomy or lithotripsy to remove stones
13
Q
Benign Prostatic Hyperplasia
(BPH)
A
- Non-malignant prostate enlargement due to excessive epithelial cell growth
14
Q
SIGNS and SYMPTOMS
Benign Prostatic Hyperplasia
(BPH)
A
S&S
- Urinary hesitancy
- Dysuria
- Straining to void
- Postvoid dribbling
- Frequent daytime voiding
- Nocturia
- Poor force of stream
- Intermittent stream
- Feelings of incomplete emptying
15
Q
TREATMENT
Benign Prostatic Hyperplasia
(BPH)
A
- Invasive treatment
- Transurethral resection of the prostate (TURP)
Drug therapy
- 5-Alpha Reductase Inhibitors
- Alpha1-Adrenergic Receptors
- Ie. Finasteride (Proscar)
Reduces prostate size, takes several months
MOA. Inhibits 5-alpha reductase enzyme that converts testosterone to dihydrotestosterone (DHT)
SE. decreased ejaculate, toxic to male fetus
- Ie. Doxazosin (Cardura), Tamsulosin (Flomax)
MOA. Blockade of alpha1 receptors, relaxes smooth muscle in bladder neck, decreasing obstruction of urethra
SE. Hypotension, fainting, dizziness
16
Q
URGE INCONTINENCE
(DETRUSOR OVERACTIVITY)
A
Common Causes:
- Stroke
- Alzheimer’s disease
- Parkinson’s disase
- BPH with overflow
Common Symptoms:
- Urgency and frequency, day or night
Pharmacological Treatment
- Anticholingergic drugs
- Oxybutynin
- Tolterodine
17
Q
STRESS INCONTINENCE
(OUTLET INCOMPETENCE)
A
Common Causes:
- Urologic procedures
- history of multiple childbirths
Common Symptoms:
- small volumes of urnie loss with coughing, sneezing
Pharmacological Treatment:
- Alpha agonists
- Topical estrogen
18
Q
MIXED UI and SI
A
Common Causes:
See UI and SI
Common Symptoms:
Pharmacological Treatment:
19
Q
OVERFLOW INCONTINENCE
A
Common Causes:
- BPH
- Fecal impaction
Common Symptoms:
- Poor stream
- Incomplete emptying
Pharmacological Treatment:
- Alpha-adrenergic blockers (e.g., terazosin and tamsulosin)
20
Q
ATONIC BLADDER
A
Common Causes:
- Severe diabetic neuropathy, stroke
Common Symptoms:
- Complete loss of bladder control
Pharmacological Treatment:
- Intermittent catherizations
21
Q
FUNCTIONAL INCONTINENCE
A
Common Causes:
- Inability to get to the bathroom
- Change in mental status
Common Symptoms:
- Symptoms will vary
Pharmacological Treatment:
- Eliminate causes
22
Q
NOCTURNAL ENURESIS
A
- involuntary urination that happens at night while sleeping, after the age when a person should be able to control his or her bladder.
23
Q
NEUROGENIC BLADDER
UNINHIBITED BLADDER
A
(loss of bladder sensation)
Uninhibited bladder: reduced awareness of bladder fullness and a low capacity bladder; urinary incontinence
24
Q
NEUROGENIC BLADDER
SPASTIC (HYPERTONIC)
A
- Spastic (hypertonic): volume is typically small, pressures increase and involuntary contractions occur; increased frequency, urine leakage
- Lesions between the pontine micturition center and sacral spinal cord
- Bladder contraction and external urinary sphincter relaxation are typically uncoordinated (detrusor-sphincter dyssynergia)
25
NEUROGENIC BLADDER
## Footnote
FLACID (HYPERTONIC)
* Flaccid (hypotonic): volume is large, pressure is low, and contractions are absent; overflow incontinence
* Lesions from the sacral cord or sacral nerve root injuries
26
DETRUSOR
(BLADDER WALL)
HYPERTROPHY
Obstructions
27
OVERACTIVE BLADDER
(OA)
4 symptoms:
* Urinary urgency
* Urinary frequency
* Nocturia
* Urge incontinence
\*\*\*Usually the result of involuntary contraction of the bladder\*\*\*
28
TREATMENT OF
## Footnote
OVERACTIVE BLADDER
Behavioral
* Schedule voiding, time fluid intake, Kegel exercises, avoid caffeine
Drug
* Anticholinergic agents which block muscarinic receptors
* Ie. Oxybutynin (Ditropan)
* These drugs block muscarinic receptors not only in the bladder but elsewhere…a way around this is using drugs that are selective for muscarinic receptors in the bladder (M3 receptors)
* Even so they have a high SE profile of anticholinergic activity causing constipation (from reducing bowel motility), blurred vision and photophobia (from preventing contraction of the ciliary muscle)
29
UTI
## Footnote
URINARY TRACT INFECTIONS
Bacteria usually enter through the urethra
Host defenses include:
* Washout phenomenon
* Protective mucin layer
* Local immune responses and IgA
* Phagocytic blood cells
* Normal bacterial flora and prostate secretions
Inflammation of urinary epithelium from bacteria
Can occur in the urethra (urethritis), prostate (prostatitis), bladder (cystitis), ureter, kidney (pyelonephritis)
Subtypes: complicated and uncomplicated; upper or lower
Risks:
* Premature newborns
* Sexually active and pregnant women
* Spermicide users
* Individuals with indwelling catheters
* DM patients
* Neurogenic bladder patients
30
ORGANISMS THAT
CAUSE UTI
Factors:Community associated
E.coli (80%)
Hospital associated
Klebsiella, Enterobacter, Proteus
Catheter-associated urinary tract infection (CAUTI)
31
TREATMENT OF
UTI's
* Sulfonamides
* Trimethoprim
* Penicillins
* Aminoglycosides
* Cephalosporins
* Fluoroquinolones
* Nitrofurantoin
32
ACUTE
CYSTITIS
* Inflammation of the bladder, most common site of UTI in women of childbearing age
* Bacteria: E.coli (80%)
* S&S: urinary frequency, urgency, dysuria, suprapubic discomfort and LBP
* Diagnosis: urinalysis (+ bacteria \> 100k,+leukocyte esterase, + nitrite reductase), urine culture for species
33
TREATMENT OF
## Footnote
ACUTE
CYSTITIS
Oral antibiotics
* Treatment ranges from 1 day to 7 days
* Drugs of choice:
* Trimethoprim/Sulfamethoxazole (Bactrim)
* Nitrofuratoin
* Ciprofloxacin
34
ACUTE UNCOMPLICATED
PYELONEPHRITIS
* Usually women of childbearing age, kids, elderly
* Infection in one or both urinary tracts (ureter, renal pelvis, interstitium)
* Shorter course of treatment
* Usually symptomatic
* Pathogen: E.coli (90%)
* Treatment: oral antibiotics
35
TREATMENT OF
ACUTE UNCOMPLICATED
PYELONEPHRITIS
oral antibiotics
36
COMPLICATED UTI
* Males & females
* Associated with a predisposing factor
* Renal stones
* Enlarged prostate
* Indwelling catheter
* Impediment to flow of urine
* Longer course of treatment 3-7 days, may take as long as 14 days
* Pathogen: E. coli
37
RECURRENT UTI's
Relapse or reinfection
If more than 3 infections a year, prophylaxis may be indicated:
* Nitrofurantoin
* Trimethoprim/sulfamethoxazole (Bactrim)
38
ACUTE BACTERIAL PROSTATITIS
* Causes: Indwelling catheter, instrumentation from urethral or prostate surgery
* S&S: High fever, chills, myalgias, localized pain as well as UTI symptoms
* Responds well to antimicrobial therapy usually a fluoroquinolone
39
NITROFURANTOIN
* Active against a large # of gram+ and gram- bacteria
* MOA. Damages DNA; slowing growth rather than killing bacteria
* Can treat lower UTIs and prophylax recurrent UTIs
* SE. GI disturbances, dyspnea, anemias
40
GLOMERULAR DISEASE
Refers to a group of related diseases
* Glomerular capillaries and the Bowman capsule are both made of epithelial cells sitting on a basement membrane.
* They are so tightly attached to each other that they share one basement membrane.
* The epithelial cells of the Bowman capsule stand up from the basement membrane on foot processes, leaving pores between the feet for filtration.
* Causes of injury include:
* Immune responses
* Toxins or Drugs
* Vascular Disorders
41
ACUTE
GLOMERULONEPHRITIS
* Inflammatory damage to the glomerulus from a streptococcal infection
* S&S. proteinuria, hematuria, significant loss of kidney function
* Diagnosis. UA, renal biopsy, electron microscopy
* Tx. Antibiotics, steroids, cytotoxic agents to reduce immune response
42
NEPHROTIC SYNDROME
## Footnote
(Proteins in Urine)
Albumin "leads to" edema and increased free drug
* Immunoglobulins and complement "leads to" immune suppression
* Binding proteins "leads to" low ions and hormones
* Clotting and anticlotting factors "leads to" thrombosis
43
ACUTE KIDNEY INJURY
(AKI)
Sudden decline in kidney function with a decrease in the glomerular filtration and accumulation of nitrogen (Cr, BUN)
Stages:
* Risk: 1.5-fold increase in the serum creatinine, or GFR decreased by 25%, or UO \<0.5 mL/kg/hr for 6 hrs
* Injury: 2-fold increase in the serum creatinine, or GFR decreased by 50%, or UO \<0.5 mL/kg/hr for 12 hrs
* Failure: 3-fold increase in the serum creatinine, or GFR decreased by 75%, or UO \<0.3 mL/kg/hr for 24 hrs or no UO for 12 hrs
* End-stage renal failure: Complete loss of kidney function \>3 mo (requiring dialysis or transplant)
44
PATHO OF
AKI
Extracellular volume depletion, decreased renal blood flow, toxic injury to kidney cells "leads to" alterations in renal function
Classifications:
* Prerenal (renal hypoperfusion)
* Intrarenal (disorders of renal parenchyma; intrinsic)
* Postrenal (urinary tract obstructive disorders)
45
PRERENAL AKI
* Most common cause of AKI
* Usually due to renal hypoperfusion (hypotension, hypovolemia, hemorrhage, low CO)
* Shock, dehydration, vasoconstriction
* Failure to restore blood volume (or BP) can cause cell injury and ATN (acute tubular necrosis)
46
INTRARENAL (INTRINSIC)
AKI
* Results from ATN, acute glomerularnephritis, vascular disease, use of nephrotoxins, interstitial disease (drug allergy, infection, tumor)
* Kidney tubule function decreased
* Ischemia, toxins, intratubular obstruction
47
POSTRENAL
AKI
* Rare
* Caused by urinary tract obstruction, enlarged prostate, neurogenic bladder
48
TREATMENT OF AKI
* Prevention and early diagnosis
* Correct fluid & electrolyte disturbances, special diet
* Correcting cause, like low BP, etc.
* Treat infections (if any)
* Avoid nephrotoxic medications
49
CHRONIC KIDNEY DISEASE
| (CKD)
* Progressive loss of renal function
* Fewer nephrons are functioning.
* Remaining nephrons must filter more
* Hypertrophy
* Defined as: GFR \< 60 for 3 months
* Associated with HTN, DM, chronic pyelonephritis, chronic glomerulonephritis
50
METABOLIC CHANGES
WITH CKD
* Na+/H2O is lost in the urine
* K+ is retained
* Metabolic acidosis develops
* Ca & phosphorus metabolism are altered
* Erythropoietin production is diminished
* Proteinuria
51
CLINICAL MANIFESTATIONS OF
CKD
* Uremia/Azotemia: increased levels of serum creatinine, urea, and other nitrogenous compounds
* CNS, GI, immune disturbances
* Cardiovascular complications
* Hypertension, heart disease
* Mineral metabolism disorders metastatic calcifications, and bone disease
* Hyperphosphatemia hypocalcemia increased PTH calcium resorption from bone bone loss
* Decreased vitamin D activation increased PTH, impaired osteoblasts
* Decreased inflammation and immunity
* CNS and PNS alternations
* Peripheral neuropathy, restless leg syndrome, uremic encephalopathy
* Sexual dysfunction
* Impotence, hypofertility, dysmenorrhea
* Skin disorders
* Dryness, bruising, Terry nails
* GI disorders
* Anorexia, nausea, vomiting, ulceration
52
CARDIOVASCULAR
COMPLICATIONS
Anemia: from hemolysis, bone marrow suppression, decreased erythropoietin and iron
* Weakness, fatigue, depression, insomnia, decreased cognitive function
* Decreased blood viscosity "leads to" increased heart rate, peripheral vasodilation
* Angina pectoris and other ischemia
Decreased platelets "leads to" bleeding
53
TREATMENT OF
CKD
* Ultrasound, CT scan to visualize kidney
* Obtain UA and serum electrolytes
* Dialysis
* Supportive therapy
* Restrict phosphate, K+
* Supplement vitamin D
* Renal transplant
