Lecture 10: Renal and Urologic Systems

Question 1

Kidney Functions

Answer 1

• maintain fluid and acid base balance
• detox blood and eliminate waste
• regulate BP
• aiding RBC production
• regulating vitamin D and calcium formation
• filter 45 gallons of fluid a day but only about 2 quarts leave body

Question 2

Urinary Tract

Answer 2

• kidneys and ureters are upper urinary tract

- bladder and urethra are lower urinary tract

Question 3

Fluid Balance

Answer 3

• continuously exchange water and solutes across cell membranes
• hormone involvement: aldosterone and ADH

Question 4

ADH

Answer 4

• produced by pituitary
• when ADH concentration is high, tubules are most permeable and causes more water to be absorbed
• low concentration of ADH causes more water to be excreted-increased volume of less concentrated urine
• this alters collecting tubules permeability to water

Question 5

Aldosterone

Answer 5

• produced by adrenal cortex
• high concentration increases sodium and water reabsorption and decreases sodium and water excretion in urine
• low concentration increases sodium and water excretion in urine
• high concentration also increases potassium in excretion
• regulates water reabsorption by distal tubules and changes urine concentration by increasing sodium reabsroption

Question 6

Acid Base Balance

Answer 6

-secrete hydrogen, reabsorb sodium and bicarbonate, produce ammonia, and acidify phosphate

Question 7

Waste Collection

Answer 7

• 3 step process
  1) glomerular filtration: filter blood through them to form filtrate-most accurate measure of clearance (complete removal of a substance from blood) is creatine because it is filtered by glomeruli, but not reabsorbed by tubules; GFR slows with kidney damage
  2) tubular reabsorption: tubules reabsorb filtered fluid in surrounding vessels
  3) tubular secretion: filtered substances (glomerular filtrate) passes through the tubules to the collecting tubules and ducts

Question 8

BP Regulation

Answer 8

• kidneys produce and secrete renin in response to decrease in ECF volume
• renin forms angiotensin I which is converted to angiotensin II
• angiotensin II increases low arterial BP by increasing peripheral vasoconstriction and stimulating aldosterone secretion

Question 9

RBC Production

Answer 9

• secrete erythropoietin when oxygen supply in tissue drops

- loss of renal function results in chronic anemia

Question 10

Vitamin D Regulation and Calcium Formation

Answer 10

• help convert vitamin D to active form

- when kidneys fail, hypocalcemia and hyperphosphatemia occur

Question 11

Aging and the Renal/Urologic System

Answer 11

• reduced ability to filter in same way
• gradual reduction of blood flow to kidneys and reduction in nephrons-kidneys become less efficient at removing waste from blood and volume of urine increases somewhat with age
• kidneys produce most of the urine during the day in young people, a shift to night production over time is common after 60
• large number of adults over 60 are incontinent

Question 12

UTIs: Etiology, Risk Factors, Pathogenesis

Answer 12

• instrumentation and urinary catheterization are predisposing factors
• people with diabetes are more prone because of associated glycosuria that provides a fertile medium for bacterial growth
• bacteria in most UTIs are acquired from the large bowel (fecal flora)
• sexually active and pregnant women are at higher risk
• patho: routes of entry of bacteria into urinary tract can be ascending (up the urethra into the bladder), bloodborne, or lymphatic

Question 13

UTIs: Clinical Manifestations, Medical Management, SIFTT

Answer 13

• fever, chills, malaise
• cloudy, bloody, foul smelling urine
• burning or painful sensation during urination or intercourse
• pain may be noted in suprapubic, lower abdominal, groin, or flank areas
• prevention: drink at least 8 8oz glasses of water each day, urinate after intercourse
• dx and tx: typically treated with antibiotics
• SIFTT: referral necessary if nausea or vomiting, fever greater than 102*, change in mental status (confusion)

Question 14

Acute Renal Failure

Answer 14

• sudden interruption of renal function
• caused by obstruction, poor circulation or kidney disease that is potentially reversible
• patho: may be classified by prerenal (decreased blood flow), intrarenal (damage to kidney structures, or postrenal (obstruction of urine outflow from kidney)
• early S&S: oliguria (increased urine output), azotemia (increased levels of urine in blood), and rarely anuria (failure to secrete urine)
• electrolyte imbalance and metabolic acidosis follows
• HA, irritability, seizures, anorexia, nausea and vomiting, bleeding, diarrhea or constipation, pruritus, pallor, HTN, hypotension, heart failure, anemia

Question 15

Acute Tubular Necrosis (ATN)

Answer 15

• destruction of tubular segment of nephron causing uremia (increased accumulation of protein by-products in blood) and renal failure
• results from: ischemic (disruption of blood flow to kidneys)-irreversible due to basement membrane damage; nephrotoxic injury (ingestion of certain chemical agents) or hypersensitive reaction of kidneys-potentially reversible
• patho: necrosis and sloughing of epithelial cells results in formation of casts causes obstruction and an increase in intraluminal pressure decreasing GFR-causes fluid to leak back from the lumen into the interstitium
• CM: oliguria,hyperkalemia (too much potassium), uremic syndrome (increased accumulation of proteins), dry mucous membranes and skin

Question 16

Glomerulonephritis

Answer 16

• bilateral inflammation of glomeruli (commonly following strep)
• caused by immune response in glomerulus
• patho: beta-hemolytic strep lodge into glomerular channels, which initiate inflammatory and immune response
• CM: oliguria, coffee-colored urine, SOB, orthopnea, HTN, nausea, arthralgia (pain in joint)

Question 17

Hydronephrosis

Answer 17

• total obstruction of urine flow with dilation of collecting system ultimately causes complete atrophy of cortex and cessation of GFR
• abnormal dilation of renal pelvis and calyces of one or both kidneys
• caused by obstruction of urine flow in genitourinary tract
• patho: if obstruction is in urethra or bladder it affects both kidneys, if it’s in a ureter it affects one kidney, if it’s distal to the bladder it causes bladder to dilate and act as a buffer zone, delaying hydronephrosis
• almost any type of disease that results in obstruction of the urinary tract can result in this
• early S&S: mild pain, slightly decreased urine flow
• severe: dull flank pain, hematuria, pyuria (pus in urine), dysuria (painful urination), alternating polyuria (large production of passage of urine) and oliguria and complete anuria
• nausea and vomiting, abdominal fullness, dribbling, urinary hesitancy
• total obstruction of urine flow with dilation of collecting system ultimately causes complete atrophy of cortex and cessation of GFR

Question 18

Pyelonephritis

Answer 18

• sudden inflammation of renal pelvis or renal tubules
• note severe dilation of calyces as well as atrophy and scarring of cortex
• caused by bacteria that primarily affects interstitial area and renal pelvis or renal tubules (less common)
• patho: infection spreads from bladder to ureters then to kidneys; may also result from inability to empty bladder, urinary stasis, or urinary obstruction
• more common in females
• CM: urinary urgency and frequency, burning during urination, dysuria, nocturia, and hematuria, cloudy urine (ammonia odor), chills, nausea, flank pain, fatigue
• RF: sexually active women, pregnant women, people with diabetes, people with other renal diseases

Question 19

Renal Cystic Disease (Polycystic Kidney Disease-PKD)

Answer 19

• inherited disorder characterized by multiple clusters of fluid filled-cysts that enlarge kidneys, eventually replacing renal tissue
• etiology and pathogenesis: multiple cysts cause grossly enlarged kidneys-cysts cause elongation of renal pelvis, flattening of calyces, and indentations in kidney; as cyst grows it detaches from nephron then fibrosis develops
• CM: simple or solidarity cysts are usually asymptomatic; WHALE: widening abdominal girth, HTN, abdominal pain, lumbar pain, enlarged kidneys
• HTN is secondary to increased sodium and water retention because of this
• most cases renal failure occurs at about 10 years after symptoms appear

Question 20

Renal Claculi

Answer 20

• stones that are crystalline, popcorn-kernel shapes to jagged starbursts and can cause urinary obstruction
• common sites: ureteropelvic junction, iliac vessels, ureterovesical junction
• 75-85% are calcium, 15% are struvite, and 7% are uric acid
• disorders that lead to over-excretion and supersaturation of calcium or oxalate can lead to stone formation
• patho: increased calcium concentration results in precipitate instead of being dissolved in urine
• CM: hematuria, nausea and vomiting, urinary hesitancy and dysuria, abdominal distention, fever and chills, flank pain, anuria, renal colic; pain occurs once stone has moved into ureter
• dx: CT scan
• tx: fluids, most stones are smaller than 5 mm and will pass, 2/3 in 4 weeks; in situ extracorporeal shock wave lithotripsy (ESWL) for small stones (smaller than 1 cm) in proximal ureter; ureteroscopy for larger (bigger than 1 cm) stones in proximal ureter allows use of laser to perform photothermal lithotripsy
• SIFTT: look for complaints of fever, chills, sweats; onset of these warrants immediate communication with MD

Question 21

Renovascular Hypertesnsion

Answer 21

• systemic BP increased d/t intrarenal atherosclerosis or stenosis of major renal arteries or branches
• failure of regulatory mechanisms for maintaining BP and volume
• patho: reduced blood flow to kidneys results in renin secretion –> converts angiotensinogen –> angiotensin I (in liver) –> angiotensin II (in lungs) –> heightens peripheral resistance and BP; angiotensin II acts on kidneys causing them to reabsorb sodium and water by stimulating the renal cortex to release aldosterone so the retention of sodium and water elevates blood volume and pressure; intermittent pressure diuresis causes excretion of sodium and water, decreased blood volume, and decreasing CO
• high aldosterone causes further sodium retention but can’t stop renin secretion which can lead to renal failure
• CM: flank pain, oliguria, HA, nausea, anorexia, anxiety, HTN, pitting edema

Question 22

Chronic Kidney Disease (CKD)

Answer 22

• irreversible deterioration and end result of gradual tissue destruction and loss of kidney function
• etiology and RF: diabetes,HTN, kidney disease; excessive OTC analgesic drug use-analgesic nephropathy
• patho: progressive loss of nephron function-kidneys maintain normal function until ~75% are non functional
• 5 stages mark progression
  1) kidney damage with normal or increased GFR (90 ml/min or more)
  2) kidney damage with mildly decreased GFR (60 to 89 ml/more)
  3) moderately decreased GFR (30-59 ml/min)
  4) severely decreased GFR (15-29 ml/min)
  5) kidney failure (ESRD; GFR of less than 15 ml/min)

Question 23

Clinical Manifestations and Medical Management of Chronic Kidney Disease

Answer 23

• hematologic: anemia; erythropoietin primarily produced by kidneys
• cardiovascular: HTN, chest pain, pericarditis, CHF
• GI: azotemia causes nausea, vomiting, and anorexia
• musculoskeletal: body retains phosphate and loses calcium, calcium reabsorption from bone-osteodystrophy, varying degrees of bone loss
• neurologic: memory loss, inability to concentrate, perceptual errors, and decreased alertness, dying of both sensory and motor nerves
• prevention: diabetic nephropathy is leading cause of kidney failure in US
• prognosis: annual mortality rate of people with ERST is 24%; CV diseases remain the number one cause of death in all categories of renal disease

Question 24

SIFTT for Chronic Kidney Disease

Answer 24

• anytime a client reports a history of prolonged and regular NSAID/analgesic use and renal symptoms, need medical eval
• potential osteodystrophy requires modification of evaluation and intervention techniques including education
• dialysis…
• depression among people on dialysis may be common
• increased susceptibility to infection
• malnutrition, anemia and loss of body mass can result in significant requiring careful assessment and rehab
• peripheral neuropathy common in people with uremia often improves symptomatically with adequate dialysis
• muscle mass will improve with consistently good dialysis and nutrition
• fluid retention results in HTN at beginning of dialysis, alternately, dialysis can result in hypotension
• when exercise is performed after dialysis, blood chemistry levels will be at their optimum
• exercise and CKD…
• adults often show S&S of anemia
• functional capacity in people on dialysis is typically more than 2 SDs below the age-and gender-predicted norm, barely enough to carry out ADLs
• regular activity and exercise can improve physical functioning, exercise tolerance and health-related quality of life
• exercise can be performed before, during, or after dialysis

Question 25

Urinary Incontinence

Answer 25

• involuntary problematic loss of urine and occurs most often when bladder pressure exceeds sphincter pressure
• 4 categories: functional, stress, urge, overflow; some have more than one type known as mixed incontinence
• only 20-50% of incontinent adults seek medical care
• UI is more prevalent in women and in aging
• 15-30% of community dwelling older adult and more than 50% of nursing home residence experience it
• 21% of women surveyed reported UI at least monthly
• RF: weakness or damage to pelvic floor musculature, drugs, obesity
• management…
• prepartum and postpartum pelvic floor muscle training has been shown to have immediate and long-term effects in preventing incontinence, improving quality of life, and improving sexual dysfunction
• brief verbal or written instruction in performing kegel is not enough
• properly performed kegel should result in significant increase in force of urethral closure without appreciable valsalva effort
• improperly done the kegel can promote incontinence
• avoiding constipation through proper nutrition
• anyone experiencing leaking during exercise needs a prescriptive exercise program for both leaking and modifying exercise that precipitates leaking

Question 26

Functional Incontinence

Answer 26

• normal urine control but can’t reach a toilet in time

- patho: lacks origin and is consequence of chronic impariments of physical or cognitive function

Question 27

Stress Incontinence

Answer 27

• loss of urine during activities that increase intraabdominal pressure such as coughing, lifting, or laughing
• patho: caused by involuntary bladder spasms and is often associated with increased frequency and urgency

Question 28

Urge Incontinence

Answer 28

• sudden expected urge to urinate and the uncontrolled loss of urine
• often related to bladder capacity or detrusor inability (overactive bladder)
• can be affected by drugs
• muscle contracts even when bladder is not full
• patho: weakness or loss in tone of pelvic floor muscles, urethral sphincter failure, hypermobility of ureterovesical junction or damage to pudendal nerve

Question 29

Overflow Incontinence

Answer 29

• constant leaking of urine from bladder that is full but unable to empty
• patho: result of neurologic problem where intravascular pressure is greater than the maximal urethral pressure as bladder distends

Question 30

SIFTT: Incontinence

Answer 30

• perimenopausal or postmenopausal women; any women who has been pregnant; anyone over 60 (earlier if prostate or bladder infection or cancer is evident); or any case of multiple risk factors should be screened
• questions to ask in history: do you leak urine when you lift, cough, sneeze, or stand up? do you get up at night to urinate (how often)? do you go to the bathroom more often than every 2-3 hours? how much water do you drink in a waking day? are you constipated?

Question 31

SIFTT: Exercise and Stress Incontinence

Answer 31

• exercises to retrain and strengthen pelvic floor muscles
• restoring normal pelvic floor strength and bladder control essential before resuming vigorous physical activity
• with verbal and manual cues, biofeedback, physiologic quieting, and EMG, client can be taught to disassociate pelvic floor muscle activity from other hip and pelvic muscle activity and to maintain pelvic floor muscle tone while avoiding Valsalva maneuver

Question 32

SIFTT: Exercise and Urge Incontinence

Answer 32

• bladder needs to be trained to respond to a specific voiding schedule
• client’s void at scheduled intervals to suppress micturition reflux, increase bladder capacity, and decrease urinary frequency
• success is marked by voiding at 3-4 hour intervals
• an episode of urge incontinence at least once a week increases the risk of fractures by 34% because of falls at night-placing night lights near bed, hallway to bathroom, and bathroom and removing objects along path are preventive steps