Module 9: Urinary Tract Obstructions, Tumors & UTI’s (b) // Glomerular Disorders AKI & CKD Flashcards
Urinary Tract Obstructions
-Definition
- Defined as a blockage of urine flow w/in the urinary tract
Can be caused by
- Anatomic defect
- Functional defect
Urinary Tract Obstructions
-Severity is based on?*TEST
- Location
- Completeness
- Involvement of one or both upper urinary tracts
- Duration
- Cause
Urinary Tract Obstructions
-Examples
- Polycystic Kidney Dz — Cyst in the kidney or Hilum
- Blood clots
- Ureteral Stones
- Renal cell carcinoma — transitional cell carcinoma of bladder — Carcinoma of cervix
- BPH
- Fibrous bands — Endometriosis — Pregnancy
- Urethral sphincter — Functional Issue
Urinary Tract Obstructions
-Upper Tract Obstructions
- Early complications
- Hydroureter — Dilation of ureter
- Hydronephrosis — Dilation of renal pelvis and cálices
- Ureterohydronephrosis — Dilation of both ureter and renal pélvis/cálices - Later Complications
- Tubulointestinal fibrosis — Extracellular matrix laid down — Leads to cellular destruction & death of nephrons
Urinary Tract Obstructions
-Renal Calculi Risks
- Masses of crystals, protein, or mineral salts form in urinary tract and may obstruct the tract
- RISK factors include:
- Male
- Most develop before 50 yrs of age
- Inadequate fluid intake
- Geographic location — hotter climates
Anytime you have higher concentration of urine leads to stone formation
Other risks
-DMT2, HTN, dysmetabolic syndrome & Genetic component
Urinary Tract Obstructions
-Kidney Stone Composition?
- Composition of mineral salts**
- MOST COMMON — calcium oxalate and calcium phosphate 70-80% — Alkaline urine pH >7.0
- Struvite —Magnesium, ammonium phosphate 10-15% — Most often composition of STAGHORN Calculi (massive stones)
- Uric acid 7% — pH <5 - Xanthine stones are caused by genetic disorders of amino acid metabolism
Urinary Tract Obstructions
-Kidney Stone Clinical Manifestations
- Renal Colic
—Mid Ureter Obstruction — Colic that radiates to lateral flank or lower abdomen
—Lower Ureter Obstruction — Urgency, frequency or urge incontinence - Moderate to Severe pain — Can have Severe pain leading to N/V, gross hematuria associated w/ pain
Functional Urinary Tract Obstructions
-Neurogenic Bladder TEST
- Upper motor neuron dysfunction — Dyssynergia is loss of coordinated neuromuscular contraction
—Loss of synergy between the bladder and the urinary sphincter (Both internal and external)
—Detrusor hyperreflexia — Bladder empties automatically when it becomes full and urinary sphincter functions normally. More forceful than normal depending on severity — Manifestations are Urge incontinence and urinary leakage
—Detrusor hyperreflexia w/ detrusor sphincter dyssynergia — Both bladder and urinary sphincter are contracting at the same time
Manifestations is a functional urinary tract obstruction — Severe case leads to tubal interstitial fibrosis
- Lower Motor Neuron dysfunction
—Detrusor areflexia (W/out reflex) — Underactive, hypotonic, or atonic bladder — Ex Cauda Equina Syndrome*
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Lower Urinary Tract Syndrome LUTS
-What is it?
- Prostate enlargement
- Urethral stricture
- Severe pelvic organ prolapse
- Partial obstruction of bladder outlet or urethra — Low bladder wall compliance
Overactive Bladder Syndrome
- Chronic syndrome of detrusor over activity
- Urgency w/ our w/out urge incontinence
- Usually associated w/ frequency and Nocturia
Tx w/ lifestyle modification and behavioral therapy
Renal Tumors
-Info/Risks
- Renal Cell Carcinoma — MOST COMMON
- Renal adenomas — Benign
- Renal Transitional cell carcinoma — Rare <10% — Highly malignant
Risks for carcinomas
- Men 2x as likely to have renal cell carcinomas
- Smoking & long term tobacco use
- HTN & Obesity
Renal Tumors
-Renal Cell Cancers Clinical Manifestations
- Hematuria
- Dull and achy flank pain
- Palpable flank or abdominal mass (depending on body habitus)
Bladder Tumors
-Info
- Papillary Tumors — 80% of tumors —Tuft-like lesions
2. Nonpapillary Tumors —METs to lymph nodes, liver, bone lungs and adrenal glands —POOR PROGNOSIS — 20%
Bladder Tumors
-Clinical Manifestations
- Early Stage
- May be asymptomatic or Painless Hematuria - Late Stage
- Frequent urination
- Pelvic pain
SMOKING common risk factor >60 yr old male
Urinary Tract Infection
-Info
- Inflammation of the urinary epithelium after invasion and colonization by some pathogen in the urinary tract
- Retrograde movement of bacteria into urethra and bladder
- Classification — Location or complicating factors
- Complicating factors include — Urethral strictures, Neurogenic bladder, Infections in immunocompromised individuals, pregnancy, atypical organisms, infections in males (UTI in males is STI until proven otherwise)**
Urinary Tract Infections
-Risk Factors
- Being female but especially
- Sexually active and pregnant women
- Women treated w/ antibiotics that disrupt vaginal flora
- Postmenopausal women - Indwelling catheters
- DM
- Neurogenic bladder
- Lower Urinary Tract Obstruction
Urinary Tract infections
-Most common pathogens
- E. Coli 80-85%
Urinary Tract infections
-Host Defenses against UTI’s?
- Washout phenomena — Sterile urine washes out bacteria
- Protective mucin layer —Higher risk in elderly due to decreased mucin production
- Local immune responses
- Peristaltic movement of ureters
Cystitis
-Info/Manifestations
1. Inflammation of the bladder Manifestations -Frequency -Dysuria -Urgency -Lower abdominal and/or suprapubic pain
—Older adults w/ cystitis may be Asymptomatic or demonstrate CONFUSION or vague abdominal discomfort TEST
Pyelonephritis
-Info/Manifestations
- Acute infection of the ureter, renal pelvis, and/or renal parenchyma
- Manifestations TEST
—Flank pain (SIGNIFICANT PAIN)
—Fever including chills
—Costovertebral Tenderness
Pyelonephritis
-Evaluation
- UA — Pyuria — Presence of WBC casts supports dx of acute pyelonephritis — Casts not always presence
- Sensitivity is probability of testing positive when disease is present
—High sensitivity test has FEW false negatives and effective at ruling conditions OUT
—CVA tenderness is only 21% sensitive — NOT a good Exam to R/O - Specificity — Probability of testing negative when a disease is absent
—High specificity test has few false positives and is good at ruling condition IN
— 88% of pt’s who do not have Pyelonephritis will NOT have CVA tenderness — Good Test for Ruling IN pyelonephritis
Acute Glomerulonephritis
Info and Types
- Immune Mechanisms
- Formation of immune (Antigen/antibody) Complexes — Complement activation — Ex: Acute Strep Glomerulonephritis - Non-Immune Mechanisms
- Systemic diseases — Diabetes & Lupus (Type 2 and type 3 hypersensitivity reactions in lupus)
- Ischemia —AKI; Acute tubular necrosis; Renal artery stenosis
- Drugs or toxins
Acute Glomerulonephritis
-Clinical Findings
- Decreased GFR
2. Proteinuria/Hematuria — increased permeability is d/t loss of negative electrical charge of basement membrane
Acute Glomerulonephritis
-Clinical Manifestations
- Hematuria w/ RBC casts
- Smoky, brown-tinged urine - Proteinuria including loss of albumin
- Low serum albumin
- Edema - Severe or progressive glomerular disease — Eventual oligúria
—Oligúria = Urine output <30 ml/hr or <400 ml/day
Acute Glomerulonephritis
-Nephrotic Sediment
- Contains massive amounts of PROTEIN and lipids and either a microscopic amount of blood or NO blood
Acute Glomerulonephritis
-Nephritic Sediment
- BLOOD is present in urine w/ RBC casts, WBC casts, and varying degrees of protein, which is not usually severe
Acute Glomerulonephritis
-Nephrotic Syndrome
- Heavy Proteinuria >3.5G/24hrs protein in urine
- Serum hypoalbuminemia
- Peripheral edema
NEED ALL 3 to be considered nephrotic syndrome
- Manifestations
- Prone to infections
- Hypothyroidism
- Vitamin D deficiency
- Hyperlipidemia
- Lipiduria
Acute Glomerulonephritis
-Nephritic Syndrome
- Hematuria (usually microscopic) and RBC casts are present in the urine in addition to proteinuria, which is not severe
- Advanced stages include — HTN, uremia, & Oligúria
- Caused by increased permeability of glomerular filtration membrane
—Pore sizes enlarge
—RBC’s and protein pass through
Acute Glomerulonephritis
-Nephritic Syndrome Causes
- Post-Streptococcal glomerulonephritis
- IgA Nephropathy
- Lupus
- Diabetic Glomerulonephritis
AKI
-Definition
- Sudden decline in kidney function w/ a decrease in GFR and accumulation of nitrogenous wast products in the blood
- Increase in serum creatinine and BUN
AKI
-Types
- Pre-Renal — Hypo-perfusion of kidney — MOST COMMON overall
- Intra-Renal — Involving renal parenchymal or interstitial tissue — Acute tubular necrosis — ISCHEMIC is Most common intra-renal cause
- Post-Renal — RARE — Acute urinary tract obstruction
CKD
-Info
- Progressive loss of renal function associate w/ systemic diseases — ie: DM, Lupus, HTN
- Kidney damage — GFR < 60 ml/min/1.73 m2 for 3 months or more **
- Clinical manifestations DO NOT occur until renal function declines to less than 25% of normal**
CKD
-Clinical Manifestations
- Affects ALL Body systems
- Uremic Syndrome
-Pro-inflammatory state w/ the accumulation of urea and other nitrogenous compounds
-Toxins — result of accumulation of end-products of protein metabolism
—Alteration of gut flora creating more toxins
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CKD Manifestations
TEST
- Calcium, phosphate, and bone — Decreased calcium, causing renal osteodystrophies — Hyperphosphatemia
- Acid-base balance — Metabolic acidosis COMMON — Hydrogen stays in circulation
- Protein, carbs, and fat metabolism — Serum protein decreases, glucose intolerance, Increase LDL, Low HDL, High Triglycerides
—Liver is compensating for loss of albumin in the kidneys - Cardiovascular System — Major cause of morbidity/mortality — Anemia (Lack of erythropoietin) — HTN d/t volume overload
- Pulmonary system — Dyspnea and Kussmaul respiration’s
- Hematologic Alterations — Normochromic normocytic anemia — Impaired platelet function (Bleeding) — Hypercoagulability
- Immune System — Immune suppression — Deficient response to vaccination — Increased risk for infection
- Neurologic System — Impaired concentration & Memory loss — Impaired judgement — Seizures, Coma
- GI System — Bleeding ulcers, blood loss — N/V/D or constipation — Uremic fetor (bad breath)
- Endocrine & Reproductive — Decrease sex steroids — Low libido — insulin resistance — low thyroid hormone levels
- Integumentary System — Anemia: pallor — Bleeding Sallow skin (Pale sickly skin)
