Renal 2 Flashcards
1
Q
Kskd
A
MDMA
2
Q
What is Cystitis?
A
• Cystitis is an inflammation of the bladder caused by irritation or, more commonly, by infection from bacteria, viruses, fungi, or parasites
3
Q
True or false
• Laboratory assessment for a UTI is a urinalysis performed on a clean-catch midstream specimen with testing for leukocyte esterase and nitrate.
A
True
4
Q
Symptoms of a UTI
A
• Frequency, urgency, and dysuria are the common manifestations of a urinary tract infection, but cloudy, foul smelling, or blood tinged urine may occur.
5
Q
True or false
• Infectious cystitis can lead to complications, including pyelonephritis and sepsis
A
True
6
Q
What is Urethritis?
A
- Urethritis is an inflammation of the urethra that causes symptoms similar to UTI.
- In men, manifestations of urethritis are burning or difficulty with urination and a discharge from the urethral meatus, usually caused by sexually transmitted diseases.
- In women, urethritis causes manifestations similar to those of bacterial cystitis
7
Q
True or false
The most common symptom of urethral stricture is obstruction of urine flow
A
True
8
Q
What is Urolithiasis?
A
- Urolithiasis is the presence of calculi or stones in the urinary tract.
- Stones often do not cause symptoms until they pass into the lower urinary tract, where they can cause excruciating pain.
9
Q
• Nephrolithiasis is stones in the kidney and ureterolithiasis is stones in the ureter.
A
True
10
Q
What is renal colic?
A
• The major manifestation of stones is severe pain, commonly called renal colic, most intense when the stone is moving or when the ureter is obstructed.
11
Q
What is lithotripsy?
A
• Lithotripsy, also known as extracorporeal shock wave lithotripsy, is the use of sound, laser, or dry shock waves to break the stone into small fragments. `
12
Q
Urothelial cancer
A
• Urothelial cancers are malignant tumors of the urothelium, the lining of transitional cells in the kidney, renal pelvis, ureters, urethra, and mostly, the bladder. • The only significant finding on a routine urinalysis is gross or microscopic hematuria
13
Q
What are used after a cystectomy?
A
• Four alternatives are used after cystectomy: ileal conduit, continent pouch, bladder reconstruction also known as neobladder, and ureterosigmoidostomy.
14
Q
What do the kidneys do?
A
- The kidneys also help regulate blood pressure and acid-base balance, produce erythropoietin for red blood cell synthesis, and convert vitamin D to an active form.
- The kidneys have both regulatory and hormonal functions.
- The “working” units of the kidney consist of 1 million nephrons per kidney, each of which forms urine from blood.
- The kidney processes are glomerular filtration, tubular reabsorption, and tubular secretion, which use filtration, diffusion, active transport, and osmosis.
15
Q
What is the normal GFR?
A
• Normal glomerular filtration rate averages 125 mL/min, but only about 1 to 3 L are excreted each day as urine and the rest is reabsorbed back into the circulation
16
Q
Renal changes that occur with age
A
o The kidney loses cortical tissue and gets smaller by 80 years of age.
o The glomerular and tubular linings thicken, reducing filtrating ability.
o Blood flow to the kidney decreases by about 10% per decade as blood vessels thicken resulting in less adaptive renal blood flow.
o The combination of reduced kidney mass, reduced blood flow, and decreased GFR contribute to reduced drug clearance and a greater risk for drug reactions and kidney damage from drugs and contrast dyes in older adults.
o Tubular changes decrease ability to concentrate urine, resulting in nocturnal polyuria.
17
Q
Labs relevant to kidney function
A
- Serum creatinine is produced when protein or muscle breaks down, which is usually constant, therefore, the serum creatinine level is a good indicator of kidney function.
- Urea nitrogen is filtered and excreted in the urine so BUN levels indicate renal clearance of this nitrogen waste product, but don’t always reflect renal disease.
- Blood urea nitrogen to serum creatinine ratio can help determine whether nonrenal factors, such as dehydration or poor renal perfusion, are causing the elevated BUN.
- Ideally, urine specimens are collected at the morning’s first voiding.
- Urine color, specific gravity, pH level, and the presence of glucose, ketone bodies, nitrates, and proteins, which normally are not present in urine, are assessed.
- Urine is analyzed for the number and types of organisms present
18
Q
What is polycystic kidney disease?
A
- Polycystic kidney disease is an inherited disorder where fluid-filled cysts develop.
- In the dominant form, patients in their 30s have cysts in only a few nephrons.
- In the recessive form of the disease, nearly 100% of patients’ nephrons have cysts present since birth.
- Over time, small cysts become larger and nephron function becomes less effective.
- The kidney tissue is eventually replaced by nonfunctioning cysts, which look like clusters of grapes, and the kidneys enlarge.
- People who inherit the recessive form usually die in early childhood.
19
Q
Hydronephrosis vs. hydroueter
A
- Hydronephrosis and hydroureter are problems of urine outflow obstruction.
- Prompt recognition and treatment are crucial to prevent permanent renal damage.
- In hydronephrosis, the kidney enlarges as urine collects in the pelvis and kidney tissue damaging the blood vessels and renal tubules.
- In patients with hydroureter and urethral stricture, obstructions are lower.
20
Q
Pyelonephritits
A
- Urinary tract infection is an infection in the normally sterile system.
- Acute pyelonephritis involves an active bacterial infection and tissue inflammation, tubular cell necrosis, and possible abscess formation anywhere in the kidney.
- Chronic pyelonephritis often occurs with a lower urinary tract defect, obstruction, kidney stones, or, most commonly, when urine refluxes from the bladder back into the ureters.
- Chronic pyelonephritis has a less dramatic presentation, such as nonspecific urinary symptoms or abdominal discomfort or repeated, low-grade fevers.
- Urinalysis shows a positive leukocyte esterase and nitrite dipstick test and the presence of white blood cells and bacteria.
21
Q
True of false
• Glomerulonephritis is the third leading cause of end-stage renal disease.
A
True
22
Q
Chronic glomerulonephritis,
A
- Chronic glomerulonephritis, or chronic nephritic syndrome, develops over 20 to 30 years or even longer, yet the exact onset of the disorder is rarely identified.
- Mild proteinuria and hematuria, hypertension, and occasional edema are often the only manifestations.
23
Q
What is nephrotic syndrome?
A
Nephrotic syndrome is a condition of increased glomerular permeability that allows massive loss of protein in urine, edema formation, and decreased plasma albumin.
• The most common cause of glomerular membrane changes is an immune or inflammatory process.
24
Q
Nephroscerosis
A
- Nephrosclerosis is a problem of thickening in the blood vessels, resulting in narrowing of the vessel lumen and decreased renal blood flow.
- Nephrosclerosis occurs with hypertension, atherosclerosis, and diabetes mellitus.
- The changes may be reversible or may progress to end-stage renal disease.
- Treatment aims to control high blood pressure and reduce albuminuria.
25
Renovascular disease
* Processes affecting the renal arteries, such as renal artery stenosis, atherosclerosis, or thrombosis, narrow the lumen and cause ischemia and atrophy of renal tissue.
* Patients with renovascular disease often have a sudden onset of hypertension, particularly in patients older than 50 years of
26
Diabetic Nephropathy
* Diabetic nephropathy occurs with type 1 or type 2 diabetes mellitus related to extent, duration, and effects of atherosclerosis, hypertension, and neuropathy.
* Proteinuria may be mild, moderate, or severe.
* Diabetic patients are always considered to be at risk for renal failure.
27
Renal cell carcinoma
* Renal cell carcinoma is also known as adenocarcinoma of the kidney.
* Renal tumors are classified into four stages and complications include metastasis and urinary tract obstruction.
* Only about 5% to 10% of patients with renal cell cancer have flank pain, obvious blood in the urine, and a kidney mass that can be palpated.
* Bloody urine is a late common sign, but urinalysis may show red blood cells.
* Renal masses may be detected by surgical exploration, IV urogram with nephrograms, or sonography.
* Interventions focus on controlling the cancer and preventing metastasis.
* Radiofrequency ablation can slow tumor growth and biological response modifiers have lengthened survival time, but chemotherapy has limited effectiveness against this cancer type.
* Renal cell carcinoma is usually treated surgically by nephrectomy and as they are highly vascular, blood loss during surgery is a major concern.
28
When caring for the client with uremia, the nurse assesses for which of these symptoms?
Nausea and vomiting
29
When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which of these?
History of a hysterectomy, The scanner must be in the scan mode for male clients to ensure the scanner subtracts the volume of the uterus from the measurement.
30
The client has returned form a captopril renal scan. Which teaching should the nurse provide when the client returns?
Rise slowly and call for assistance, The drug can cause severe hypotension during and after the procedure. Warn him or her to avoid rapid position changes and of the risk for falling as a result of orthostatic (positional) hypotension.
31
The nurse in the urology clinic is providing teaching for a female client with cystitis. Which of these should be included in the teaching plan?
Try to take in 64 ounces of fluid each day.
Be sure to complete the full course of antibiotics.
If your urine remains cloudy, call the clinic.
32
The nurse has the following assignment. Which client should be encouraged to consume 2 to 3 liters of fluid each day
Client with hyperparathyroidism. A major feature of hyperparathyroidism is hypercalcemia, which predisposes to kidney stones; this client should remain hydrated.
33
When preparing the client who is undergoing urography with contrast, the nurse plans to administer which medication before the procedure?
Acetylcysteine, (an antioxidant) may be used to prevent contrast-induced nephrotoxic effects; this client has kidney impairment demonstrated by increased creatinine.
34
The client is in the emergency department (ED) for an inability to void and for bladder distention. What is most important for the nurse to provide to the client?
Privacy
35
When assessing the older adult, the nurse teaches the older adult that which age-related change causes nocturia?
Decreased ability to concentrate urine
36
Which percussion technique does the nurse use to assess the client with reports of flank pain?
While the client assumes a sitting, side-lying, or supine position, form one of the hands into a clenched fist. Place the other hand flat over the costovertebral (CVA) angle of the client. Then, quickly deliver a firm thump to the hand over the CVA area.
37
Which urinary assessment information indicates the potential need for increased fluids in the client?
Increased blood urea nitrogen (BUN) can indicate dehydration.
38
The RN is caring for a client who has just had a kidney biopsy. Which of these actions should the nurse perform first?
The client is positioned supine for several hours after a kidney biopsy to decrease the risk for hemorrhage.
39
A nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective?
Drinking 2½ liters of fluid a day flushes out the urinary system and helps reduce the risk for cystitis
40
A nurse is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body parts?
Words that the client uses
41
Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise?
Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence.`
42
A nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation?
Dysuria-painful urination-is a symptom of a UTI Frequency-frequent urinating and in small amounts-is a sign of a UTI.
Nocturia-urinating at night-is (or can be) a symptom of a UTI.
Urgency-having the urge to urinate quickly-is a symptom of a UT
43
A cognitively impaired client has urge incontinence. Which method for achieving continence does a nurse include in the client's care plan?
Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis.
44
A 53-year-old postmenopausal woman reports "leaking urine" when she laughs. She has five children, all delivered vaginally. She is in good health and has tried pelvic floor (Kegel) exercises, which have not helped. She is not taking any medications and has no allergies to medication. She is diagnosed with stress incontinence. The health care provider prescribes the drug, estrogen (Premarin). Which risks does the nurse tell the client to expect?
Estrogen use can increase the risk for endometrial cancer.
| Correct: Estrogen use can increase the risk for thrombophlebitis. Women who smoke-especially-should not use this drug.
45
The nurse assists the client with acute kidney injury to modify the diet in which way?
Restricted protein
Fluid restriction
Low potassium
46
What diseases are more common in people with chronic kidney disease?
Diabetes, hypertension, and cardiovascular disease are much more common people with chronic kidney disease
47
Chronic kidney disease is most commonly caused by what?
Chronic kidney disease is most commonly caused by hypertension and diabetes
48
What must be destroyed before kidney dysfunction is obvious?
When kidney function declines gradually, as occurs most often with chronic kidney disease, 90 to 95% of the nephrons must be destroyed before kidney dysfunction is obvious
49
True or false
| Acute kidney injury affects many body systems, chronic kidney disease affects every body system
True
50
What is acute kidney injury?
Acute kidney injury is a rapid decrease in kidney function, leading to the collection of metabolic waste in the body. AKI can result from conditions that reduce blood flow to the kidneys, damage to the glomeruli, interstitial tissue, or tubules, or destruction of urine flow
51
Acute kidney patho 1....
With Shock or other problems causing an acute reduction in blood flow to the kidney (hypoperfusion), the kidney compensates by constricting renal blood vessels, activating the renin angiotensin aldosterone pathway, and releasing antidiuretic hormone. These responses increase blood volume and improve kidney perfusion. However, the same responses reduced urine volume, resulting in oliguria ( urine output of less than 400 ml a day) and azotemia ( retention of nitrogenous waste).
52
Acute kidney patho 2....
Nephron cell injury is more likely to occur from the lack of oxygen related to reduce blood flow. Toxins can cause blood vessel constriction in the kidney, leading to reduced kidney bloodflow and kidney ischemia. Kidney tissue inflammation caused by infection, drugs, or cancer results and immune mediated changes and kidney tissue. With extensive tubular damage, tubular cells slough and combine with other formed elements. Which then obstruct tubular lumens and prevent urine outflow. When pressure in the kidney tubule's exceeds glomerular pressure, globular filtration stops. This problem allows nitrogen base ways to collect in the blood, increasing the blood urea nitrogen and surround creatinine levels. When the bun rises faster than the serum creatinine level, because it usually related to protein breakdown or dehydration. When both the bun and creatinine levels rise in the ratio between the two remains constant, this indicates kidney dysfunction
53
True or false
When the bun rises faster than the serum creatinine level, the cause is usually related to protein breakdown or dehydration
True
54
True or false
When both the BUN and creatinine levels rise in the ratio between the two remains constant, this indicates kidney dysfunction
True
55
What is Prerenal azotemia?
Any condition decreasing blood flow to the kidneys and leading to ischemia in the nephrons such as Hypovolemic shock and heart failure!!! 2 main ones.....
Also pulmonary embolism, anaphylaxis, sepsis, pericardial tamponade
56
What is Intrarenal acute kidney injury?
Actual physical, chemical, hypoxic, or anyone nonchicken damage directly to the kidney tissue.
Infections, drugs, and invading tumors can cause acute interstitial nephritis. Other causes of intrarenal AKI include inflammation of the glomeruli or glomerulonephritis or the small vessel of the kidneys vasculitis or an obstruction bloodflow the kidney
57
What is Postrenal azotemia?
Obstruction of the urine collecting system anywhere from the calyces to the urethral meatus such as cancer, kidney stones, strictures
58
What types of problems can reduce kidney function?
Severe hypotension from shock or dehydration reduces kidney bloodflow and can lead to prerenal AKI. Cardiac disease or heart failure can also reduce kidney bloodflow. The patient may be oliguria or even anuric if kidney blood flow reduction is severe
59
What type of a AKI has the lowest rates of recovery?
AKI caused by nephrotoxic substances have the lowest rates of recovery
60
True or false
Decreased urine specific gravity indicates a loss of urine concentrating ability and is the earliest sign of kidney tubular damage
True
61
What are common drugs that have nephrotoxic side effects?
Antibiotics are common drugs that have nephrotoxic side effects. NSAIDs can cause or increase the risk for a AKI
62
What are some manifestations of prerenal azotemia?
Hypotension, tachycardia, decreased cardiac output, decreased central venous pressure, decreased urine output, lethargy
63
Intrarenal AKI usually occurs with damage to the glomeruli, interstitial tissue, or tubules. Manifestations are related to the retention of fluid and Nitrogenous waste. What are some manifestations?
These manifestations include oliguria or Anuria, edema, hypertension, tachycardia, shortness of breath, distended neck pain, elevated CVP, weight gain, respiratory crackles, anorexia, nausea, vomiting
64
What is oliguria?
Decreased urine output
65
What is Anuria?
Absence of urine
66
What are some manifestations for Postrenal AKI?
Oliguria, Anuria, symptoms of uremia, lethargy
67
What are some symptoms of uremia?
Anything related to kidney failure
68
What type of changes in lab values should be seeing a patient with acute kidney infection?
You should expect to see you rising BUN & creatinine levels and abnormal blood electrolyte values
69
Normal creatine level for men?
0.6-1.2 mg/dl
70
Normal creatine level for females?
0.5-1.1 mg/dl
71
Normal blood urea nitrogen levels?
10-20 mg/dl
72
Normal serum phosphate levels?
3-4.5 mg/dl
73
In chronic kidney disease will the Serum creatinine levels be decreased or increased?
Increased, may be as high as 15-30 before symptoms of CKD are present
74
In acute kidney injury will the serum creatinine levels be increased or decreased?
Increase, gradual
75
Chronic kidney disease will BUN levels be increased or decreased
Increased to 180-200 before symptoms develop
76
What are some increases and decreases you will see in lab values with acute kidney injury?
```
Sodium: varies
Potassium: increased
Phosphate: increased
Calcium: decreased
Blood osmolatiy : increased
```
77
What are some considerations for the oliguric phase versus the diuretic phase?
Oliguric, The plan of care focuses on close monitoring for life-threatening electrolyte changes and nitrogen retention that may require intervention
Diuretic, hypovolemia and electrolyte loss are the main problem
78
_________ Maybe used to treat a AKI resulting from nephrotoxic acute tubular necrosis
Calcium channel blockers
79
Unlike acute kidney injury, chronic kidney disease is a progressive, irreversible disorder and kidney function does not recover
True
80
What are some terms used with kidney dysfunction?
Azotemia: build up of nitrogen-based wastes in the blood
Uremia : Azotemia with clinical symptoms
Uremic syndrome
81
True or false
Because The healthy nephrons become larger and work harder, the GFR is effective until about three force of the kidney function is lost
True
82
Information about creatinine
Creatinine comes from proteins present in skeletal muscle. The rate of creatinine excretion depends on muscle mass, physical activity, and diet. Without major changes in diet or physical activity, the serum creatinine level is constant. Creatinine is partially excreted by the kidney tubule, and a decrease in kidney function leads to a build up of serum creatinine.
83
Information about urea
Urea is made from protein metabolism and is excreted by the kidneys. The bun level normally varies directly with protein intake and hydration status
84
Information about sodium
Sodium excretion changes are common. Early in chronic kidney disease, the patient is at risk for hyponatremia because there are fewer healthy nephrons to reabsorb sodium. The sodium is lost in the urine. The polyuria of early kidney dysfunction also causes sodium loss. In the later stages of chronic kidney disease, kidney excretion of sodium is reduced as urine production decreases. Then sodium retention and high sodium levels or hypernatremia can occur with only modest increases and dietary sodium intake. This problem leads to severe fluid and electrolyte imbalances
85
Information about potassium
Potassium excretion occurs mainly through the kidney. Any increase in potassium load during the later stages of chronic kidney disease can lead to hyperkalemia. Normal serum potassium levels of 3.5 to 5 are maintained until the 24 hour urine output falls below 500 mL. High potassium levels then develop quickly, reaching 7 to 8 or greater. Severe ECG changes result from this elevation, fatal dysrhythmias can occur
86
Information about acid-base balance
Acid-base balance is affected by chronic kidney disease. In the early stages, blood pH changes little because of the remaining healthy nephrons increase the rate of acid excretion. As more nephrons are lost, acid excretion is reduced and metabolic acidosis results. Many factors lead to acidosis and chronic kidney disease. First, the kidneys cannot excrete excess of hydrogen ions. Normally, tubular cells move hydrogen ions into the urine for excretion, but ammonia and bicarbonate are needed for this movement to occur. In patients with CKD, ammonia production is decreased and reabsorption of bicarbonate does not occur. This process leads to a build up of hydrogen ions and reduced levels of bicarbonate. High potassium levels further reduced kidney ammonia production and excretion
87
Information about acid-base balance continued...
As chronic kidney disease worsens and acid retention increases, increased respiratory action is needed to keep blood pH normal. The respiratory system compensates for the increased blood hydrogen ion levels by increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. This breathing pattern called Kuszmaul respiration, increases with worsening kidney disease. Bicarbonate measures the extent of metabolic acidosis. Patients with chronic kidney disease usually need Alkali replacement to counteract acidosis
88
Chronic kidney disease
* Chronic kidney disease is a progressive, irreversible kidney injury.
* When kidney function cannot sustain life, it becomes end-stage renal disease (ESRD).
* The kidneys fail in an organized fashion, usually progressing toward end stage disease with a gradual decrease in renal function of 30% to 50%.
* Renal damage raises systemic blood pressure, which also increases glomerular pressure and damage to remaining unaffected nephrons.
* Heart failure may occur because renal damage increases the workload on the heart as a result of anemia, hypertension, and fluid overload.
* Cardiac disease is the leading cause of death in patients with end stage failure.
89
When caring for the client with acute kidney injury and a temporary subclavian hemodialysis catheter, which of these should the nurse report to the provider?
Temp of 100.8, Infection is a major complication of temporary catheters. Report all symptoms of infection, including fever, to the provider. The catheter may have to be removed.
90
Which teaching by the nurse will help the client prevent renal osteodystrophy?
Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes.
91
The client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted?
Auscultate for pericardial friction rub., The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST segment elevation.
92
The nurse recognizes that the client with end-stage kidney disease has difficulty adhering to the fluid restriction when which of these is found?
Dyspnea and anxiety at rest, Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse assists the client in correlating symptoms of fluid overload with nonadherence to fluid restriction.
93
When administering medications to the client with chronic kidney disease, the nurse recognizes that which of these medications is most effective in slowing the progression of kidney failure?
Lisinopril (zestril), Angiotensin-converting enzyme (ACE) inhibitors appear to be the most effective drugs to slow the progression of kidney failure.
94
The nurse carefully observes for toxicity of drugs excreted through the kidney. Which of these represents a sign or symptom of digoxin toxicity?
Anorexia, nausea, and vomiting are symptoms of digoxin tox
95
Which of the following represents a positive response to administration of erythropoietin (Epogen, Procrit)?
Treatment of anemia with erythropoietin will result in increased (H&H) and decreased shortness of breath (SOB) and fatigue
96
Which of these interventions is essential for the client in the oliguric phase of acute kidney injury (AKI)?
Restrict fluids, During the oliguric phase of AKI, the client will be at risk for fluid overload; fluid restriction is necessary to limit this problem
97
The nurse in the transplantation unit assesses for which of these signs and symptoms of rejection of the transplanted kidney.
1. Crackles in lung fields
2. +3 edema of lower extremeties
3. BP 169/90
98
The client is receiving immune suppressive therapy after kidney transplantation. Which measure is most important for the nurse to implement?
Handwashing
99
To prevent prerenal acute kidney injury, which person is encouraged to increase fluid consumption?
Construction worker, Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place a construction worker at risk for dehydration and prerenal azotemia.
100
Which clinical manifestation indicates the need for increased fluids in the client with kidney failure?
Increased BUN, An increase in blood urea nitrogen can be an indication of dehydration, and an increase in fluids is needed
101
Which finding in the first 24 hours after kidney transplantation requires immediate intervention?
Abrupt decrease in urine output, An abrupt decrease in urine output may indicate complications such as rejection, acute tubular necrosis (ATN), thrombosis, or obstruction.
102
Hypertension and chronic kidney disease
Hypertension is common in most patients with chronic kidney disease. CKD itself elevates blood pressure by causing fluid and sodium overload and dysfunction of the renin angiotensin aldosterone system. The retention of sodium and water causes circulatory overload, which elevates blood pressure. The kidneys respond to a decrease in kidney bloodflow or too low sodium levels by trying to improve blood flow to the kidney. The release of Renin triggers the production of more angiotensin and aldosterone. Angiotensin causes blood vessel constriction and increases blood pressure. Aldosterone, hormone released by the adrenal glands, stimulates kidney tubules to reabsorb sodium and water. These actions increased plasma volume and raise blood pressure. The damaged kidneys do not recognize increasing blood pressure and continue to produce Renin.The result is severe hypertension that is difficult to treat and worsens kidney function. Many patients with CKD also have heart damage and heart enlargement from the long-term hypertension
103
Heart failure and chronic kidney disease
Heart failure may occur in chronic kidney disease because it increases the workload on the heart as a result of anemia, hypertension, fluid overload. Left ventricular enlargement and heart failure are common in end-stage kidney disease. Cardiac disease continues to be the leading cause of death in patients with end-stage kidney disease
104
What is the leading cause of death in patients with end-stage kidney disease
Cardiac disease
105
Pericarditis and chronic kidney disease
Pericarditis also occurs in patients with EKD. The pericardial sac becomes inflamed by uremic toxins or infection. It is not treated, this problem leads to pericardial effusion, cardiac tamponade, and death. Manifestations include severe chest pain, increased pulse rate, low-grade fever, and a pericardial friction rub that can be heard with the stethoscope
106
What is the most common problem in patients in the later stages of CKD?
Anemia is a common problem in patients in the later stages of CKD, and it worsens with CKD manifestations. The causes of anemia included decreased Erythropoietin level that decreases red blood cell production, decreased RBC survival time resulting from uremia, iron and folic acid deficiencies, and increased bleeding as a result of an impaired platelet function
107
What are two main causes of end-stage kidney disease?
Hypertension and diabetes mellitus
108
True or false
| Hemodialysis is the most common renal replacement therapy used with end-stage kidney disease and kidney failure
True
109
True or false
| most patients require about four hours per week of total dialysis time
False, bout 12 hours per week
110
What are the two most common choices for vascular access devices
An AV fistula or AV graft
111
True or false
| Peritoneal dialysis is more hazardous than hemodialysis
False, peritoneal dialysis is less hazardous and hemodialysis
112
What is the major complication of peritoneal dialysis?
Peritonitis is a major complication of peritoneal dialysis. The most common cause of peritonitis is connection site contamination. Manifestations of peritonitis include cloudy dialysate affluent, fever, abdominal tenderness, abdominal pain, nausea, vomiting. Cloudy or opaque effluent is the earliest sign of peritonitis
113
What is the most common type of rejection?
Acute rejection is most common type with kidney transplant. It is treated with increased immunosuppressive therapy and often can be reversible
114
Why do patients with polycystic kidney disease have high blood pressure?
The cause of hypertension is related to kidney ischemia from enlarging cysts on the nephrons
115
True or false
| Polycystic kidney disease is more common in white people then in people of other races
True it is more common in white people. Men and women have an equal chance of inheriting the disease
116
Manifestations of polycystic kidney disease
Pain is often the first manifestation. Distended abdomen is common as the cystic kidneys swelling push the abdominal contents forward. When a cyst ruptures, the patient may have bright red or cola colored urine. Infection Is suspected is the urine is foul smelling or if there is dysuria. Nocturia is an early manifestation and occurs because of decreased urine concentrating ability
117
What what are urinalysis on a patient with polycystic kidney disease show?
Urinalysis shows proteinuria once the glomeruli are involved. Hematuria maybe gross or microscopic. Bacteria in the urine indicate infection, usually in the cysts. As kidney function declines, serum creatinine and blood urea nitrogen levels rise. With decreasing kidney function, creatinine clearance decreases. Changes in kidney handling of sodium may cause either sodium losses or sodium retention
118
What is pyelonephritis?
Pyelonephritis is a bacterial infection in the kidney and renal pelvis. It's either the presence of active organisms in the kidney or the effects of kidney infection.
119
What is pyelolithotomy?
Stone removal from the kidney
120
What is nephrectomy?
Removal of the kidney
121
True or false
| Glomerulonephritis is the third leading cause of end-stage kidney disease
True
122
What is nephrotic syndrome?
Nephrotic syndrome is a condition of increased glomerular permeability that allows larger molecules to pass through the membrane into the urine and then the excreted. This process causes massive loss of protein into the Urine, edema formation, and decreased plasma albumin levels. Many agents and disorders are possible causes of nephrotic syndrome. The main feature of MS is severe proteinuria
123
What is nephrosclerosis?
Is a problem of thickening in the nephron blood vessels, resulting in narrowing of vessel lumens. This change decreases kidney blood flow, and the tissue is chronically hypoxic. Ischemia and fibrosis develops over time. Nephrosclerosis occurs with all types of hypertension, atherosclerosis, and diabetes mellitus.
124
True or false
| Hypertension is the second leading cause of end-stage kidney disease
True
125
What is the leading cause of end-stage kidney disease?
Diabetes mellitus
126
What is diabetic nephropathy?
It's a vascular complication of diabetes. It's first manifestation is albuminuria
127
Renal cell carcinoma
Reno cell carcinoma is usually treated surgically by nephrectomy. Renal cell tumors are highly vascular, and blood loss during surgery is a major concern. Before surgery, the artery supplying the kidney may be occluded by radiation to reduce bleeding during the Nephrectomy
128
What is renal cell carcinoma?
Renal cell carcinoma is the most common type of kidney cancer and is also known as adenocarcinoma of the kidney
129
What is the cystitis?
Inflammation of the bladder
130
True or false
| The combination of a positive leukocyte esterase and nitrate is 68-88% sensitive in the diagnosis of a UTI
True
131
What is the most common symptom of a urethral stricture?
Obstruction of urine flow
132
Is the most common type of incontinence?
Stress incontincence, coughing, sneezing, jogging, or lifting are triggers
133
What is urolithiasis ?
The presence of stones in the urinary tract
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What is nephrolithiasis?
The formation of stones in the kidney
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What is ureterlithiasis?
The formation of stones in the ureter
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True or false
The presence of red blood cells is usually caused by stone induced trauma on the lining of the ureter, bladder, or urethra
True
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What is the second most common sight of urinary tract cancer?
The second most common sight of urinary tract cancers the kidney and renal pelvis
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Urinary diversion procedures
Uteterostomies: divert urine indirectly to the skin surface
Conduits: collect urine in a portion of the intestine
Sigmoidostomies: Divert urine into the large intestine, so no stoma is required. Patient excretes urine with bowel movement
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What is a pyelolithotomy ?
Stone removal from the kidney
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True or false
| You need less protein in acute kidney infection and more protein in chronic kidney disease
True
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Replacement therapy Typically used
Continuous venovenous hemofiltration
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Polysistic kidney disease info
100% of people who inherit the gene will develop renal cysts by age 30.
Most PKD patients have hypertension as a result of renal ischemia from enlarging cysts- as vessels are compressed, blood flow decreases and activates the renin-angiotensin system raising the BP. Must control hypertension- can disrupt the process that leads to further kidney damage.
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Hydronephrosis vs. hydroureter
Hydronephrosis: kidney enlarges as urine collects in the pelvis and kidney tissue. The renal pelvis usually holds 5-8mls, does not take long to cause vessel damage.
Hydroureter: enlargement of the ureter- obstruction is lower in the urinary tract. Ureter dilation occurs above the obstruction.
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Acute vs. chronic pyelonephritis
Acute pyelonephritis: active bacterial infection, can be seen in pregnancy, obstruction, or reflux
Chronic pyelonephritis: repeated or continued upper urinary tract infections. Often occurs with a urinary tract defect(deformities), obstruction, or when urine refluxes from the bladder back into the ureters.
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What are some bacteria that cause kidney infections
```
Bacterial infection in the kidney and renal pelvis (upper urinary tract)
E-coli
Staph
Pseudomonas
Enterococcus
Klebsiella
```
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Glomerularnephritis
Glomerulonephritis is the 3rd leading cause of ESRD, immunologic renal disorder verses infectious
Primary glomerular diseases p. 1589 table 70-1
*Acute glomerulonephritis, *Rapidly progressive glomerulonephritis (RPGN), *Chronic GN, *Nephrotic syndrome
Secondary Glomerular diseases and syndromes p. 1590 table 70-2
*Lupus *good pasture’s *wegener’s granulomatosis *Amyloidosis, *Multiple myeloma, *Hep B/C, *Cirrhosis, *HUS, *TTP
Infectious causes of Acute Glomerulonephritis: p. 1590 table 70-3
Group A beta strep, staph/gram neg bacteremia, pneumococcal pneumonia, syphilis, hep B, infectious mono, measles, mumps, rocky mountain spotted fever, histoplasmosis, toxoplasmosis, chlamydia, coxsackievirus
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Acute glomerularnephritis info
**Onset of symptoms is usually 10 days from time of infection and people typically recover quickly and completely
Skin- looking for lesions, recent incisions (including body piercings)
UA shows RBCs, protein
24 hr urine shows total protein- will be increased, GFR, creatinine clearance- decreased (50mls/min)
GFR normal 90-120 mls/min. Results below 60mls/min x3 indicate CKD, below 15mls/min sign of renal failure.
Chemistries: increased BUN, creatinine
Biopsy provides a precise diagnosis of condition, assists in determining prognosis, outlines treatment
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Does chronic glomerularnephritits always lead to kidney failure?
Yes
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Chronic glomerularnephritis
Diagnostics- UA shows protein, maybe some RBCs, specific gravity is contant and is normal in appearance (unless a UTI is present), but there is a decreased amount of urine.
GFR is low, creatinine and BUN is ↑, and abnormal electrolyte levels (Na+ retention), high phosphorus, low calcium
Acidosis develops from loss of bicarb, however, there may be a decrease in CO2 levels as patient breathes more rapidly to compensate for acidosis.
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Nephrotic syndrome
Cause is usually identified by renal biopsy
Cholesterol lowering agents may lower liver enzymes
ACE inhibitors decrease protein loss in ursine
Heparin may reduce urine protein, and reduce renal insufficiency.
Mild diuretics and sodium restriction to control edema and hypertension
Maintain good renal blood flow to avoid ARF.
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Leading causes of end stage renal disease, in order
1. Diabetes
2. Hypertension
3. Glomerularnephritis
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Acute renal failure
ARF: rapid decrease in kidney function, leading to the collection of metabolic wastes in the body.
Many factors contribute to renal insults, but the acute failure may be reversible with prompt intervention.
Any of the causes (reduced blood flow, toxins, etc.) can reduce GFR, damage nephron cells, and obstruct urine flow.
Prerenal: conditions that reduce blood flow to the kidneys
Intrarenal/intrinsic renal: damage to the glomeruli, interstitial tissue or tubules
Postrenal: obstruction of urine flow
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What are the phases of acute renal failure?
Onset: begins with precipitating event, lasts hours to days. Gradual accumulation of nitrogenous wastes- creat, BUN
Oliguric phase: UOP of 100-400 mL/24hrs and does not respond to fluid challenges or diuretics, lasting 1-3 wks. ↑ creat, BUN, hyperkalemia, bicarb ↓ (metabolic acidosis), etc.
Diuretic phase: sudden onset 2-6 wk after oliguric stage, urine increases rapidly over a period of several days. Electrolyte losses typically precede clearance of nitrogenous wastes (lytes stabilize before BUN), later phases, BUN starts to fall and continues to fall until the level reaches normal limits or reaches a plateau. Normal renal tubular function is re-established.
Recovery phase: patient begins to return to normal levels of activity, complete recovery may take up to 12 months. Patient functions at a lower energy levels than prior to illness. Residual renal insufficiency may be noted through regular monitoring of renal function, function may never return to pre-illness levels, but renal function sufficient for a long and healthy life is likely.
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What are some nephrotoxic substances?
Nephrotoxic substances: antibiotics (ampho B, rifampin, vanco, gent), chemo (methotrexate), NSAIDS (ibuprofen, toradol, naproxen), tylenol, cyclosporines, ethylene glycol, radiographic contrast dye, pesticides, arsenic, lead
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True or false
| Hemofiltration is better tolerated by the critically ill because of the slower fluid and electrolyte shifts.
True
156
CHronic kidney disease changes in lab values
Creatinine is an end product of
Urea is a product of protein metabolism
Sodium- risk for hyponatremia as there are fewer healthy nephrons to reabsorb Na+, later stages, urine production decreases and sodium is not excreted, causing hypernatremia- leading to fluid overload.
Acid base changes: blood pH changes little because the remaining healthy nephrons increase their rate of acid excretion. When nephrons die, acid excretion is reduced and metabolic acidosis results.
Increased respiratory action is needed to keep blood pH normal. The resp system adjusts for the increased blood hydrogen levels (decreased pH) by increasing the rate and depth of breathing to excrete carbon dioxide through the lungs (Kussmaul). If too much carbon dioxide is “blown off” respiratory alkalosis results. These patients generally have low bicarb and need replacement.
Calcium phosphorus: complex relationship and is influenced by Vit D. Kidney excretes hormone to activate vit D, which then enhances intestinal absorption of calcium. Phosphate retention and vit D deficiency disrupt the balance. Phosphorus is excreted by the kidney, PTH controls the amount of phos in the blood. As phos levels increase in blood, calcium levels decrease. Chronically low calcium levels stimulate the parathyroid glands to produce more PTH. PTH stimulates the release of calcium reserve in the bones into the blood- resulting in bone density.
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What is the biggest symptom of systemic infection?
Fever
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Cystitis in men and women
After 73 years old men get with prostate and women over 80 changes in skin and mucous membranes from lack of estrogen
159
What kind of scan is used in pyelonephritis
Gallium scan
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Osteodystrophy and CKD
In CKD, scans may show renal osteodystophy
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Diabetes and kidney failure
Chronic high blood glucose levels cause hypertension in kidney blood vessels and excess kidney perfusion. The increased pressure damages the kidney in many ways. The blood vessels become leakier, especially in the glomerulus. This leakiness allows filtration of larger particles (including albumin and other proteins), which then form deposits in the kidney tissue and blood vessels. Blood vessels narrow, decreasing kidney oxygenation and leading to kidney cell hypoxia and death. These processes worsen over time, with scarring of glomerular blood vessels and loss of urine filtration ability, leading to kidney failure. Kidney damage is also related to hypertension for patients with DM and cardiovascular disease. Both systolic and diastolic hypertension speed the progression of diabetic nephropathy.
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Diabetic nephropathy
Nephropathy is a pathologic change in the kidney that reduces kidney function and leads to kidney failure. Diabtees is the leading cause of end stage kidney disease and kidney failure. Risk factors for nephropathy include a 10-15 year history of DM, diabetic retinopathy, poor blood glucose control, uncontrolled hypertension. Studies have shown that the onset of diabetic kidney disease may be prevented and the progression to ESKD can be delayed by maintaining optimum blood glucose control, keeping bp within normal range, and using drug therapy to protect the kidneys. Kidney disease causes progressive albumin excretion and a declining GFR. The earliest manifestation of nephropathy is microalbumineria.
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What are some drugs that protect the kidneys?
ACE inhibitors and ARBs ( angiotnesin receptor blockers)
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What is the earliest manifestation of nephropathy?
Microalbumineria
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Drugs to treat urinary tract infections
1. Sulfonamides
2. Fluoroquiolones
3. Penicillins
4. Cephalosporins
5. Antiseptics
6. Antispasmodics
7. Analgesics
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Examples of drug therapy for urinary incontince?
1. Anticholinergics
2. Spasmodics
3. Tricyclic antidepressants
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What is the main feature of nephrotic syndrome?
Proteinuria, more than 3.5 g of protein in 24 hours
168
What is urine pH?
Urine pH is 4.6-8
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What is the most common form of pkd?
The autosomal dominant form of pkd is most common
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What are key symptoms of PKD?
1. Flank pain
2. Hypertension
3. Nocturia
4. Increased abdominal girth
5. Constipation
6. Bloody or cloudy urine
7. Kidney stones
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Key symptoms of acute pyelonephritis?
1. Fever
2. Chills
3. Tachycardia, tachypnea
4. Flank pain
5. Tender CVA
6. Nausea, vomiting
7. Fatigue
8. Burning, urgency, frequency
9. Nocturia
10. Recent cystitis or UTI
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Key symptoms of chronic pyelonephritis
1. Hypertension
2. Inability to conserve sodium
3. Decreased urine concentrating ability, results in nocturia
4. Tendency to develop hyperkalemia and acidosis
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True or false
| the less common manifestations of acute GN are more likely to occur in older adults
True, circulatory congestion often is present, causing acute GN to be easily confused with CHF
174
Key symptoms of Nephrotic syndrome
1. Massive proetinuria
2. Hypoalbuminemia
3. Edema
4. Lipiduria
5. Hyperlipidemia
6. Increased coagulation
7. Reduced kidney function
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Key symptoms of renovascular disease
1. Significant difficult to control high BP
2. Sustained hyperglycemia
3. Elevated serum creatine
4. Decreased creatinine clearance
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Key symptoms of Uremia
1. Metallic taste in mouth
2. Anorexia
3. Nausea, vomiting
4. Muscle cramps
5. Uremic frost
6. Itching
7. Hiccups
8. Dyspnea
9. Muscle cramps
10. Paresthesias
