Renal conditions and drugs Flashcards
How often do patients that need it have dialysis?
Patients receiving haemodialysis usually attend the dialysis clinic 2-3 times a week for approximately 3-5 hours each time.
Patients receiving peritoneal dialysis spend typically 1-3 hours a day draining and refilling fluid from their abdomen or have a machine do it overnight for them.
These are estimates. Each patient will require different levels of care and different prescriptions dependant on the stage of their kidney disease.
What is renal colic?
Severe pain caused by the body trying to pass a kidney stone
What is the nature and site of renal pain?
Sharp severe to extreme pain in the flank, radiating to the groin
Apart from pain, what are the other symptoms of passing kidney stones?
Nausea and vomiting
Fever
Dehydration
Tachycardia
Haematuria
Dysuria
How does infection reach the kidneys usually?
Most infections are ascending, arising from organisms in the perineal area and travelling along the continuous mucosa in the urinary tract to the bladder and then along the ureters to the kidneys.
Occasionally pyelonephritis results from a blood-borne infection
How are UTIs defined?
A urinary tract infection is defined by a combination of clinical features and the presence of bacteria in the urine. Can be defined by location e.g.
Pyelonephritis (acute and chronic infection of kidney and renal pelvis)
Cystitis
Urethritis
Epididymitis
Prostatitis
What makes UTIs so common?
Urine generally provides an excellent medium for growth of microorganisms.
What can cause UTIs?
Behaviour or anatomical changes make people vulnerable to UTI.
Bacteria need stagnant urine to proliferate.
This can be caused by:
Renal calculi (stones)
Obstruction
Prostatic hypertrophy
Diverted urinary system (catheters)
Surgery
Are men or women more prone to UTIs, why?
Women are anatomically more vulnerable to UTIs than men because of the shortness and width of the urethra, its proximity to the anus, and frequent irritation to the tissues.
The irritation may be caused by sexual activity, baths, and use of some feminine hygiene products.
Which groups of men are usually more suscepitble to UTIs, why?
Older men (over 60) with prostatic hypertrophy and urine retention frequently develop UTIs.
Because the male reproductive system shares some of the structures of the urinary system, any infection of the prostate or testes is likely to extend to the urinary tract
Which gram negative bacteria most commonly cause non-complicated, newborn and hospital acquired UTIs respectively?
Escherichia coli (or E. coli) – cause most uncomplicated cystitis and pyelonephritis cases.
Klebsiella pneumonia – notorious for causing bloodstream infections. Common in newborns.
Pseudomonas aeruginosa – cause hospital-acquired UTIs, more common in catheterised patients, this also could lead to sepsis.
How can catheters increase the chance of UTIs?
When a catheter is inserted, it could damage the mucosal layer of the urethra, which disrupts the natural barrier and allows bacterial colonization. Moreover, the catheter tube is like a highway for bacteria that makes it easier for them to enter the bladder as well as establish their biofilm colonies on its surface.
Which gram negative bacteria usually causes Catheter Acquired UTIs (CAUTIs) and why are these difficult to manage?
Proteus mirabilis (favors patients with longterm catheters) - very difficult to treat due to its ability to form biofilms and develop drug resistance.
P. aeruginosa one of the organisms most commonly responsible for infections in immuno-suppressed patients.
Which gram positive bacteria commonly cause UTIs and to which demographic and with what common complications?
Staphylococcus saprophyticus (S. saprophyticus) More common in young girls/women.
Group B Streptococcus (GBS) – more common in elderly
Aerococcus - Can move quickly through the system and cause fatal sepsis.
Enterococcus - 3rd leading cause of hospital acquired UTI’s
What are the NICE guidelines around UTIs in patients over 65 years old?
In people aged 65 years and over asymptomatic bacteriuria is common but is not associated with increased morbidity. The diagnosis of urinary tract infection is particularly difficult in elderly people, who are more likely to have asymptomatic bacteriuria as they get older. The prevalence of bacteriuria may be so high that urine culture ceases to be a diagnostic test. Elderly institutionalised patients (e.g. people in care homes) frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.
For what demographic is there the highest incidence of UTIs of any type?
Young women (Around 10– 20% of women will experience a symptomatic urinary tract infection at some time)
What commonly causes adult men to contract UTIs?
Most infections in adult men are complicated and related to abnormalities of the urinary tract, although some can occur spontaneously in otherwise healthy young men
What are the symptoms of pyelonephritis?
Dull aching pain in the lower back or flank area resulting from inflammation that stretches the renal capsule.
Systemic signs of infection are more marked in pyelonephritis.
Signs and symptoms of cystitis, if infection present in both kidneys and bladder
What is the general treatment for pyelonephritis?
Treatment includes antibiotics, analgesics and encouraging the patient to increase fluid intake
What are the common UTI signs and symptoms?
Frequent urges to urinate
Burning or itching sensation while urinating
Feeling that the bladder is full, even after urinating
Turbidity (cloudy urine)
Haematuria
Foul-smelling urine
Pressure in the lower back or lower abdomen
Malaise, or a feeling of being generally unwell
What are the signs and symptoms of urosepsis?
Previous or current S&S of UTI plus:
Flank pain
Nausea/vomiting
Extreme fatigue
Reduced urine volume or no urine
Tachypnoea/dyspnoea
Confusion or unusual anxiety levels/lowered GCS
Tachycardia
Weak pulse/hypotension
Pyrexia or low body temperature
Diaphoresis
What si the treatment for sepsis precipitated by a kidney infection?
Give three;
IV antimicrobials
Fluids
Oxygen
Take three;
Blood culture
Mid stream urine sample (or catheter sample if diverted system)
Monitor Urine output
What is urinary retention and its common causes?
Urinary retention is the inability to urinate.
Possible causes include:
Urethral stricture
Prostate enlargement
Central nervous system dysfunction
Foreign body obstruction
The usage of parasympatholytic or anticholinergic agents
Is urinary retention more common in men or women, why?
Men are affected more than women. This is most commonly due to an enlarged prostate.
What are the symptoms of acute urinary retention?
The inability tourinate
Pain—often severe—in your lowerabdomen
The urgent need to urinate
Swelling of your lower abdomen
What are the symptoms of chronic urine retention?
The inability to completely empty yourbladderwhen urinating
Frequent urination in small amounts
Difficulty starting the flow ofurine, called hesitancy
A slow urine stream
The urgent need to urinate, but with little success
Feeling the need to urinate after finishing urination
Leaking urine without any warning or urge
Lower abdominal pain or discomfort
What is the treatment for urine retention?
In the emergency department, passage of a urethral catheter to empty the bladder is often required.
The pre-hospital care is mainly supportive, (analgesia) although emergency care practitioners may be able to perform urinary catheterisation.
The cause should be detected and corrected. This may involve a medication review, investigation for prostate enlargement, ultrasound. The investigation would depend on the history.
What is a Foley catheter?
An indwelling catheter usually attached to a drainage bag with a valve that can be opened to allow urine to flow out. The Foley catheter has a small balloon that can be inflated with sterile water after it has been inserted into the bladder to secure in place. The catheter is regularly exchanged for a new one to prevent infections.
What is suprapubic catheterisation?
Suprapubic catheterisation is when a cut is made in the lower abdomen and the catheter inserted directly into the bladder. It works the same as a urethral catheter.
What are the benefits of suprapubic catheterisation?
Avoids damage to the urethra, bladder neck and external urethral sphincter
The catheter is less likely to be sat on and accidentally ‘pulled’
If a suprapubic catheter becomes blocked, urine can drain via the urethra (condition dependant)
The site of a suprapubic catheter is easier to keep clean
The procedure is easily reversed
A larger size catheter can be used suprapubically, reducing the risk of a blocked catheter.
What is Intermittent Self Catheterisation (ISC)?
Intermittent Self Catheterisation (ISC) is a technique used to empty the bladder at regular intervals, varying from several times a day to once a week, depending on fluid intake, how quickly remaining (residual) urine increases in the bladder, and whether any urine is passed urethrally. Incomplete bladder emptying can lead to incontinence, urgency, frequency and recurrent infections.
This technique is often used in patients with spinal injuries, MS, spina bifida etc.
How do kidney stones form?
When the level of insoluble salts or uric acid in the urine is high, or the urine lacks citrate (a chemical that normally inhibits the stone formation), or insufficient water is present in the kidneys to dissolve waste products, kidney stones form.
Most stones form within the kidney, but can form anywhere within the system
Where do most kidney stones originate?
Most originate in the collecting tubules or renal papillae. Then they pass into the renal pelvis where they may increase in size.
What are kidney stones formed from?
Hard insoluble crystalized minerals & salts that have formed from filtrate
What is a percutaneous nephrostomy?
This is where a thin catheter is introduced, through the back of the patient into the renal pelvis in order to draw off the build-up of urine.
It can be into one or both kidneys depending on the level of hydronephrosis.
The patient would have a bag fitted to the end of the catheter, similar to a regular urinary catheter.
This would be fitted for a period of time until the obstruction can be relieved.
These nephrostomies should not leave the patient in any pain, but pts may find it uncomfortable to sleep on their back.
It would drain and need emptying the same way a regular urethral catheter would.
What are the two types of dialysis?
Haemodialysis
Peritoneal dialysis
How does haemodialysis work?
Using one fistula access point, blood is transferred - at a low flow rate - from the body to the machine. Heparin is then added to the blood to prevent clotting, and the blood is passed into the dialyser where the waste products and toxins are removed. The cleaned blood is then returned to the body via the second fistula access point.
What access is used for haemodialysis?
An arteriovenous (AV) fistula is inserted into the patient, usually in the forearm. This provides permanent access points.
How does peritoneal dialysis work?
Peritoneal dialysis takes advantage of the peritoneal membrane surrounding the intestine being a natural semi-permeable membrane. Dialysis fluid is introduced to the abdominal cavity, where waste products transfer through the peritoneal membrane into the fluid, thus doing the work normally done by the kidneys. On draining the abdomen, the waste is removed.
What can be a specific sign of peritonitis for patients using peritoneal dialysis?
Cloudy used dialysis fluid or visible white flecks in the fluid
What are the 3 types of AKI?
Pre-renal
Renal
Post-renal
How does chronic renal failure progress?
As the number of functional nephrons decrease the filtration load is taken up by the remaining functional nephrons
As function declines the remaining nephrons must work harder to maintain homeostasis
This creates a snowball effect with an accelerating decline in renal function
Diabetic nephropathy and interstitial nephritis are examples of conditions that precipitate chronic renal failure
What are the symptoms of chronic kidney failure?
High blood pressure
Mineral Bone disease
High phosphate causes itching and bone disease
High creatinine & urea, itching, nausea, gout
Anaemia
High potassium & calcium can result in cardiac arrythmia, muscle cramps, fatigue.
