Renal Disorders

Question 1

Pyelonephritis: Upper UTI, Kidney Infection

Answer 1

– Inflammation of the kidneys

– Etiology: Ascending infection or bloodstream infection
– Risk factors: pregnancy, recurrent lower UTIs, antibiotic resistant strain
– Inflammatory response → kidney tissue DAMAGE
– Abscesses and necrosis can develop impairing renal
function

Question 2

Pyelonephritis: Clinical Manifestations

Answer 2

Sudden onset:
* Fever
* Chills
* CVA tenderness

Lower UTI symptoms (dysuria)

Hematuria may occur

Accompanying symptoms:
* N/V
* Anorexia

Question 3

Pyelonephritis: Treatment

Answer 3

Antibiotics: trimethoprim/sulfamethoxazole [Bactrim], ciprofloxacin, nitrofurantoin [Macrobid]

Question 4

Pyelonephritis: Complications

Answer 4

Complication: urosepsis
– More likely in elderly
– Severe systemic response
– High mortality rates

Question 5

Nephrolithiasis/renal obstruction Locations

Answer 5

– Renal Pelvis
– Ureter
– Bladder or Pelvis

– Blockages in any point of the
‘plumbing’ system prevents the flow
of the liquid causing the system to
back up

Question 6

Obstruction Causes

Answer 6

Renal Pelvis: Renal calculi (stones)

Ureter: Renal calculi, preganancy, tumors

Bladder and Urethra: Bladder cancer, nerogenic bladder, prostatic hyperplasia, prostate cancer, urethral strictures

Question 7

Complication of obstruction

Answer 7

Stasis of urine flow

Back-up presssure
-Hydroureter
-Hydronephrosis
-Postrenal acute kidney injury

Question 8

Manifestations of Acute Obstruction

Answer 8

Depend on the
* Site
* Cause (ex., kidney stones, prostate problems)
* Speed of onset

Which factor primarily
determines severity of pain?

Question 9

Nephrolithiasis
Definition, size, shape

Answer 9

Definition: Renal calculi or “kidney stones”
-clumps of crystals in the urinary tract
-most common cause of renal obstruction

Size: small as a grain of sand

Shape: may be smooth or jagged

Question 10

Nephrolithiasis: Pathogenesis

Answer 10

Urine is a solution of solvent (water) and
solutes (particles)

Problem: Super-saturation with a solute
– Crystals begin forming in the NEPHRON

Question 11

Crystal formation is enhanced by:

Answer 11

– PH changes: example: UTI
– Excessive concentration of insoluble salts in the urine (dehydration, bone disease, gout, renal disease)
– Urinary Stasis - immobility/sedentary lifestyle

Question 12

Nephrolithiasis: Risk Factors

Answer 12

– Sex: Men (for now)
– Age: 20s – 30s
– Race: white
– Family history
– Congenital defect
– Weather?
– Obesity

Question 13

Types of kidney stones

Answer 13

-Calcium oxalate
-Calcium phosphate
-Struvite (staghorns)
-Uric acid

Question 14

Calcium oxalates/Calcium phosphate kidney stone
-Incidence and specific risks

Answer 14

Incidence: 70-80%

Specific risks: family history, idiopathic
-High calcemia
-High oxaluria

Question 15

Struvite kidney stone
-Incidence and specific risks

Answer 15

Incidence: 15%

Specific risks: Urinanry tract infection

Question 16

Uric acid kidney stone
-Incidence and specific risks

Answer 16

Incidence: 7%

Specific risks: gout

Question 17

Nephrolithiasis: Clinical Manifestations (Pain)

Answer 17

Pain of Acute Renal Colic:
– location – “flank”
– radiation – “lower abd and groin”
– spasms – “colicky” last 20-60 minutes
– intermittent - ”ureter spasms”
– sharp - “calculi scrape the ureter wall”

Question 18

Nephrolithiasis: Pharmacotherapy

Answer 18

Acute Pain:
-Morphine
-IV fluids

Preventive meds:
* Calcium = thiazide diuretics
* Struvite = antibiotics
* Urate = allopurinol (covered in gout lecture)

Question 19

Nephrolithiasis: Clinical Manifestations (symptoms)

Answer 19

Accompanying symptoms:
– N/V
– Dysuria
– Chills, Fever (ONLY if infection is present)
– Hematuria
– Foul smelling urine
– Diaphoresis

Question 20

Urologic Cancers: Kidney
-Risk factors

Answer 20

Risk factors:
– Smoking
– Obesity
– Age
– Male
– Genetics

– Prognosis depends on metastasis
-Renal Cell Carcinoma (85%)

Question 21

Renal Cell Carcinoma: Clinical manifestations &
Treatment

Answer 21

Early manifestations: none

Late manifestations:
– CVA tenderness
– Hematuria
– Possible palpable abdominal mass

Metastasis usually occurs to bone or lung

Usually resistant to chemo but surgery to remove kidney likely

Question 22

Urologic Cancers: Bladder

Answer 22

– Risk factors:
– Smoking*
– Male
– Occupations with exposure to toxins
– Low fluid intake

Fourth most common cancer in men
Urothelial carcinoma (>90%)

Question 23

Bladder Cancer: Clinical Manifestations & Treatment

Answer 23

Early symptoms:
– Hematuria

Later symptoms:
– Frequency
– Urgency
– Dysuria

Chemotherapy (depends on the stage!)
– Stage 1 = Intravesical chemo
– Advanced stages = Systemic chemo

Question 24

BCG Vaccine: Intravesical Therapy
Indication and MOA

Answer 24

For early stage bladder cancer
– Given weekly for 6-12 weeks
– MOA: stimulates inflammatory response in the bladder
(goal is for immune system to recognize cancerous cells
and attack)

Question 25

BCG Vaccine: Intravesical Therapy
Adverse Effects and Patient Education

Answer 25

Adverse effects: bladder irritation, systemic infection

– Patient instructions:
1. Empty bladder
2. Instill BCG vaccine into the bladder [dwell time 2
hours]
3. Change position q 15 minutes
– Disinfect urine for 6 hours post treatment; watch for
infection

Question 26

Glomerulonephritis: Definition

Answer 26

Definition: A variety of conditions that cause inflammation of glomeruli

Can be focal or diffuse

3rd leading cause of kidney failure in the U.S.

Primarily an IMMUNE process

Question 27

Glomerulonephritis: Where does the damage occur?

Answer 27

Glomerulus
– Delicate network of arterioles within the Bowman’s capsule

Tubules
– Massive consumer of oxygen

Question 28

3 capillary membrane layers of the glomerulus

Answer 28

1. Endothelium
2. Basement membrane
3. Podocytes (special epithelial cells)

Question 29

Type II vs. Type III

Answer 29

Type II and Type III both have immune complexes, but they are different because:

– Type II- reactions occur on the cell surface and result in direct cell death or malfunction

– Type III- immune complexes are deposited into tissues and the resulting inflammation destroys the tissue

Question 30

Etiology of Glomerulonephritis

Answer 30

Two types of injury:
1. Antibodies attach to antigens of the glomerular basement membrane (“anti-GBM antibodies”) - 5%
2. Antibodies react with circulating antigens and are deposited as immune complexes in the GBM – 90%

BOTH forms have this in common:
– Accumulation of antigens, antibodies, and complement
– Complement activation results in tissue injury

Question 31

Acute Glomerulonephritis
-Manifestations

Answer 31

Abrupt sudden onset
Manifestations: HARP
–(H)ematuria
-(A)zotemia
–(R)etention: sodium & water [oliguria] (hypertension, edema)
– (P)roteinuria

Question 32

Acute Glomerulonephritis: Triggers

Answer 32

Post-Infectious
– Poststreptococcal infection
– Nonstreptococcal infection
– Bacterial, viral, parasitic

Primary Disease
– Berger disease

Multisystem Disease
– Goodpasture syndrome, systemic lupus
erythematosus (SLE), vasculitis

Question 33

Chronic Glomerulonephritis

Answer 33

– Long term inflammation of the glomerulus –> scar tissue

– Clinical Manifestations like presentation of acute
glomerulonephritis

Prognosis
– Slow progressive destruction –> ESRD

Question 34

Nephrotic Syndrome

Answer 34

Definition:
– The glomerulus is too permeable to plasma proteins
– Elimination of >3 grams of protein per day

Etiology:
– Glomerulonephritis
– Diabetes mellitus

Question 35

Nephrotic Syndrome: Pathogenesis

Answer 35

1. Increased glomerular permeability
2. Proteinuria
3. Hypo-albuminemia

Question 36

Nephrotic Syndrome: Clinical Manifestations

Answer 36

Edema
Hypertension
Liver Problems
–Hyperlipidemia
–Hypercoagulation
–Loss of antithrombin III and plasminogen

Question 37

Glomerulopathy: Diabetes & Hypertension Complications

Answer 37

Diabetic Nephropathy
– Major complication
– Gross thickening of the GBM
– Ultimately leading to –> ESRD

Hypertensive Glomerular Disease
– Decreased renal perfusion –> sclerotic glomerular changes

Question 38

Glomerulopathy: Manifestations

Answer 38

Hematuria
Oliguria
Fluid retention
Increased BUN/Cr ratio
Proteinuria
Low albumin [hypoproteinemia]