The Renal and Urologic System Flashcards
1
Q
What are the 2 parts of the urinary tract?
A
- Upper urinary tract (kidney,ureters)
2. Lower urinary tract (urinary bladder, urethra)
2
Q
Kidney functions:
Maintains osmotic pressure
A
Regulates blood concentrations of numerous ions
3
Q
Kidney functions:
Regulates volume of extra cellular fluid
A
Controlling Na and water excretion
4
Q
Kidney functions:
Helps regulate acid-base balance
A
Excreting H+ when there is excess acid, or HCO3 when there is an excess of base
5
Q
Kidney functions:
Helps regulate blood pressure
A
Regulating fluid volume/RAS system
6
Q
Kidney functions:
Endocrine function
A
- Produces erythropoietin and renin
- Responds to ANG II, aldosterone, ADH
7
Q
The kidney receives what % of the CO?
A
20%
8
Q
What are the 3 mechanisms of action that take place in the nephron?
A
- Filtration
- Reabsorption
- Secretion
9
Q
What makes up the glomerular filtration barrier?
A
- Endothelial cells
- Glomerular basement membrane
- Slit process of the podocytes
10
Q
What is the passage of urine through the urinary tract starting at kidney?
A
kidney -> renal pelvis -> ureter -> urinary bladder -> urethra
11
Q
The renal system has a storage filtration in addition to a filtration function resulting in what?
A
Exposes these organs and tissues to prolonged exposure to carcinogens resulting in cancer
12
Q
The urethra of females lies close to the vaginal and rectal openings allowing for what?
A
- relative ease of bacterial transport
but also - increased risk of urinary tract infections
13
Q
T/F The shorter urethra in females also contributes to the increased incidence of UTIs.
A
True
14
Q
What two groups comprise the majority of UTIs?
A
- Women
2. Older adults
15
Q
T/F For those living in long term health care facilities the numbers are even greater and include males
A
True
16
Q
Risk factors for urinary tract infections:
A
- Age
- Immobility (impaired bladder emptying)
- Instrumentation and urinary catheterization
- Atonic bladder (spinal cord injury; diabetic neuropathy)
- Increased sexual activity
- Spermicide use with diaphragm or condom
- Uncircumcised penis (first year of life)
- Obstruction
- Renal calculi
- Prostatic hyperplasia
- Pregnancy
- Kidney transplantation
- DM
- STD’s
17
Q
What are the bacteria most often responsible for UTI’s ?
A
fecal-associated gram-negative organisms
- E. Coli-80%
- Staphylococcus saprophyticus 5-15%
18
Q
Describe the pathogenesis of urinary tract pathogens:
A
- Adhere to the urinary tract mucosa, colonize, and cause infection
- migrate upwards through the urinary tract to the kidney (migration opposed by a urine stream)
19
Q
S&S of Urinary Tract Pathologies:
A
- Urinary frequency
- Urinary urgency
- Nocturia: night time urination
- Pain (shoulder, back, flank, suprapubic, pelvis, lower abdomen)
- Costovertebral tenderness
- Fever & Chills
20
Q
S&S of Urinary Tract Pathologies:
Dysuria -
A
Painful urination (not difficult urination)
21
Q
S&S of Urinary Tract Pathologies:
Hematuria -
A
blood in urine
22
Q
S&S of Urinary Tract Pathologies:
Pyuria -
A
Urine containing pus, excessive number of neutrophils in urine
23
Q
S&S of Urinary Tract Pathologies:
Dyspareunia -
A
Painful sexual intercourse
24
Q
UTI infection sites:
Cystitis -
A
bladder
25
UTI infection sites:
| Urethritis -
urethra
26
UTI infection sites:
| Pyelonephritis -
kidney
27
T/F All ages affected by UTI, both genders, but are most frequent in females
True
28
What is pyelonephritis?
1. Kidney infection (acute disease), often 20 to a UTI traveling “upstream”
2. Or, a chronic inflammatory disease involving the kidney parenchyma or renal pelvis
29
Most cases of pyelonephritis are complications of what?
Common bladder infections
30
Chronic pyelonephritis is defined by what?
Scarring in the calices
31
Risk factors for pyelonephritis: (8)
1. Frequent sexual activity
2. Recent UTI
3. Recent spermicide use
4. Diabetes
5. Recent incontinence
6. Immunocompromised individuals
7. Urine reflux
8. Ureter/ bladder obstruction
32
Causes of chronic pyelonephritis:
1. Chronic infection
2. Urine reflux
3. Ureter/ bladder obstruction
4. Atonic bladder (bladder doesn't fully contract)
33
Pathogenesis of pyelonephritis?
Scarring resulting in deformity of the calices (abnormal movement of urine)
34
T/F pyelonephritis is responsible for upwards of 25% of cases of end stage renal disease
True, require dialysis & transplantation
35
Symptoms of acute pyelonephritis:
* Back pain or flank pain
* Fever (usually present) or chills
* Feeling sick (malaise)
* Nausea and vomiting
* Confusion (especially in the elderly)
36
Urine changes caused by acute pyelonephritis:
Blood in the urine (hematuria)
Cloudy or foul-smelling urine
Painful urination
Increased frequency or urgency of urination
37
What group is at an increased risk for UTIs?
Geriatric patients
38
Presence of UTI increases risk for what?
Sepsis or infection elsewhere
39
What is the PT role with UTIs?
Recognizing the risk factors and presentation of UTIs
40
T/F UTI may limit participation in rehabilitation
True
41
Implications for PT with patient with UTI?
- Be aware of N&V
- temp > 102.0
- change in mental status
- unexplained or insidious onset of back or shoulder pain
- Personal hygiene of patient
42
Therapists role in helping to manage renal/urinary tract disorders:
1. Management of urinary incontinence
- Pelvic floor Physical Therapy: improve the strength and function of pelvic floor muscles and alleviate pain, weakness and dysfunction in
2. Reconditioning patients who are on dialysis and/or post kidney transplant
3. Infection control in the context of urinary catheters
43
Problem list secondary to kidney disease? (12)
1. Cognitive problems
2. Increased cardiac risk
3. Anemia
4. Electrolyte imbalance
5. Hypovolemia
6. Hypervolemia
7. Poor blood pressure control
8. Reduced urine output
9. Improper blood pH
10. Impaired drug metabolism
11. Impaired muscle function
12. Osteoporosis
44
What is glomerular filtration rate (GFR)?
- Direct measure or an estimation of the rate (volume/unit) at which materials in the blood are filtered out by the kidneys.
- An assessment of the functionality of the kidneys
45
What is a normal GFR?
> 90 ml/min/1.73m2
46
How do you determine GFR?
- Assess clearance of exogenous filtration markers (e.g. inulin and iohexol)
- Inject the compound into the blood and monitor its disappearance from the blood and appearance in the urine
47
T/F Determining GFR is a complex procedure and generally not routinely performed
True
48
GFR can be estimated based on what?
1. blood creatinine test
2. the patient’s age
3. body size
4. gender
4. race
49
What will happen to serum creatine and urea levels in presence of kidney dysfunction?
Increase
50
Laboratory tests for Assessing Kidney Function:
| Blood Urea Nitrogen (BUN) -
serum BUN level rises as kidney function worsens (in blood levels)
51
Laboratory tests for Assessing Kidney Function:
| Urine Albumin -
Increasing amounts of albumin in the urine can be a sign of kidney disease.
52
What is acute renal failure (ARF)?
An abrupt decrease in renal function sufficient enough to result in retention of nitrogenous waste and disrupt fluid and electrolyte homeostasis
53
Diagnosing ARF:
| Serum Creatinine levels -
(↑)
54
Diagnosing ARF:
| Urine output -
oliguria - low urine output
| Anuria - absence of urine output
55
Diagnosing ARF:
| Lab results -
- hyperkalaemia
- acidaemia
- hypocalcaemia
- hyperphosphataemia
56
Diagnosing ARF:
| Clinical findings -
- fluid overload
- altered mental status
- nausea
- anorexia
- pericarditis
57
Drugs and toxins cause renal failure in what ways?
1. Decreased renal perfusion (NSAIDs, ACE Inhibitors, contrast media, anti-rejection drugs)
2. Direct tubular injury
3. Intratubular obstruction (ethylene glycol)
4. Immunological–inflammatory (Penicillin, aspirin, NSAIDs)
58
PT interventions for ARF?
Recondition patients
Gait appropriate
Balance
59
What is chronic kidney disease (CKD)?
- gradual loss of kidney function over time.
| - Persistent proteinuria (protein in the urine) means CKD is present
60
T/F Early detection can slow CKD progression
True
61
What groups of people are at greatest risk for CKD?
African Americans, Hispanics, Pacific Islanders, American Indians and seniors
62
Causes of CKD?
1. DM
2. HTN (causes CKD and vice versa)
3. Glomerulonephritis
4. Inherited diseases, such as polycystic kidney disease
5. Anatomic anomalies
6. Autoimmune disorders (lupus)
7. Obstructions (kidney stones, tumors, enlarged prostate)
8. Repeated UTIs
63
```
Stages of Kidney Failure: GFR numbers
1 -
2 -
3a -
3b -
4 -
5 -
```
```
1 - Mild >90
2 - 60-90
3a - Moderate 45-59
3b - 30-44
4 - 15-29
5 - Severe/kidney failure <15
```
64
Stages of Kidney Failure:
| Stage 1:
- Gradual onset of symptoms
- Possibly reversible
- Microalbuminia
- Elevated BUN and creatinine
65
Stages of Kidney Failure:
| Stage 2-4:
- Progressive kidney damage
- Progressive increase in urine albumin levels
- Azotemia: Accumulation of nitrogen containing waste products (urea, creatinine) in the blood
66
Stages of Kidney Failure:
| Stage 5:
End stage renal disease (ESRD)
- Loss or nearly complete loss of kidney function
- Uremia: an excess of amino acid and protein metabolism end products, such as urea and creatinine, in the blood that would be normally excreted in the urine.
- Kidneys unable to excrete toxins, maintain pH, fluid or electrolyte balance
- Transplantation or dialysis
67
Clinical manifestations of stage 5 (ESRD) CKD: (6)
1. Anemia - Loss of erythropoietin, GI bleeds
2. CV - Increased presence of CV risk factors including diabetes, HTN, CAD, CHF
- Volume overload
3. GI - N&V, anorexia, gastritis, malnutrition
4. MS - Renal osteodystrophy-Increased bone resorption
- Myopathy (proximal muscle weakness)
5. Neurologic - (when GFR < 10) Uremic encephalopathy (memory loss) inability to concentrate, perceptual errors, decreased alertness
6. Hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis
68
What is hemodialysis for CKD?
- Removes blood from the body and sends it across a semipermeable membrane and dialysate
- pressure gradient filter favors the removal of harmful substances
- blood is then returned to the body
69
How often does CKD patient receive hemodialysis?
3 treatment sessions/week of 3-4 hrs. each
70
What is an atriovenous graft (AVG)?
Hemodialysis requires vascular access so an artery and a vein are directly connected to each other
71
What measures the dialysis adequacy?
- Urea reduction ratio (URR)
| - Each treatment should reduce your urea level (also called BUN or blood urea nitrogen) by at least 65%
72
What is peritoneal dialysis?
- continuous ambulatory peritoneal dialysis
- A sterile solution is run through a tube into the peritoneal cavity.
- Exchange occurs between this dialyzing solution and the vasculature of the peritoneal cavity
73
Is peritoneal dialysis more or less efficient?
Less
74
Repeated abdominal cavity refilling of peritoneal dialysis occurs how often?
4-5 X daily
75
Fewer or less adverse effects of peritoneal dialysis compared to hemodialysis?
Fewer
76
T/F Access of peritoneal dialysis favors infection.
True
77
Describe the diet prescribed to patient with CKD on dialysis:
keep the levels of electrolytes, minerals, and fluid in your body balanced:
1. Patient fluid intake is limited (
2. Patient intake of salt, potassium, phosphorous, and other electrolytes is limited
78
Describe the progression of the protein diet of patient with CKD on dialysis:
Initially they eat a low-protein diet then progress to a higher-protein diet
79
Adverse effects of dialysis:
1. Fluid shifts
2. Depression/oscillation mood status
3. Increased risk of infection (immunosuppressed, openings in skin)
4. Malnutrition, anorexia, loss of lean body mass
5. Progressively increasing osmotic concentrations as time since dialysis lengthens
80
T/F Kidney transplants done by matching tissue type and blood type
True
81
What is the most common cause of CKD?
Diabetic nephropathy (DM)
82
Describe how DM causes CKD:
Hyperglycemia -> glomerular hyperfiltration -> damaging the arterioles and capillaries in the glomeruliae & thickening of the glomerular basement membrane -> intraglomerular hypertension and further destruction of glomeruli
83
Describe how HTN causes CKD:
HTN → damage to renal/glomerular blood vessels
1. Blood flow to the kidney is reduced and kidney function becomes compromised
2. O2 and nutrient delivery to the nephrons are limited, causing an ischemic situation for kidney cells
3. Damaged kidney loses ability to regulate whole body blood pressure
84
PTs must do what in regard to patients with CKD?
1. MONITOR BLOOD PRESSURE IN THEIR PATIENTS WITH DM
2. KNOW THE HbA1C LEVELS OF THEIR PATIENTS WITH DM
3. EDUCATE on DM, HTN so not to cause CKD
85
What is primary glomerular diseases?
- group of disorders characterized by pathologic alterations in normal glomerular structure and function
- independent of systemic disease processes such as diabetes and HTN
86
Primary glomerular diseases results from damage to what?
kidney’s filtering units (capillary-bowman's capsule)
87
What is the effect of Deposition of antigen/antibody complexes into some portion of the glomerulus?
→ inflammatory response → sclerotic damage
88
Describe the effect of lupus nephritis on glomerulus:
Deposition of an antigen in the glomerulus → localized antigen/antibody reaction → inflammation and sclerotic damage
89
Describe pathogenesis of primary glomerular disease causing proteinuria:
Damage to glomerular epithelial cells allows larger molecules (proteins) to escape the circulation and enter the proximal tubule resulting proteinuria
90
Describe pathogenesis of primary glomerular disease causing hematuria:
Damage to the capillary wall allows RBCs to escape and enter the proximal tubule and resulting in hematuria
91
Clinical signs of primary glomerular disease: (7)
1. Proteinuria
2. Hematuria
3. Hypertension: Kidney damage & hypervolemia
4. Decline in glomerular filtration rate [GFR]
5. Edema
6. Hypoalbuminemia: secondary to proteinuria, contributes to observed edema (decreased osmotic pressure), leads to a perceived hypovolemia by the kidney and it responds by increasing reabsorption of water (activate RAS)
7. Hypercholesterolemia secondary to proteinuria which stimulates liver production of cholesterol
92
Treatment of primary glomerular disease: (6)
1. Fluid Restriction
2. Renal hypertension: ACE inhibitors, Angiotensin Receptor Blockers
3. Edema: Diuretics
4. Hypercholesterolemia: Statins
5. Anemia: Erythropoietin
6. Immune Associated injury: Glucocorticoids, cyclosporine, cytotoxic agents
93
What are the two types of glomerular disease?
1. Nephritic
| 2. Nephrotic
94
What is the key feature of nephritic glomerular disease?
hematuria (blood in urine ) Distinguishes from nephrotic
95
What is the key feature of nephrotic glomerular disease?
protein in the urine (proteinuria) but, often, little to no blood in the urine (hematuria)
96
What is another name for kidney stones?
Renal Calculi (Urinary Stones or Nephrolithiasis)
97
What are the 3 most common urinary tract disorders?
1. UTI
2. Prostate disease
3. Kidney Stones
98
Kidney stones are classified by their location:
1. kidney (nephrolithiasis)
2. ureter (ureterolithiasis)
3. bladder
99
Kidney stones will cause what?
1. Urinary obstruction
| 2. Severe pain
100
What is the pain pattern if kidney stones?
- flank pain
| - groin pain
101
What is hydronephrosis?
- distension and dilation of the renal pelvis and calyces secondary to urine accumulation
- Spasms of ureter
- chronic kidney stones
102
Where is pain felt because of hydronephrosis?
flank (the area between the ribs and hip), lower abdomen, and groin
103
Treatment for kidney stones:
1. Watchful waiting: most stones < 5 mm ultimately pass
2. Shock wave lithotripsy (ultrasound): 5 mm < stones < 1 cm
3. Surgery: > 1 cm
- Ureteroscopy: small scope inserted into bladder and ureter and used to diagnose treat problems of urinary tract
- Percutaneous nephrolithotomy
104
Describe Percutaneous nephrolithotomy surgery treatment for kidney stones:
- Inpatient procedure to remove large stones or a large number of small stones
- Involves small incision in back
- Path to drainage system of kidney
- Once stones are located they are broken up and pieces removed
- Drain tube left in kidney
105
What is Multiple Organ Failure Syndrome (MOFS)? What are the causes?
- Progressive deterioration of organ function secondary to disease in distant organs
- Involved 2 or more organ systems
- Causes: renal failure, shock, acute brain injury, acute respiratory failure, sepsis, burns, severe necrosis, major surgery, multiple blood transfusions
106
T/F Multiple Organ Failure Syndrome (MOFS) is typically seen in the ICU
True
107
How does MOFS occur?
Exuberant activation of endogenous metabolic pathways -> systemic inflammatory response -> distant organ failure
(linked it sepsis)
108
Treatment of MOFS?
Treatment of individual organ failure
109
What muscles line the wall of the urinary bladder?
Detrusor muscles
110
What innervates the detrusor muscles?
Parasympathetic neurons
111
T/F Input to the detrusor muscles of the bladder in normally inhibited
True
112
What is the internal urethral sphincter innervated by and what type of muscle?
Smooth muscle innervated by Sympathetic neurons
113
What is the external urethral sphincter innervated by and what type of muscle?
Skeletal muscle under voluntary control
114
Describe the guarding reflex of the bladder muscles:
Induce inhibition of the parasympathetic nerves to the detrusor muscles
115
Describe micturition process:
- Coordinated activity
- Remove inhibition of detrusor muscle
- Remove stimulation of internal sphincter muscle
- Reduce tonic activity to the external sphincter
116
Stretch of the bladder initiates what reflex? Describe the reflex.
The voiding reflex:
1. Removes inhibition of the parasympathetic neurons-> cause detrusor muscles to contract rhythmically
2. Initiates an inhibition of the sympathetic nerves which deinnervate the internal urethral sphincter causing it to relax thereby allowing this sphincter to open
117
What is sensory neurogenic bladder disorder?
Disruption of sensory information to the spinal cord or CNS
118
What is Motor Paralytic Bladder disorder?
Destruction of the parasympathetic nerves to the bladder. Inability to initiate or maintain a urine stream
119
What is reflex neurogenic bladder disorder?
- Complete disruption between the sacral spinal cord and the brainstem (micturition reflex control centers)
- Acute post spinal cord injury
120
What is Autonomous neurogenic bladder disorder?
- Neurologic isolation of the bladder from the spinal sacral cord.
- Complete loss of sensory and motor input to and from the sacral spinal cord
121
What is urinary incontinence?
Involuntary loss of urine that is sufficient to be a problem and occurs most often bladder pressure exceeds sphincter resistance
122
What risk factors for urinary incontinence?
1. Age
2. Pelvic floor weakness
3. Benign prostatic hyperplasia
4. Obesity
5. XRT injury
123
What is functional incontinence?
Normal urine control but who have trouble reaching a toilet in time b/c of muscle or joint dysfunction
124
What is stress incontinence?
Loss of urine during activities that increase intra abdominal pressure i.e. coughing, lifting, laughing, Valsalva maneuver
125
What is urge incontinence?
Sudden and unexpected urge to urinate and an inability to prevent the loss of urine
126
What is overflow incontinence?
- Constant leaking of urine from a bladder that is full but unable to be emptied
- Drugs, DM, SCI
