URINARY Flashcards
1
Q
Pyelonephritis
THIS IS AN UPPER URINARY TRACT INFECTION
A
Is an infection of the kidney that is characterized by infection within the renal pelvis, tubules, or interstitial tissue that may be unilateral or bilateral, may be acute or chronic.
2
Q
Pyelonephritis/UPPER URINARY TRACT INFECTIONS
A
The chronic condition leads to changes in the kidney that create atrophy and scarring of the kidney and calyceal deformity that may eventually lead to renal failure
3
Q
Pyelonephritis/ UPPER URINARY TRACT INFECTIONS
A
The actual infectious insult to the kidney may be from hematogenous seeding or urinary tract reflux, but most commonly it is an ascending infection from the bladder.
Thus, it can often be attributed to an untreated lower UTI that spreads to the upper urinary system or is introduced through instrumentation.
4
Q
UPPER URINARY TRACT INFECTIONS- ETIOLOGY AND PATHOPHYSIOLOGY
A
- E. coli (75% to 95% of cases), P. mirabilis, Klebsiella, and Pseudomonas are the most common gram-negative causative agents.
- Between 5% and 10% of cases are caused by gram-positive organisms, including Enterococcus, S. saprophyticus, and S. aureus (particularly in severe infection
5
Q
Upper Urinary Tract Infection: Diagnosis
RISK FACTORS
A
Anatomical abnormalities such as ureterovesical reflux, urinary obstruction, stress incontinence, multiple or recurrent UTIs, renal disease, kidney trauma, pregnancy, prostatic enlargement, and metabolic disorders such as diabetes mellitus. Having an indwelling urinary catheter
6
Q
Upper Urinary Tract Infection: Diagnosis
HISTORY
A
- Classic triad of fever, costovertebral angle pain, and nausea and/or vomiting
- May have shaking, chills, nausea, vomiting, unilateral flank or localized back pain over the affected kidney, fatigue, diarrhea, or S/S of sepsis
- In the older patient, altered mental status may be the initial manifestation of pyelonephritis
7
Q
Upper Urinary Tract Infection: Diagnosis
PHYSICAL
A
- General and VS (possible sepsis and/or shock)
- Abdominal Exam
- CVA Tenderness?
- May perform and pelvic/genital exam as pyelonephritis can mimic pelvic inflammatory disease
8
Q
Upper Urinary Tract Infection: Diagnosis
TESTING
A
- Urinalysis: WBC casts (reflecting the passage of neutrophils through the renal tubules)
- Urine C&S
- Blood Cultures
- CBC and BMP (renal function and electrolytes)
9
Q
Upper Urinary Tract Infection: Treatment & Ongoing Care
A
- May need hospitalization
- May need referral to Nephrology and/or Urology
- Oral antibiotics may be prescribed in mild cases of acute pyelonephritis, characterized by the absence of nausea and vomiting or signs of sepsis.
- Antibiotic choice should consider the local antibiogram and drug-resistance rates for the community and patient population in which the infection was likely acquired
10
Q
Upper Urinary Tract Infection: Treatment & Ongoing Care
A
- Titrate treatment based on urine C&S
- If undergoing outpatient treatment, the patient should be seen 48 hours later to assess responsiveness to therapy.
- A renal ultrasound, renal colic CT scan, or voiding cystourethrogram may detect structural abnormalities, renal stones, or vesicoureteral reflux—all of which predispose the patient to infection. Patients should also be monitored and treated for other conditions secondary to pyelonephritis such as hypertension, chronic infection, renal insufficiency, or renal failure.
11
Q
A
12
Q
Nephrolithiasis: Basics
DESCRIPTION
A
- Nephrolithiasis is a condition in which stones (renal calculi) originate in the kidney.
- Renal stones can occur because of obstruction, urinary stasis, infection, dehydration and urinary concentration, increased consumption of calcium or vitamin C or D, excessive excretion of uric acid, or vitamin A deficiency.
- These stones often cause acute episodes of urinary tract obstruction, infection, and severe pain.
13
Q
Nephrolithiasis: Basics
DESCRIPTION
RISK FACTORS
A
- Ages 20 to 60 years, but the incidence peaks in those ages 20 to 30 years
- Hereditary factors
- Dry, warm climates
- Sedentary lifestyle or occupation that involves exposure to high environmental temperatures.
- Calcium oxalate stones occur more often in males, whereas struvite stones are more common in females.
14
Q
A
15
Q
What is Nephrolithiasis: Diagnosis &
HISTORY?
A
- Renal Colic
- Depends on the location, size, and type of stone
- The pain may present with a referral pattern that originates in the flank or kidney area and radiates across the abdomen down into the groin, perineal area, and inner thigh.
- This colicky pain occasionally progresses to constant pain at a level that can be excruciating and intractable.
16
Q
What are some other symptoms of renal calculi?
A
include
nausea
urinary frequency
vomiting
diaphoresis
dysuria
hematuria
weakness
17
Q
What should the physical include for Nephrolithiasis (kidney stones)?
A
- General and VS (Blood pressure (as well as pulse rate and respiratory rate) may be elevated because of pain, may have fever if infection also present)
- Abdominal Exam (guarding)
- CVA Tenderness
- May perform and pelvic/genital exam to rule out other causes
18
Q
What is the lab work for nephrolithiasis?
A
19
Q
What is the treatment for nephrolithiasis?
A
- decrease the symptoms and complications arising from existing renal stones and to prevent subsequent recurrence. Initially, pain management is the priority.
- Most patients with renal calculi are treated and followed on an outpatient basis. The patient may need hospitalization for secondary complications that can occur, such as severe nausea and vomiting leading to dehydration, urinary obstruction, decreased renal function, severe bleeding, intractable pain, and significant infection.
- Prevent reoccurrence: Certain drugs help to reduce urinary excretion of stone forming substances.
- Thiazide diuretics (e.g., hydrochlorothiazide) reduce calcium excretion; allopurinol reduces uric acid production by inhibiting xanthine oxidase; and D-penicillamine aYects the excretion of cystine.
- Importantly, loop diuretics such as furosemide (Lasix) and triamterene increase calciuria and typically worsen renal stone formation. REFERRAL: Urologist and/or Nephrologist for stone removal
20
Q
A
21
Q
What is acute kidney injury?
A
Acute renal failure, is the sudden and rapid deterioration of renal function resulting in the
inability to maintain acid-base, fluid, and electrolyte balance and accumulation of nitrogenous wastes
22
Q
What is acute kidney injury?
A
- Increase in serum creatinine (SCr) of ≥0.3 mg/dL within 48 hours; a 50% increase in SCr within 7 days
- Urine output of <0.5 mL/kg/hr for 6 to 12 hours ETIOLOGY AND PATHOPHYSIOLOGY
23
Q
What is acute kidney injury?
A
- Prerenal (reduced renal perfusion, typically reversible):
- Decreased renal perfusion (often due to hypovolemia) leads to a decrease in glomerular filtration rate (GFR). Caused by hypotension, volume depletion, renal artery stenosis, if decreased perfusion is prolonged or severe, it can progress to ischemic acute tubular necrosis (ATN)
- Intrarenal (intrinsic kidney injury, often from prolonged or severe renal hypoperfusion)
24
Q
What is acute kidney injury?
A
- ATN—from prolonged prerenal azotemia, radiographic contrast material, aminoglycosides, nonsteroidal anti-inflammatory drugs (NSAIDs), or other nephrotoxic substance. Glomerulonephritis (GN). Acute interstitial nephritis (AIN; drug induced)
- Postrenal (obstruction of the collecting system)
- Extrinsic compression (e.g., benign prostatic
hypertrophy [BPH], carcinoma, pregnancy); intrinsic obstruction (e.g., calculus) decreased function (e.g., neurogenic bladder), leading to obstruction of the urinary collection system.
25
What are some risk factors for acute kidney injury?
* Hypovolemia
* Chronic kidney disease (CKD); comorbid conditions; advanced age; radiocontrast material exposure (intravascular)
* Medications that impair autoregulation of GFR (NSAIDs, angiotensin converting enzyme inhibitors [ACEI], angiotensin II receptor blockers [ARB], * Nephrotoxic medications (aminoglycosides)
26
Acute kidney injury risk factors?
* Hypovolemia
* Chronic kidney disease (CKD); comorbid conditions; advanced age; radiocontrast material exposure (intravascular)
* Medications that impair autoregulation of GFR (NSAIDs, angiotensin converting enzyme inhibitors [ACEI], angiotensin II receptor blockers [ARB], * Nephrotoxic medications (aminoglycosides)
27
History & Physical for acute kidney injury?
* Varies; try and determine the underlying cause of AKI
28
Acute Kidney Injury Testing
* CBC, BMP, Mag, Phos, Uric Acid:
* Common lab abnormalities in AKI
* Increased: potassium, phosphate, magnesium, uric acid
* Decreased: hemoglobin, calcium
* Compare renal function tests to baseline
* Urinalysis
* Consider CK (rhabdomyolysis) and immunologic testing (if GN or vasculitis suspected)
* KUB, Renal US, or CT scan may be indicated depending on cause
29
What is the treatment and ongoing care for acute kidney injury?
* Identify and treat underlying cause
* May need to be hospitalized due to life-threatening complications: hyperkalemia, metabolic acidosis, volume overload, and advanced uremia
* In cases of prerenal and postrenal AKI, short duration of AKI correlates with good rates of recovery.
* Intrarenal etiologies take longer to recover.
* Even with complete recovery from AKI, aYected patients are at higher subsequent risk of developing CKD and ESRD
30
When do you refer for acute kidney injury?
Nephrology and/or Urology depending on underlying cause and response to treatment
31
What is the pt. education for acute kidney injury?
32
What is the definition of chronic kidney disease?
* CKD is characterized by a progressive loss of functional nephrons, eventually leading to end-stage renal disease (ESRD). As the functional reserve of the kidneys is lost, signs and symptoms of renal failure appear.
* The U.S. Preventive Services Task Force has concluded the evidence is insuYicient to recommend screening asymptomatic adults for CKD.
* Although no universally agreed-on definition of CKD exists, GFR and proteinuria are often used to stratify CKD patients by disease severity.
33
What are the stages of CKD?
* Stage 1 disease is characterized by persistent albuminuria with a normal GFR greater than 90 mL/min per 1.73 m2 of body surface area (BSA).
* Stage 2 disease is characterized by albuminuria with a GFR between 60 and 89 mL/min per 1.73 m2 of BSA.
* Stage 3 disease is defined as a GFR between 30 and 59 mL/min per 1.73 m2 of BSA.
* Stage 4 disease is defined as a GFR between 15 and 29 mL/min/1.73 m2 of BSA.
* Stage 5 disease is ESRD, defined as a GFR less than 15 mL/min/1.73 m2 of BSA.
34
Stage 1- CKD?
Disease is characterized by persistent albuminuria with a normal GFR greater than 90 mL/min per 1.73 m2 of body surface area (BSA).
35
Stage 2- CKD?
Disease is characterized by albuminuria with a GFR between 60 and 89 mL/min per 1.73 m2 of BSA
36
Stage 3- CKD?
Disease is defined as a GFR between 30 and 59 mL/min per 1.73 m2 of BSA.
37
Stage 4- CKD?
Disease is defined as a GFR between 15 and 29 mL/min/1.73 m2 of BSA.
38
Stage 5 disease is end stage renal disease?
Defined as a GFR less than 15 mL/min/1.73 m2 of BSA
39
What are the risk factors for chronic kidney disease?
-Type 1 or 2 diabetes mellitus (DM) (most common), -age >60 years
- low socioeconomic status
- obesity
- smoking
- drug use
- chronic infection
- cardiovascular disease (CVD)
-prior kidney transplant
- BPH
-autoimmune disease
-vasculitis
-connective tissue disease,
40
What are some examples of nephrotoxic drugs?
nephrotoxic drugs
-(NSAIDS
-lithium
-sulfonamide
-aminoglycosides
-vancomycin
-allopurinol
-loop diuretics
- chemotherapeutic agents
41
What do these medications cause?
nephrotoxic drugs
-(NSAIDS
-lithium
-sulfonamide
-aminoglycosides
-vancomycin
-allopurinol
-loop diuretics
- chemotherapeutic agent
congenital anomalies, obstructive uropathy, reflux nephropathy
42
What do you see on physical exam for chronic kidney disease?
Patients with CKD stages 1 to 3 are usually asymptomatic;
- oliguria, nocturia, polyuria, change in urinary frequency, bone disease, edema, HTN, dyspnea, fatigue, depression, weakness, pruritus, ecchymosis, anorexia, nausea, vomiting, hyperlipidemia, claudication, erectile dysfunction, decreased libido, amenorrhea
43
True or False Patients with CKD stages 1 to 3 are usually asymptomatic
True
44
What is the testing for CKD?
CMP (Renal Function Tests, Electrolytes, Albumin) CBC, Parathyroid Hormones, Vitamin D,
UA, Microalbumin
Imaging and/or Biopsy may be indicated
45
What is the treatment & ongoing care for Chronic Kidney Disease?
Manage Comorbid Conditions, Risk Factors & Complications of CKD:
* Hyperlipidemia
* Glycemia Control
* HTN
* Secondary Hyperparathyroidism
* Hyperphosphatemia
* Hyperkalemia
* Anemia
* Fluid/Electrolyte Imbalances
* Metabolic Acidosis
* Uremia
46
What is Kerendia (finerenone)?
Is a non-steroidal mineralocorticoid receptor antagonist (MRA)
-Reduces the risk of sustained eGFR decline
-End stage kidney disease
-cardiovascular death
- non-fatal myocardial infarction, and hospitalization for heart failure in adult patients with chronic kidney disease(CKD) associated with type 2 diabetes (T2D).
47
Chronic Kidney Disease?
48
49
Glomerulonephritis: Basics
DESCRIPTION?
* Acute glomerulonephritis (GN) is an inflammatory or immune-mediated process involving the glomerulus of the kidney, resulting in a clinical syndrome consisting of sudden-onset of hematuria, proteinuria, and renal insuYiciency.
* Acute GN may be caused by primary glomerular disease or secondary to systemic disease.
* Clinical severity ranges from self-limited asymptomatic microscopic or gross hematuria to a rapidly progressive loss of kidney function over days to weeks.
50
What is acute glomerulonephritis?
Is an inflammatory or immune-mediated process involving the glomerulus of the kidney, resulting in a clinical syndrome consisting of sudden-onset of hematuria, proteinuria, and renal insuYiciency.
51
* Acute GN may be caused by?
primary glomerular disease or secondary to systemic disease.
