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Exam 6 – Renal / Urinary

KIDNEY AND URINARY SYSTEMS


FUNCTIONS:
• ADH – decreased water intake = increased osmolality, this stimulates release of ADH that acts on kidney to increase
reabsorption of water and return osmolality to normal.
• Osmolality – degree of dilution or concentration, Serum normal = 250 – 300 mOsm/kg, Urine normal = 250 – 900
mOsm/kg/24h
• Osmolarity – ratio of solute to water, minute changes in the serum osmolarity causes conscious desire to drink and
conserve water by the kidneys.
• Water regulation – regulates amount of water excreted; high intake = large amount excreted, low intake = less amount
excreted; daily weights are most reliable way of determining overall fluid status – 1lb = 500ml of fluid
• Regulation of electrolyte excretion – amount excreted = amount ingested; aldosterone regulates Na and K
– RAAS: renin angiotensin aldosterone system
– ↓ in BP / renal perfusion / ↓ salt → RENIN release from kidneys and ANGIOTENSINOGEN release from the liver,
renin converts angiotensinogen into ANGIOTENSIN I → angiotensin 1 is converted by lungs (ACE)to ANGIOTENSIN II
→ ALDOSTERONE secretion (reabsorb Na and excrete K), ADH secretion (reabsorb H2O), vasoconstriction
• Regulation of acid/base balance – normal pH = 7.35 – 7.45; reabsorb bicarb and excrete acid in the urine
• Renal clearance – ability of kidneys to clear solutes from plasma; measure creatinine clearance (24 hr urine collection) =
good measure of GFR
• GFR – amount of plasma filtered through the glomeruli per unit of time; BEST TEST OF KIDNEY FX; Norm = > 90
• Excretion of waste products – Urea (protein metabolism, Uric Acid (purine metabolism), Creatinine (waste product of
muscle), phosphates, sulfates, and drug metabolites.
• Erythropoietin – RBC production
• Activates vitamin D
• Secretes prostaglandins – vasodilation, maintain renal blood flow
• Controls BP

GERONTOLOGIC CONSIDERATIONS:
• Older adults may intentionally limit fluids to decrease frequency or incontinence
• Diminished thirst, need reminding to drink, increased dehydration. More prone to developing hypernatremia and fluid
volume deficit.
• Incomplete emptying of bladder, urinary stasis, decreased nerve innervations
• Decreased GFR
• Decreased drug clearance = increased drug–drug interactions

URINE FORMATION – 3 step process


• Glomerulus
– Filtration-Efficient filtration is dependent on adequate blood flow-this maintains a consistent pressure throughout
the glomerulus.
– H2O, electrolytes, glucose, creatinine and other substances are filtered through the glomerulus.
• Tubule
– Reabsorption-different amounts of these substances are selectively reabsorbed by the renal tubule into the blood.
• Most reabsorption occurs in the proximal tubule-but it does take place along the entire tubule.
• Amino acids & glucose are not excreted-they are reabsorbed at the level of the glomerulus.
• Proteinuria-not normal finding. Low molecular wt proteins may excrete out such as albumin.
– Secretion-or excreted in the urine.
• Filtrate becomes concentrated in the distal tubule & collecting ducts-becomes urine through hormonal
influence-enters renal pelvis.
ASSESSMENT HISTORY
• Heart failure, HTN, DM, autoimmune diseases, recent strep infection
• Bladder infections – fever, chills, pain
• Kidney stones
• GI symptoms – close proximity
• Prior test/procedures
• Nephrotoxic drugs and other medications
• Urinary pattern and characterisitcs – dysuria, hematuria, nocturia, oliguria (<0.5 ml/kg/hr), anuria (<50ml/24 h)
• S/S of kidney disease: hematuria, nocturia, HTN, proteinuria – foamy urine, edema, fatigue, N/V, itchiness

URINE
• SPECIFIC GRAVITY – 1.010 – 1.025, largely depends on hydration status = ↑fluid / ↓SG or ↓fluid / ↑SG
• OSMOLALITY – 250 – 900 mOsm/kg/24h
• STORAGE – bladder fullness sensation at 150-200 ml, functional capacity at 400-500 ml, neurologic changes can cause
abnormal high volumes up to 2,000 ml. Normal storage period is 2 -4 hours during day and 6-8 hr at night. Residual <50 ml
in middle age adults and < 50-100 ml in older adults.
• COLOR
RENAL FUNCTION TESTS
• SPECIFIC GRAVITY – 1.010 – 1.025, largely depends on hydration status = ↑fluid / ↓SG or ↓fluid / ↑SG
• OSMOLALITY – 250 – 900 mOsm/kg/24h
• 24 HR URINE – creatinine clearance, 52 – 146 depending on age and sex (decreases with age, females slightly lower)
• BLOOD SERUM TESTS:
– Creatinine-effectiveness of renal function (0.6-1.2)
– BUN-affected by protein intake, tissue breakdown & fluid volume. (7-18) (patients >60 y = 8-20)
– BUN-Creat ratio - hydration status. hypovolemia=increase (10:1)
• ULTRASONAGRAPHY – bladder scan: volume; kidneys: size, structure, obstructions, full bladder before procedure
• CT / MRI – relaxation techniques/anxiety management, MRI check list – no metal objects
• NUCLEAR SCANS – radioactive isotope injected through blood vessels of kidneys, scan provides info about kidney function,
GFR, drink plenty of fluids after to flush from system
• KUB xray – kidneys, ureters, bladder; size, shape, position, no specific prep
• IV UROGRAPHY / IV PYELOGRAM – contrast dye, outlines renal system/structural visualization, identifies abnormalities and
lesions, contrast dye prep: check allergies to iodine, shellfish, seafood, notify radiologist, health hx – meds/disease inc. risk,
check kidney function, tell pt they may experience temp feeling of warmth, flushing and have fishy flavor in mouth, post
procedure – maintain fluids, monitor for allergic reaction, I & O
• RETROGRAD PYELOGRAPHY – catheters into ureters through cystoscope and injects contrast agent, done if pts allergic to IV
contrast
• CYSTOGRAPHY – catheter into bladder and injects contrast agent to outline bladder wall, used to evaluate vesicoureteral
reflux and bladder injury
• RENAL ANGIOGRAPHY, ANGIOGRAM, ARTERIOGRAM – gives images of renal arteris, evaluates blood flow, differentiates
renal cysts from tumors, preop procedure for renal transplant.
– Laxative for better visualization, mark pulse site, VS, check sites for bleeding, hematoma, color and temp of
extremity, cold compress to site for edema/pain.
– Complications: hematoma, arterial thrombosis, altered renal function
• CYSTOSCOPIC EXAM - go through the urethra or make a small incision to visualize the urethra and bladder. After exam:
warm bath to relax pelvic muscle, Tylenol, blood in urine is common and clears up, low risk of infection but minimized with
drinking fluids. Notify physician if chills, shaking, cloudy/foul smelling urine, burning more than 2 days, blood in urine more
than 2-3 days, or difficulty emptying bladder.
• BIOPSIES – preop coag studies, NPO 6 – 8 hrs before, urine specimen; intra-op: breathe in and hold breath while needle is
inserted, sandbag under abd in prone position; post-op: IV fluids to clear kidneys and prevent clots, hematuria that clears in
24-48 hr
URINARY DISORDERS

FACTORS CONTRIBUTING TO UTI


• Function of glycosaminoglycan (GAG)-hydrophilic protein
– Attracts water molecules-forms water barrier-defensive layer between the bladder and urine
– (Cyclamate, saccharin can impair GAG)
– Normal bacterial flora of vagina and urethra, normal shedding of bladder cells-protects against bacteria
• Urethrovesical reflux-from urethra to bladder
• Ureterovesical reflux-from the bladder into the ureters
• Uropathogenic bacteria
– Most common-E-coli
– Klebsiella, proteus, pseudomonas, serratia.
ROUTES OF INFECTION
• Ascending
– Transurethral route-bacteria enters the bladder through the urethra; Women have shorter urethra
• Hematogenous
– Through the blood stream-from another infected site
• Direct extension
– Fistula from the intestinal tract
ASSESSMENT
• Pain, burning upon urination, frequency, nocturia, incontinence, hematuria
• About half are asymptomatic
• Association of symptoms with sexual intercourse and personal hygiene
• Gerontologic considerations-most common fatigue and MS changes.
• Assessment of urine, urinalysis, and urine cultures: Bacteria, sediment, WBC, RBC, + leukocyte esterase, + nitrate
• Other diagnostic tests-cystoscopy for complicated UTI’s.
INTERVENTIONS
• Personal hygiene: wipe front to back
• Medications as prescribed: antibiotics, analgesics, and antispasmodics
• Sitz bath: relieve pain and spasm
• Increased fluid intake
• Avoidance of urinary tract irritants such as coffee, tea, citrus, spices, cola, and alcohol
• Frequent voiding q 3-4 hrs.
• Patient education to prevent recurrent infection. Educate patient on how to collect clean catch urine when collecting urine.
PYELONEPHRITIS – INFLAMMATION OF RENAL PELVIS
• Acute: active infection
– Inflammation, tubular necrosis, abscess formation, temporary altered renal fxn.
– s/s=chills, fever, low back pain, flank pain, leukocytosis, bacteriuria, n/v/headache, malaise, + s/s of uti.
• Chronic: result of repeated infections
– No symptoms of infection unless acute exacerbation
– Progressive/permanent scarring resulting in renal failure
– Hypertension & Formation of kidney stones=complications of pyelo.
• Management
– Long term prophylactic abx help limit recurrence of infections and renal scarring.

URINARY INCONTINENCE
• An under diagnosed and underreported problem that can have significant impact on the quality of life and decrease
independence, which may lead to compromise of the upper urinary system. (WHY under diagnosed?)
• Urinary incontinence is not a normal consequence of aging

TYPES OF URINARY INCONTINENCE


• Stress-cough, laugh, sneeze, position change
– Weak pelvic muscles
• Urge-strong urge to void that can’t be stopped
– Overactive detrusor muscle + increased bladder pressure
• Reflex-involuntary loss of moderate amount of urine-usually without warning.
– Hyperreflexia of the detrusor muscle r/t altered spinal cord activity.
• Overflow-associated with bladder over distension and frequent loss of small amounts of urine.
– R/t obstruction of urinary output or impaired detrusor muscle.
• Functional-can’t make it to bathroom b/c of physical, cognitive, social impairment
• Iatrogenic-involuntary loss of urine due to extrinsic medical factors-primarily medications.
• Mixed incontinence-several types of urinary incontinence together.
• Total incontinence-unpredictable involuntary loss of urine that does not generally respond to treatment.

ASSESSMENT: voiding history, I&O, residual urine, U/A and culture

***MANAGEMENT: behavioral 1st choice: log, fluid intake, bladder training, avoid bladder irritants, Kegels, bladder
compression, vaginal cone retention exercises, transvaginal or transrectal electrical stimulation
• Pharmacological Thearapy
• Anticholinergic/ Antispasmotics: decrease urgency
• Oxybutynin (Ditropan)
• Propantheline bromide (Pro-Banthine
• Tolterodine tartate (Detrol)
• Oxybutynin (Oxytrol) OTC Patch
• Tricyclic antidepressants: Urge
• Amitriptyline (Endep)
• Decrease bladder contractions
• Has anticholinergic effects
• Pseudoephedrine (Sudafed)
• Stress incontinence
• Estrogen therapy-controversial
• Surgical Corrections-bladder lifting, bulking.

URINARY RETENTION
• Inability of the bladder to empty completely
– Leads to overflow incontinence
• Residual urine: amount of urine left in the bladder after voiding
• Causes: age, (decreased detrusor muscle activity), diabetes, prostate enlargement, pregnancy, neurologic disorders,
medications, postoperative (anal/perineal surgeries), anesthesia.
• Assessment:
– Time, how much urine, pain, distention, suprapubic region dullness with percussion, restlessness, agitation
(urinary retention), + post void residual.
• Complications: UTI, hydronephrosis, skin breakdown, renal stones, pyelonephritis, sepsis.
• Management:
– Prevent over distention of bladder
– Treat infection and correct obstruction
– Normal pattern
– Provide privacy, natural position for urinating, assisting patient to bathroom, bedside commode.
– Triggers: stroking the abd or inner thigh, tapping above the pubic area, dipping pts hands in hot water.
– Catheter

UROLITHIASIS AND NEPHROLITHIASIS


• Calculi (stones) in the urinary tract or kidney
• Types:
– Calcium 80% ↑ calcium in urine
• Oxalate: binds calcium
• Phosphate
– Struvite 15%
• Urinary tract infections
– Uric Acid 5%
• Pathophysiology: super saturation and crystallization of substances in the urine.
• Causes: not clearly understood.
• Symptoms: Depend on location and presence of obstruction or infection
• Pain and hematuria
• Diagnosis: radiography, blood chemistries, and stone analysis; strain all urine and save stones
• Complications:
– Obstruction-blockage of the passage of urine
– Hydronephrosis: urine becomes backed up and causes distention of the kidney
***KIDNEY STONE DIETS
• Calcium phosphate
– Calcium in diet –limit is ?-no hard research-individualized
– Low protein & sodium(high levels of these increase ca+)
– Thiazide diuretic-decrease calcium loss in the urine-decreases PTH levels.
• Calcium Oxalate Stones
– Restrict spinach, beets, rhubarb, beans, nuts, tea, cola, chocolate, wheat bran
– Low sodium: sodium increases calcium in urine
• Uric Acid Stones
– Low purine: Restrict organ meats, sardines, anchovies, herring, asparagus, mushrooms, red wines
– Allopurinol (Zyloprim)
– Alkalinize urine w/ K citrate, Na Citrate, NaHCO3 TYPES OF SURGERIES / PROCEDURES
• Struvite Stones(mg ammonium phospate) • Lithotripsy: use of shock waves to crush
– Avoid high phosphate foods; Dairy, Red Meats, Whole Grains stones
o Conscious sedation, EKG
KIDNEY STONE MANAGEMENT
monitoring
• Pain Management o Assess for gross hematuria and
– Opiods (what do you want to watch for?) strain urine, send segments to
– NSAID lab for eval
– Antispasmotics o Admin analgesics
• Ditropan (oxybutynin)-decreases bladder spasms. o Educate pt bruising normal and
there will be hematuria after
• Pro-Banthine (propantheline)
• Nephrolithotomy: incision into kidney
• Detrol (tolterodine tartrate)
w/ removal of stone
• Fluids-mainstay of therapy. 3L unless contraindicated. • Pyelolithotomy: Incision into pelvis
• Strain urine • Ureterolithotomy: Incision into ureter
• Save stone • Nephrectomy: removal of kidney if
• Ambulation kidney nonfunctional due to hydro or
• Monitor for infection infection.
• Nephrostomy: insertion of tube into
• Antibiotics if infection
pelvis
• Surgery if too large to pass • Cystoscopy: insertion of scope to
remove objects & visualize bladder
URINARY CANCERS
• Bladder cancer more common after age 55 years
• Men four times as often as women; 15,000 deaths annually
• Smoking increases risk 50%

• S/S: visible painless hematuria; pelvic or back pain may indicate metastasis
• Diagnosis: cystoscopy, CT, ultrasonography, biopsy
• Treatment: surgery, BCG regimen-topical chemo, IV chemo with radiation.
• Kidney:
– Many produce no symptoms
– Manifestations:
• Dull flank pain
• Palpable mass
• Painless hematuria
– 30% have metastasis at diagnosis
– Compression: obstruction of urinary tract
• Management
– If encapsulated: nephrectomy
– Immunotherapy: IL2
– Renal artery embolization & chemotherapy
– Radiation

URINARY DIVERSION
• Reasons: bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic
infection or intractable cystitis; used as a last resort for incontinence
• Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy
– Urine drains through an opening created through the abd wall into a bag
– Illeal conduit post care: skin barrier and disposable urinary drainage bag applied, Monitor output hourly <30ml is
problematic, stoma and skin care
• Continent urinary diversion: Indiana pouch, Kock pouch, ureterosigmoidostomy
– Part of intestines is used to create a new reservoir for urine.
– Catheter is used to drain the pouch
– Ureterosigmoidostomy – urine flows through colon and out rectum, more frequent urination
BPH
 Risk factors: age > 40 and family history
 Manifestations: hesitancy, recurrent bladder inf., retention, frequency, urgency, sm. amounts of urine voided, weak stream,
post urination dribbling.
 Diagnostic tests – annually starting at age 50: DRE – enlarged, rubbery, non-tender, smooth prostate; PSA - < 4 ng/mL is
normal, performed prior to DRE because it can rise levels; transrectal US/needle or aspiration biopsy to rule out prostate
cancer
 Management: depends on severity of obstruction or s/s; cath if cannot void
 Pharmacological treatment:
 Alpha-adrenergic receptor blockers: Relax smooth muscle of bladder and prostate
– Hytrin (tearazosin hydrochloride)
– Flomax (tamsulosin hydrochloride)
– Doxazosin(cardura)
– Alfuzosin(uroxatral)
– Side effects: dizziness, headache, fatigue, postural hypotension, rhinitis, sexual dysfunction
 Anti androgens: decrease size of prostate
– finasteride(Proscar)
– Dutasteride (Avodart)
– Side effects: decreased libido, ejaculatory dysfunction, ED, gynecomastia, flushing

Post prostatectomy
• Hemorrhage-bleeding and hemorrhagic shock greatest risk. Red-pink → light pink 24 hours
• Infection
• Fluid balance maintenance.
• DVT & PE: early post-op ambulation & DVT prevention measures
• Pain: Incision/Catheter/ Bladder Spasms
• Obstructed cath: obstructed cath produces distention of the prostatic capsule resulting in hemorrhage.
• CBI: adjust rate
• If bladder spasms-administer meds-irrigate Reduced irrigation outflow-contact Dr.
• Record irrigation volumes and output
• Meds: analgesics, antispasmodics, abx, stool softeners for preventing straining.
• Discharge Instructions:
– Color of urine should progress to amber in 2-3 days
– Expected output is 150-200mL every 3-4 hrs
– Contact provider if unable to void.
– Avoid heavy lifting, strenuous exercise, straining, sexual intercourse as directed
KIDNEY DISORDERS
• Fluid and electrolyte imbalances
• Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight
• Also monitor I & O

Table 54-1 DISTURBANCE MANIFESTATIONS MANAGEMENT


Fluid volume deficit Acute wt loss >/= 5%, decreased skin turgor, Fluid challenge, fluid replacement orally or
dry mucous membranes, oliguria or anuria, inc parenterally
Hct, BUN inc out of proportion to Cr,
hypothermia
Fluid volume excess Acute wt gain >/=5%, edema, SOB, crackles, Fluid and sodium restriction, diuretics, dialysis
dec Hct, dec BUN, JVD
Na (135 – 145) deficit Nausea, malaise, lethargy, headache, abd Diet, normal saline or hypertonic saline
cramps, apprehension, seizures solutions
Na excess Dry, sticky mucous membranes, thirst, rough Fluids, diuretics, dietary restriction
dry tongue, fever, restlessness, weakness,
disorientation
K (3.5 – 5.0) deficit Anorexia, abd distenion, paralytic ileus, muscle Diet, oral or parenteral K replacement
weakness, ECG changes, dysrhythmias
K excess Diarrhea, colic, nausea, irritability, muscle Dietary restriction, diuretics, IV glucose /
weakness, ECG changes insulin, Na bicarb, calcium gluconate, dialysis,
kayexlate
Ca (8.6 – 10.2) deficit Abd and muscle cramps, stridor, carpopedal Diet, oral or parenteral calcium salt
spasm, hyperactive reflexes, tetany, + replacement
chvosteks and trousseaus signs, tingling of
fingers and around mouth, ECG changes
Ca excess Deep bone pain, flank pain, muscle weakness, Fluid replacement, etidronate, pamidronate,
depressed deep tendon reflexes, constipation, mithramycin, calcitonin, glucocorticoids,
N/V, confusion, impaired memory, polyuria, phosphate salts
polydipsia, ECG changes
Bicarbonate (22-28) deficit Headache, confusion, drowsy, N/V, warm Bicarb replacement, dialysis
flushed skin, tachypnea
Bicarbonate excess Depressed RR, muscle hypertonicity, dizzy, Fluid replacement if volume depleted, ensure
tingling of fingers and toes adequate chloride
Protein deficit Chronic wt loss, emotional depression, pallor, Diet, dietary supplements, hyperalimentation,
fatigue, soft flabby muscles albumin
Mg (1.3 – 2.3) deficit Dysphagia, muscle cramps, hyperactive Diet, oral or parenteral Mg replacement
reflexes, tetany, + chvosteks or trousseaus
sign, tingling of fingers, dysrhythmias, vertigo
Mg excess Facial flushing, N/V, sense of warmth, drowsy, Calcium gluconate, mechanical ventilation,
depressed deep tendon reflexes, muscle dialysis
weakness, respiratory depression, cardiac
arrest
Phosphorus (2.5 – 4.5) deficit Deep bone pain, flank pain, muscle weakness Diet, oral or parenteral phos supplementation
and pain, paresthesia, apprehension,
confusion, seizures
Phosphorus excess Weak bones, calcifications in soft tissues, bone
pain, itching, inc risk of CV complications

KIDNEY FAILURE
• Results when the kidneys cannot remove wastes or perform regulatory functions
• A systemic disorder that results from many different causes
• Acute renal failure is a reversible syndrome that results in decreased glomerular filtration rate and oliguria
• Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia
AKI – acute kidney injury / failure – rapid loss of renal function r/t kidney damage
 Causes: hypovolemia, hypotension, reduced cardiac output and heart failure, obstruction of kidney or lower urinary tract, obstruction of
renal arteries or veins
 3 types:
 PRERENAL
– Hypovolemia – Increased vascular resistance
– Volume shifts – Vascular obstruction
– Decreased cardiac ouput – Septic shock
– MI
 INTRARENAL
– Acute tubular necrosis – Metabolic disorders
– Trauma – Glomerulonephritis
– Antibiotics – Vascular lesions
– Severe muscle exertion – Solvents, pesticides, heavy metals
– Infection
 POSTRENAL
– OBSTRUCTION – ureteral, bladder, urethral
 Phases:
 Onset(Initiation)
– begins with initial insult and ends with oliguria
 Oliguria
– Increase in the serum concentration of substances that are excreted out normally by the kidneys
– Uremic symptoms appear-hyperkalemia develops
 Diuretic
– Gradual increase in urine output, GFR starts to recover
– Monitor for dehydration. With dehydration uremic s/s increase
 Recovery
– 3-12 months to recover
– Improved renal function, normal lab values
– May have 1-3% reduction of GFR
 Prevention:
 Maintain / restore renal perfusion
 Avoid nephrotoxins – NSAIDS, abx (gentamicin), radiocontrast dyes
 Increase elimination of nephrotoxins – prehydrate with saline
 Manifestations:
 Lethargy
 s/s of dehydration
 CNS changes – drowsy, headache, muscle twitching, seizures
 Hypotension, tachycardia, decreased cardiac output (per ATI)
 Pt problems and management:
 Fluid imbalance – diuretics, I&O, daily wt, edema
 Electrolyte imbalance – s/s of hyperkalemia, treat with insulin + glucose, kayexalate, Na bicarb (metabolic acidosis), dialysis
 Nutrition – highly individualized
– High carb meals
– Limit foods containing K and Phos: bananas, citrus fruits, juices, coffee
– Check lab work to determine and s/s of over and under hydration
– After diuretic phase – high protein and high calorie diet
 Risk of infection – reduce metabolic rate b/c inc. catabolism, monitor for fever and s/s of infection, check lines, try to keep
foley’s out
 Altered skin integrity – dry, breakdown, itching – use cool water, turn, cut nails, moisture
 Pulmonary function – TCDB
 Emotional support
CHRONIC KIDNEY FAILURE
STAGE DESCRIPTION GFR
125ml/min/1.73 m3 = normal
1 Kidney damage with normal or ↑GFR >/= 90
2 Kidney damage with mild ↓ GFR 60 – 89
3 Moderate ↓ GFR 30 – 59
4 Severe ↓ GFR 15 – 29
5 ESKD / ESRD < 15
Causes:
• Diabetes mellitus-#1 • Hereditary lesions
• Hypertension-#2 • Vascular disorders
• Chronic glomerulonephritis-#3 • Medications or toxic agents
• Pyelonephritis or other infections-#3 • Congenital
• Obstruction of urinary tract
Musculoskeletal manifestations:
 ↑ PO4
 ↓ Calcium
 ↑ PTH b/c ↓ Ca
 Body does not respond normally to increased PTH-Ca leaves the bones=changes in bones
– Interventions: Diet modifications, Phosphate binders, Vitamin D analogs, Parathyroidectomy

TREATMENT:
• Prevent Progression/Maintain Function /Prevent Complications
– Diabetic: glucose control, BP control, CV risk reduction, limit exposure to risk factors that decrease kidney function, treat
manifestations, education
• Pharmacological
– Calcium phos binders: calcium carbonate, calcium acetate, sevelamer: bind to phos in the GI system, give with meals.
– Antihypertensives: variety-manage HTN and related heart issues
– Antiseizure meds: assess for twitching, headache delirium, seizure activity: meds: Valium or Dilantin.
– Erythropoietin: Epoeitin alfa IV or SQ. AE=HTN, increase clotting and decrease iron stores.
– Heparin to prevent clotting of lines, monitor H&H, assess serum iron. May get Venofer or INfeD. Contol HTN.
• Nutrition
– Regulate protein-restricted - Allowed protein must be high biologic value (diary, eggs & meats)
– Fluid intake: 500mL-600mL more than previous day’s urinary output.
– Calories from carbs and fats to prevent wasting
– Vit supplements-vit loss during dialysis also b/c of protein restriction.
PRIMARY GLOMERULAR DISEASE
GLOMERULONEPHRITIS – inflammation of the glomerulus bilaterally – causes porous capillaries that results in proteinuria and hematuria
• Immunologic abnormalities (most common) - Circulating antigen-antibody immune complex deposition-biochemical mediators of
inflammation
• Drugs or toxins
• Vascular disorders-ischemia
• Systemic diseases: Diabetes and Lupus
• Viral causes
ACUTE
 Cause: Typically follows streptococcal infection, Consequence of immune reactions in the body to the infection, Antigen-antibody
immune complexes are formed and trapped in glomerular membrane, These cause an inflammatory response activating the complement
system and releasing inflammatory mediators, Leads to inflammation=glomerular capillaries becoming more porous=escape of plasma
proteins and blood cells into the urine.
 Clinical manifestations: hematuria, proteinuria, decreased GFR, oliguria, HTN, orbital edema, lower ext. edema
CHRONIC
• Slow, progressive destruction of glomeruli
– Repeated acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia. Diabetes and lupus may also play a role.
– Deposition of immune complexes or formation of antibodies against glomerular basement membrane
• Renal insufficiency or failure: asymptomatic for years as glomerular damage increases before signs and symptoms develop
• Abnormal laboratory test results: urine with fixed specific gravity, casts, proteinuria, electrolyte imbalances and hypoalbuminemia
• Medical management determined by symptoms

ACUTE NEPHRITIC SYNDROME


• Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis-minimal chance of recovery and membranous
glomerulonephritis-thick glomerular walls
• Manifestations include hematuria, edema, azotemia, mild proteinuria, and hypertension
• May be mild or may progress to acute renal failure or death
• Medical management includes supportive care and dietary modifications; treat cause if appropriate—antibiotics, corticosteroids, and
immunosuppressants
NEPHROTIC SYNDROME
• Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins
• Excretion of 3.5 g or more of protein in the urine per day
• Very little/no blood
• The protein excretion is caused by glomerular injury - Results in hypoalbuminemia and edema
• Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis, lupus erythematosus,
multiple myeloma, and renal vein thrombosis
• Medical management includes drug and dietary therapy
Nephrosclerosis – hardening of renal arteries r/t HTN & DM, major cause of CKD – ESKD, tx: antihypertensives

Polycystic kidney disease – genetic disorder, no cure – manage s/s, palliative care, genetic testing / counseling

DIALYSIS
 Who needs it: acid/base problems, electrolyte problems, intoxications, overload of fluids, uremic symptoms

HD – hemodialysis
 Schedules:
– Traditional: 3x / wk, 3-4 hrs
– Daily: 6-7x / wk, 2-3 hrs
– Nightly: 3x / wk, 6-8 hrs
– Home HD canbe used – careful assessment of home environment is necessary
 AV fistula – vein and artery anastomosed together , check for bruit and thrill – if absent notify Dr., do not use
arm for BP or blood draws
 AV graft – synthetic tubing used to connect artery and vein, used when pt’s vessels are not suitable
 Catheters – also used for dialysis, subclavian, jugular, or femoral
 CV meds must be held prior to dialysis
 Complications:
– Hypotension-fluid removal & associated N/V diaphoresis, tachy, dizzy.
– Cramping-fingers/toes/legs-rapid loss of F&E
– Bleeding-needle dislodgment
– Dysrhythmias-electrolyte/pH changes, removal of heart meds during HD
– Chest pain
– Air Embolism: rare!!
– Dialysis disequilibrium: rapid fluid shifts from ECF to ICF
 Nutrition:
– Restrict protein, fluid, Na, K, Phos
– Need adequate calories to prevent protein wasting
– Vitamin and folic acid
PD – peritoneal dialysis
 Schedule – 7 days / wk
 Methods:
 CAPD – continuous ambulatory peritoneal dialysis
– No machine
– Pt does 4-6 cycles/exchanges (exchange old dialysate for new, fill-dwell-drain) during the day
and dwells 1 cycle while sleeping
 CCPD – continuous cycler peritoneal dialysis
– Machine used
– Cycles are done by machine while sleeping and pt dwells 1 cycle during the day
 PD vs HD:
 Patients who do not want HD
– Want self-care or have transportation issues, Live far from HD center
 Patients who refuse HD
 Patients who are unable to tolerate HD
– Hypotension/Angina
– No vascular access for hemodialysis
 Dialysate solution:
 Contain glucose
– 1.5%; 2.5%; 4.25%
– Hypertonic to blood
– Glucose concentration determines how much water will be removed from the blood
 Osmosis
 Contains electrolytes:
– Diffusion controls solute removal
 Drain: wash hands, prepare environment, old fluid drained, fluid is measured and inspected
 Fill: sterile fluid introduced to abd cavity via catheter by gravity
 Dwell: fluid sits in peritoneal cavity for predetermined time, dialysate pulls fluid and wastes across the
peritoneal membrane and into the dialysate by osmosis and diffusion
 Complications:
 Peritonitis
– Abx through PD cath
– Observe the drained fluid
– Strict Aseptic Technique
 Leakage at cath site initially when cath inserted
 Bleeding
– Bloody drainage
– Should stop in 1-2 days.
– Common in young menstruating women
– Common in first few exchanges after new cath
 Exit site infection
– Characterized: drainage, edema, redness, tenderness
– Notify nephrologist
– Treatment: C & S if drainage, antibiotics, remove catheter if no improvement
– Asses if catheter care being done properly
 Clean q day: clean technique
 Hyperglycemia
– Glucose absorbed from dialysate or insufficient insulin
– Characterized: increased blood glucose, weight, and thirst
– Treatment: insulin coverage, adjust glucose content of dialysate
 Fluid deficit
– Removal of too much fluid
– Treatment: restrict activity until increase in BP, ↓ dextrose in dialysate, increase fluid intake
 Fluid excess
– Not enough fluid removed
– Treatment: increase dextrose of dialysate, correct hyperglycemia if present, decrease fluid
intake
 Other considerations
– High protein diet: continuous loss due to CAPD, monitor albumin levels
– Normally do not need to restrict intake of K, Na, and fluid
– Folic acid
– Increase fiber intake to prevent constipation – can cause obs of in/out flow
– Strict aseptic technique to prevent infection
KIDNEY SURGERY
 PRE-OP: encourage fluids, abx for infection, labs, encourage pt to voice concerns
 PERI-OP: assist with positioning
 POST-OP: potential hemorrhage and shock, abd distention and paralytic ileus, infection, thromboembolism
– Assessment: include all body systems, pain, fluid and electrolyte status, and patency and adequacy of
urinary drainage system
– Diagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety,
impaired urinary elimination, and risk for fluid imbalance
– Complications: bleeding , pneumonia, infection, and DVT
– Interventions:
 Pain relief measures, analgesic medications
 Promote airway clearance and effective breathing pattern, turn, cough, deep breathe, incentive
spirometry, positioning
 Monitor and maintain patency of urinary drainage systems
 Use strict asepsis with catheter
 Monitor for signs and symptoms of bleeding
 Encourage leg exercises, early ambulation, and monitor for signs of DVT
TRANSPLANT
 PRE-OP: prepare pt, optimize physical status, tx infection
 POST-OP: maintain homeostasis, s/s of rejection – oliguria, edema, fever, inc BP, wt gain, swelling or tenderness
over transplant area, rise in serum Creatinine
 Immunosuppression: life time, started pre-op, steroids, anti-rejection meds: cyclosporine (no grapefruit juice)
mycophenolate, tacrolimus

RENAL NUTRITION (student ppt)


 Renal diet 101: low K, low Phos, low Na, high protein, fluid restricted, often diabetic
 Dialysis diet 101: vitamin D, PTH levels, Ca
 Potassium (2000-3000 mg/day) – high content foods include: bananas, oranges, potatoes, tomatoes, V8 juice,
cantaloupe, dried fruit, dairy products, nuts/legumes, no salt substitutes
 Phosphorus (800-1000 mg/day)
– high content foods include: dairy products, nuts/legumes, powder mixes, colas, processed and fast
foods
– low content foods: fresh meat, rice, pasta, non-dairy creamer, clear sodas
 Calcium (<2 g/day) – high calcium = calcification of soft tissue
 Sodium (2000 – 3000 mg/day) – use fresh, unprocessed foods, flavor foods with herbs and spices, choose low
sodium items except canned soups that may contain extra potassium, read labels carefully
 Protein - use supplements if necessary: Nepro, boost, ensure, pro-stat, protein powder, protein cookies
– Needs
 Acute - .6 - .8 g/kg
 CKD - .6 - .75 g/kg
 HD – 1.2 g/kg
 PD – 1.2 – 1.3 g/kg
 Transplant
 1.3 – 2.0 post op, 8 – 1.0 chronic

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