I

ntr
oduct
ion

 Iam Ashadoi ngNPCC1sty eari

nSav eet
haCol legeofNur singSav eetha
Universi
tyduringmyst udyper i
odIwaspost edinI CUunitinICUuni tICUone
patientMr sSarojawas76y earsoldgotadmi t
tedinSav eethaMedi calCollege
andHospi talwit
ht hecomplaintsofvomitingfor3day sandl oosest oolsfor
severalepisodeandt her
eisapr esenceofal l
oliguri
asheunder wentallthe
i
nv esti
gati
onsandphy si
ci
andi agnoseddiagnosedhert ohav eadehy drati
onand
chronickidneydiseasestage5andshei saknowncaseofchr onickidney
diseaseanddi abeticmell
it
us
 Pat
ientpr
ofi
l
e

Name- Mr
sSar
oja

Age- 76Year
s

Sex- Femal
e

Educat
ion- 10t
h

Occupat
ion- -

I
ncome- -

Rel
i
gion- Hi
ndu

Language- Tami
l

Address- 18Jeev
anandam Mai
nRoadKamar
ajarNagar
Avadi.

Dat
eOfAdmi
ssi
on- 10-
5-2018

Di
agnosi
s- chr
oni
cki sease5thst
dneydi age
 HEALTHHI
STORY

Familyhi
story
shelivenucl
earfamil
yhisfamilymember saretwoinnumbert her
eis
nohistor
yofheredit
arydi
seaselikediabeti
cmell
itusthyr
oidepi
lepsy
hypert
ensionandnoblooddisorderandt her
eisnohistor
yofany
communi cabl
ediseasenofamilyhist
oryofpsychiat
ri
cdisease.

Fami
l
ypedi
gree

Mr
s.Sar
oja Mr
.Mani

Mr
.kumar Mr
s.Thangam Mr
s.Jay
a Mr
.Raj
kumar

-
Mal
e -
Femal
e -
Pat
ient

Soci
oEconomi
c

MrsSar
ojahusbandisthebreadwinnerofthefami
lyhousehaveall
the
faci
l
ityl
i
kegoodventi
lat
ionadequateelect
rici
tyandnear
byschoolshospi
tal
s
andshops

Per
sonal
hist
ory

Therei
sahist
oryofsmoki
nghabi
tandnooccupat
ional
hazards,
he
mai
ntai
nedgoodper
sonalhy
gene.
shevoi
dsur
ine3timesperday(
oli
gur
ia
i
spresent
)andbowelpat
ter
nisnor
mal
.wat
chi
ngTVi
sherhabi
t.No
hi
stor
yoffoodal
ler
gy

Pr
esentHeal
thHi
stor
y

Mr sSarojawas76y ear
soldgotadmittedi
nSav eet
haMedicalCol
lege
andHospi talwiththecomplai
ntsofvomit
ingfor3daysandloosestool
sfor
severalepisodeandt her
eisapresenceofal
loli
guri
asheunderwentallt
he
i
nv est
igati
onsandphy si
ci
andiagnosedhertohaveadehy dr
ati
onandchroni
c
ki
dneydi seasest age5andsheisaknowncaseofchr onicki
dneydi
seaseand
diabeti
cmel li
tus.

PastMedi
cal
Hist
ory

MrsSarojaisaknowncaseofdi abeti
cmelli
tusforthepast20yearsand
chroni
ckidneydiseaseforthepast5y earsandshei salsoaknowncaseof
hypert
ensionforthepast20y ear
sshei snowundert reatmentanddrug
managementt hereisnocardiachistor
yandmedi calall
ergyther
eisnohist
oryof
anycommuni cablediseaseli
kemal ari
atubercul
osis

Menst
rual
Hist
ory

sheatt
imemanarchattheageof14y
earsshehadaregul
arcy
cleoff
low5
day
spermont handr
egulart
heageofMenopausei
s50years.
 HEALTHASSESSMENT

vi
talscience
Temper atur
e-
Pulse -
Respiration -
BloodPr essur
e-

Ski
nAssessment

General
Pigmentat
ion EvennessI sPresent
Syst
emicColourChanges NoEv idenceOfSy st
emicCol
our
changes
FranklsAndMol
es Normal
Temper at
ure 98.6Degr eeFahrenheit 
Moister Dry
Edema Pedal EdemaI sPr esent
Bruisi
ng NoEv idenceOfBr uising
Lesions NoEv i
denceOfLesi ons
Hair wellDistri
buted
Nails Normal NoCl ubbingOfNai l
s.

Neur
ologi
cal
Assessment

12Pai
rsOfCrani
alNer
vesCr
ani
alNer
ves Ar
eNor
mal
NoEv
idenceOf
Abnor
mali
ty

Mot
orSy
stem

MuscleAppropr
iat
e Appropri
ateToTheBodyWeight
MuscleStr
ength StrengthTestNormal
MuscleTone MuscleToneI sNormal
I
nvol
untar
yMov ement Ther eIsNoEv i
denceOfI
nvol
unt
ary
Movement

AssessmentOf 
Spi
nal
Thal
ami
cTr
ack
Abil
it
yTo
Pain
Temperatur
e
Li
ghtTouch Spi
noThal
ami
cIsNor
mal
Abi
l
ityTo
FeelThe
Sensat
ion

Post
eri
orCol
umnTr
act

Vibr
ationPosit
ion
Tacti
leDiscr
iminat
ion
TwoPoi ntDi
scriminat
ion Posi
ti
onCol
umnTr
actI
sNor
mal

Ref
lex

DeepTendonRef
lex
Super
fi
cial
Ref
lex Ther
eIsANor
mal
AndRef
lex

Lev
elOfConsci
ousness

Gl
asgowComaScal
e 15By15 E4V5M6

HeadFaceThr
oatAssessment

GeneralFaci
alSymmetr
y PresenceOfFacialSymmetry
HairDist
ri
buti
on   I
tIsWel lDi
str
ibutor
GeneralFaci
alExpr
essi
on Normal ButDull
nessIsPr
esent
LymphNode ThereIsNoLy mphNodeEnl ar
gement

AssessmentOfEy
eVi
sual
Acui
ty

VisualAcuity Normal
VisualFiel
d NormalVisual
Fiel
dIsPresent
Extr
aocularMuscl
eFunct
ion NoExt
raocul
arMuscleFunction
Congecti
v a NoRednessDrynessI
sPr esent
Pupil NormalFuncti
onOfPupil
OcularFundus NoPapill
aryEdema

AssessmentOfEar

Si
ze Shape Nor
mal
SizeAndShapeSameSki
n
Col
our
Ext
ernalCanul
a Ther
eIsNoEv
idenceOfSwel
l
ing
RednessAnd
Discharge
TympanicMembrane NoEv i
denceOfDi
schar
ge
I
nflammati
on
Heari
ngAcuit
y
TheWeber'
sTest Nor
mal
AssessmentOfNoseNasal
Cav
ity NoDi schar
geSwell
i
ngRedness
Sinus NoEvidenceOfTenderness

AssessmentOfMout
hAndThr
oat

SkinIntegri
ty Normal
Teeth NoEvi
denceOfBl
eedi
ngAnd
Discolorat
ion
Tongue NoEv i
denceOfCoat
edTongue
Buckl eMucosa Nor
mal
Uv ul
a Midl
ine
Throat Normal NoRedness

Car
diov
ascul
arSy
stem

CarotidArt
ery Nor
mal
AndSt
rengt
hNoEv
idenceOf
Mur mur
Precardi
um NoEvidenceOfEnlargement
JugularVein Di
stensionIsNotPresent
 
Hear tSound S1AndS2Her eThereIsNoEvi
dence
Of
Abnar
mal
Sound
Ext
remity
Capi
ll
aryRef
il
l Wi
thi
n3Second

Pul
monar
yAssessment

I
nspecti
on Asy
mmet r
icExpansi
onI
sSeen
Palpat
ion NoFlui
dMov ement
Auscult
ati
on NormalBr
onchovesi
cul
arSoundTher
e
I
sNo
Additi
onalSoundsAbnor
mal Sound
Per
cussi
on ResonentIsPresentWhi
chIndi
cates
Nor
mal
Gast
roi
ntest
inal
Syst
em

I
nspecti
on NoEvi
denceOfScarRedness
Auscultati
on BowelMov ementHyperact
ive
Pal
pati
on NoHepatomegalySplenomegalySeen
Percussion NoEvidenceOfDull
nessOv erThe
Spl
een

Muscul
oskel
etal
Syst
em

I
nspecti
on NoEvi
denceOfSkinUlcerat
ion
Palpat
ion NoEv
idenceOfTenderness
UpperExtr
emi
tyLowerExt
remi
ty NoEnlargementOverTheJoint
Normal
RangeOfMot
ionFemal
e

Repr
oduct
iveSy
stem

I
nspection NoEv
idenceOfDi
schar
geAnd
Redness
Pal
pat i
on NoEv
idenceOfTender
nessAnd
I
nformat i
onNut
ri
ti
onal
Assessment
Age 76Years
Wei ght 53KgAppr oxi
matel
y
Height 120m Appr
oximat
ely
BodyMassI ndex

I
nfer
ence
I
nphysi
cal
exami
nat
ionshehav
eadul
ll
ookandpr
esenceofpedal
edema
 I
NVESTI
GATI
ON

NameOfThe Pat
ientVal
ue Nor
mal
Val
ue Remar
ks
Repor
t

bl
ood 2.
02 5.
02-
11.
0 Decr
eased

HB 6gper/
dl 12-
146mgper/
dl Decr
eased

pl
atel
etcount 2.
46 250000-
800000 Nor
mal

ur
ea 45.
3mg/
dl 15-
16mg/
dl I
ncr
eased

cr
eat
ini
n 10.
9mg/
dl 1.
0-2.
0mg/
dl I
ncr
eased

sodi
um 130mmol
/l 135-
144mmol
/l Nor
mal

pot
assi
um 4.
43mmol
/l 3.
5-4.
5mmol
/l Nor
mal

chl
ori
de 102mmol
/l 110-
126mmol
/l Nor
mal

Bi
car
bonat
e 16 22-
24 Nor
mal

ABGv
alue

PH 7.
36 7.
35-
7.45 Nor
mal

pco2 23mmhg 22-

24mmhg Nor
mal

02 180wi
th5l
o2 100 Nor
mal

I
ntakeoutputchar
t
 Ti
me I
ntake Amount Output

8am

9am I
dlywi
thsambar 150ml

10am I
V 100ml

11am I
V 100ml

12n I
V 100ml

1pm Ri
ce 400ml 50ml

2pm I
V 100ml

3pm I
V 100ml

4pm I
V 100ml

5pm Mi
l
k 300ml 50ml

6pm I
V 100ml

7pm I
V 100ml

8pm I
V 100ml

9pm Dosawi
thsambar 150ml

10pm I
V 100ml

12pm

1am

2am

3am 50ml

4am
5am

6am

7am

8am 50ml

Tot
al =I
ntake-
2000mlout
put
-200ml
 ANATOMYANDPHYSI
OLOGYOFURI
NARYSYSTEM

Or gansi ntheUr inarySy stem Ki dney sAndThei rStr uctur

eTheki dney sare
apai rofbeanshaped, reddishbr ownor gansaboutt hesi zeofy ourf i
st.It
measur es10- 12cm l ong.Theyar ecov eredbyt her enal capsul e, whichi sat ough
capsul eoff i
brousconnect i
v etissue.Adher ingt ot hesur faceofeachki dneyi s
twol ay ersoff attohel pcushi ont hem.Ther eisaconcav edsi deoft heki dney
thathasadepr essionwher ear enal arteryent ers,andar enal veinandaur et
er
exittheki dney .Theki dney sar el ocat edatt her earwal loft heabdomi nal cavit
y
j
ustabov ethewai stl
ine, andar epr otect edbyt her i
bcage.Theyar econsi dered
retr
oper i
toneal, whichmeanst heyl i
ebehi ndt heper itoneum.Ther ear et hree
maj orr egionsoft heki dney, r
enal cor tex,renal medul l
aandt her enal pelvis.The
outer, granulatedl ayeri sther enal cor tex.Thecor texst retchesdowni nbet ween
aradi allystri
atedi nnerl ayer.Thei nnerr adiallystri
at edlay eristher enal medul l
a.
Thiscont ainspy rami dshapedt i
ssuecal l
edt her enal pyrami ds,separ atedby
renal columns.Theur etersar econt inuouswi tht her enal pel vi
sandi st hev ery
centeroft heki dney .

Renal
Vei
n
 Ther enal v
einsareveinsthatdraint heki
dney.Theyconnecttheki dneyto
thei
nfer i
orvenacav a.Becauset heinf
er i
orvenacavaisontherighthal fofthe
body,theleftrenalvei
nisgener all
ythelongerofthetwo.Unli
ket heri
ghtr enal
vei
n,theleftrenalveinoft
enr eceivestheleftgonadalv
ein(l
eftt
esticularveinin
males,leftovari
anv ei
ninfemal es).I
tfrequentl
yrecei
vesthelef
tsupr arenalvei
n
aswell.

Renal
Art
ery

Ther enal arteriesnor mallyar i

seof ftheabdomi nalaor t
aandsuppl ythe
kidneyswi thblood.Thear t
erialsuppl yoft heki
dneysar ev ari
ableandt heremay
beoneormor erenal arter
iessuppl yi
ngeachki dney.Duet ot heposi t
ionoft he
aorta,t
hei nferi
orv enacav aandt heki dneysinthebody ,therightrenal art
eryi
s
normallylongert hant hel eftrenal artery.Theri
ghtrenal arter
ynormal lycrosses
posteri
orl
yt ot heinf eriorvenacav a.Ther enalart
eri
escar ryal ar
gepor tionofthe
totalbl
oodf l
owt ot heki dneys.Upt oat hirdofthetotalcardiacout putcanpass
throughther enal arteriestobef ilteredbyt hekidneys.

Ur
eter
s

Theur et
er saret wot ubest hatdr ainur i
nef rom t heki dney stot hebl adder .
Eachur eteri samuscul art ubeabout10i nches( 25cm)l ong.Muscl esi nt he
wal lsoft heur eterssendt heur i
nei nsmal lspurtsi ntot hebl adder , (acol lapsi ble
sacf oundont hef or war dpar toft hecav i
tyoft hebonypel vi
st hatal l
ows
tempor ar yst orageofur ine) .Af tertheur ineent er st hebl adderf rom t heur eter s,
smal lfoldsi nt hebl addermucosaactl i
kev alvespr event ingbackwar df lowoft he
urine.Theout l
etoft hebl adderi scont rolledbyasphi nctermuscl e.Af ullbl adder
sti
mul at essensor yner v esi nt hebl adderwal lthatr el
axt hesphi nct erandal low
rel
easeoft heur ine.Howev er ,relaxat ionoft hesphi ncteri sal soi npar tal ear ned
responseunderv olunt arycont rol.Ther el easedur ineent er st heur ethra.Ur inar y
BladderTheur i
nar ybladderi sahol low, muscul aranddi stendi bleorel ast icor gan
thatsi tsont hepel vicfloor( super i
ort ot hepr ost ateinmal es).Oni tsant er i
or
bor derl iest hepubi csy mphy sisand, oni tspost eriorbor der ,thev agina( i
n
femal es)andr ect um ( i
nmal es).Theur inar ybladdercanhol dappr oxi mat el y17
to18ounces( 500t o530ml )ofur ine, howev ert hedesi ret omi ctur atei susual l
y
exper iencedwheni tcont ainsabout150t o200ml .Whent hebl adderf illswi t
h
urine( abouthal ffull),
st ret
chr ecept or ssendner vei mpul sest ot hespi nal cor d,
whi cht hensendsar eflexner vei mpul sebackt ot hesphi ncter( muscul arv alve)
att heneckoft hebl adder ,
causi ngi ttor elaxandal l
owt hef lowofur i
nei nt ot he
urethr
a.TheI nternal ur
ethral
sphincterisinvoluntary.Theuret
ersentert
he
bladderdiagonal l
yfrom itsdorsol
ateralfl
oorinanar eacall
edthetri
gone.The
tr
igoneisat r
iangularshapedar eaont hepost ero-i
nferi
orwalloft
hebladder.The
urethr
aexi tsatthel owestpointofthet r
iangleoft hetri
gone.Theuri
neinthe
bladderalsohel psregulatebodytemper ature.Ifthebladderbecomescompl etel
y
voidoffluid,i
tcausest hepat i
enttochi l
l
.

Theur ethrai samuscul art ubet hatconnect sthebl adderwi t

ht heout si
de
oft hebody .Thef unct i
onoft heur et hraistor emov eur i
nef rom thebody .It
measur esabout1. 5i nches( 3.8cm)i nawomanbutupt o8i nches( 20cm)i na
man.Becauset heur ethrai ssomuchshor t
eri nawomani tmakesi tmucheasi er
forawomant ogethar mf ul bact eri
ai nherbl addert hisi scommonl ycal l
eda
bladderi nfect i
onoraUTI .Themostcommonbact eri
aofaUTIi sE- colif
rom the
l
ar gei ntestinest hathav ebeenexcr etedi nfecal mat t
er .Femal eur et hraInthe
humanf emal e,theur ethraisabout1- 2inchesl ongandopensi nthev ulv
a
bet weent hecl itorisandt hev agi nalopeni ng.Menhav eal ongerur et hrathan
women.Thi smeanst hatwoment endt obemor esuscept i
blet oinfect i
onsoft he
bladder( cyst i
ti
s)andt heur inar ytract.Mal eur ethraI nt hehumanmal e,t
he
urethr ai sabout8i nchesl ongandopensatt heendoft heheadoft hepeni s.The
l
engt hofamal e'sur ethra,andt hef actitcont ainsanumberofbends, makes
cathet er i
sat i
onmor edi ff
icult.Theur ethralsphi ncteri sacol l
ectivenamef orthe
muscl esusedt ocont rolthef lowofur i
nef r
om t heur inar ybladder .These
muscl essur roundt heur ethra, sot hatwhent heycont ract,theur ethrai sclosed.•
Ther ear etwodi stinctar easofmuscl e:theinter nal sphi ncter,atthebl adderneck
and•t heext ernal ,ordistal ,
sphi ncter .Humanmal eshav emuchst ronger
sphi nctermuscl est hanf emal es, meani ngthatt heycanr etai
nal ar geamountof
urinef ort wi ceasl ong, asmuchas800mL, i
.e."hol dit".

Nephr
ons

Anephr oni sthebasi cstr

uctural andf uncti
onalunitofthekidney .Thename
nephroncomesf r
om t heGr eekwor d( nephros)meani ngkidney.I
tschi ef
functi
onist oregulatewat erandsol ubl esubstancesbyf il
teri
ngthebl ood,
reabsorbingwhati sneededandexcr et i
ngtherestasur ine.Nephronsel i
minate
wastesf r
om t hebody ,r egulat
ebloodv ol
umeandpr essure,contr
ollev el
sof
elect
rolyt
esandmet abol i
tes,andregul atebloodpH.I tsfuncti
onsar ev it
altol
if
e
andar eregulatedbyt heendocr i
nesy stem byhor monessuchasant idiuret
ic
hormone, aldosterone, andpar at
hyroidhor mone.
Eachnephr onhasi tsownsuppl yofbl oodf rom t wocapi llar yregi onsf rom t he
renal ar ter y .Eachnephr oni scomposedofani ni tial fi
lter ingcomponent( the
renal cor puscl e)andat ubul especi alizedf orr eabsor pt ionandsecr et ion( t
he
renal t ubul e) .Ther enal cor puscl ef i
lter soutl ar gesol utesf r
om t hebl ood,
deliver ingwat erandsmal l solut est ot her enal tubul ef ormodi fi
cat i
on.
Glomer ulusThegl omer ulusi sacapi llaryt uf tt hatr ecei v esi tsbl oodsuppl yfrom
anaf fer entar terioleoft her enal ci rcul ation.Thegl omer ul arbl oodpr essur e
prov i
dest hedr ivi
ngf or cef orflui dandsol ut est obef il
ter edoutoft hebl oodand
i
nt ot hespacemadebyBowman' scapsul e.Ther emai nderoft hebl oodnot
fi
lteredi nt ot hegl omer uluspassesi nt ot henar roweref fer entar ter i
ol e.I tthen
mov esi ntot hev asar ect a, whi char ecol l
ect ingcapi llariesi nter twi nedwi tht he
conv ol ut edt ubul est hr ought hei nt er st i
ti
al space, wher et her eabsor bed
subst anceswi llalsoent er .Thi st hencombi neswi thef fer entv enul esf rom ot her
nephr onsi ntot her enal vei n,andr ejoinswi tht hemai nbl oodst ream.
Affer ent /Ef ferentAr teriol esTheaf fer entar ter iolesuppl iesbl oodt ot he
glomer ulus.Agr oupofspeci alizedcel l
sknownasj uxt agl omer ularcel lsar e
l
ocat edar oundt heaf ferentar ter iolewher ei tent er st her enal cor puscl e.The
efferentar t er i
ol edr ainst hegl omer ulus.Bet weent het woar teriol esl ies
speci al i
z edcel lscal l
edt hemacul adensa.Thej uxt agl omer ularcel lsandt he
macul adensacol lectiv elyf ormt hej uxt agl omer ularappar at us.I ti si nt he
j
uxt agl omer ularappar at uscel lst hatt heenzy mer enini sf or medandst ored.
Reni ni sr eleasedi nr esponset odecr easedbl oodpr essur ei nt heaf ferent
arteriol es, decr easedsodi um chl or i
dei nt hedi stal conv olut edt ubul eand
sympat het icner v est imul at i
onofr ecept or s( bet a-adr eni c)ont hej uxt agl omer ular
cells.Reni ni sneededt of or m Angi otensi nIandAngi otensi nI Iwhi chst imulat e
thesecr et ionofal dost er onebyt headr enal cor tex .Gl omer ularCapsul eor
Bowman' sCapsul eBowman' scapsul e( alsocal ledt hegl omer ularcapsul e)
sur r
oundst hegl omer ulusandi scomposedofv iscer al (simpl esquamous
epithel ial cel ls)( inner )andpar iet al (si mpl esquamousepi thel i
al cells)( outer)
l
ay ers.Thev i
scer al l
ay erl i
esj ustbeneat ht het hi ckenedgl omer ularbasement
membr aneandi smadeofpodocy teswhi chsendf ootpr ocessesov ert hel ength
oft hegl omer ulus.Footpr ocessesi nt erdigitat ewi thoneanot herf or mi ng
fi
ltrationsl itst hat , i
ncont rastt ot hosei nt hegl omer uluarendot hel i
um, ar e
spannedbydi aphr agms.Thesi zeoft hef il
tr ationsl i
tsr est rictst hepassageof
l
ar gemol ecul es( eg, albumi n)andcel ls( eg, r edbl oodcel lsandpl at elet s).In
addi tion, f ootpr ocesseshav eanegat iv
el y-char gedcoat( glycocal yx)t hatl imits
thef iltrationofnegat ivel y-char gedmol ecul es, suchasal bumi n.Thi sact ionis
call
edel ectr ostat
icrepulsion.Thepar i
etall
ayerofBowman' scapsulei slinedby
asinglel ayerofsquamousepi thelium.Bet weent hev i
scer alandpar ietal l
ayersis
Bowman' sspace, i
ntowhi chthef il
trateentersaf t
erpassi ngt hrought he
podocytes' f il
tr
ati
onsl it
s.Itisher et hatsmoot hmuscl ecel lsandmacr ophages
l
iebetweent hecapillari
esandpr ovidesuppor tforthem.Unl ikethev i
scer all
ay er
,
thepariet allayerdoesnotf unctioni nfilt
rati
on.Rat her
,thef i
l
t r
ati
onbar r
ieris
formedbyt hreecomponent s: t
hedi aphragmsoft hefil
trationsl i
ts,
thet hick
glomerularbasementmembr ane, andt heglycocalyxsecr etedbypodocy tes.99%
ofglomer ularfil
tr
atewi llult
imat elyber eabsorbed.Thepr ocessoff i
ltrati
onof
thebloodi nt heBowman' scapsul eisultrafi
l
trat
ion( orglomer ul
arfil
trati
on) ,and
thenormal r ateoffi
ltrati
oni s125ml /min,equiv
alentt otent imest hebl ood
volumedai ly.Measur ing

Thegl
omer
ularf
il
tr
ati
onr
ate(
GFR)

Itisadi agnostictestofki dneyf unct ion.Adecr easedGFRmaybeasi gn

ofrenal failure.Condi t
ionst hatcanef fectGFRi nclude: arterialpressure, aff
erent
art
eriol
econst ricti
on,efferentart
er i
oleconst rict
ion, plasmapr otein
concent rationandcol l
oidosmot i
cpr essur e.Anypr ot einst hatar eroughly30
kil
odaltonsorundercanpassf r
eelythrought hemembr ane.Al t
hough, thereis
someext rahindr ancefornegat iv
elychar gedmol ecul esduet ot henegat ive
chargeoft hebasementmembr aneandt hepodocy tes.Anysmal lmolecul es
suchaswat er,
gl ucose,salt(NaCl )
,ami noaci ds,andur eapassf r
eelyinto
Bowman' sspace, butcells,pl
atel
et sandl argepr oteinsdonot .Asar esul t,t
he
fi
lt
rateleav i
ngt heBowman' scapsul eHumanPhy siology /TheUr inarySy stem 7is
verysimi lart obl oodplasmai ncomposi ti
onasi tpassesi ntothepr oximal
convolut edt ubul e.Together,theglomer ulusandBowman' scapsul earecal l
ed
therenal corpuscl e.

Phy
siol
ogy

TheUrinar
ySy stem i
sagr oupofor gansinthebodyconcer nedwith
fi
lteri
ngoutexcessf l
uidandot hersubstancesfr
om thebloodstream.The
substancesaref i
l
teredoutfrom thebodyi nthefor
m ofurine.Urineisali
quid
producedbyt hekidneys,col
lectedinthebladderandexcretedthroughthe
urethra.Ur
ineisusedt oextr
actexcessmi neral
sorv i
taminsaswel lasblood
corpuscl
esf r
om thebody .TheUrinaryor
gansi ncl
udethekidneys,uret
er s,
bl
adder ,
andur et
hra.TheUr i
nar
ysy stem workswiththeothersystemsoft he
bodytohel pmaintai
nhomeost asis.Thekidneysarethemai norgansof
homeost asi
sbecauset heymaintaintheacidbasebalanceandt hewat ersalt
bal
anceoft hebloodFunct i
onsoft heUri
narySy st
em Oneoft hemajorf uncti
ons
oftheUrinarysyst
em istheprocessofexcr eti
on.

Excret ionist hepr ocessofel i

mi nat i
ng, f
r om anor gani sm, wast e
product sofmet abolism andot hermat er i
alsthatar eofnouse.Theur inary
system mai nt ainsanappr opriatef lui
dv olumebyr egul ati
ngt heamountofwat er
thatisexcr et edi nt heur ine.Ot heraspect sofi tsf unct ioni ncluder egul ati
ngt he
concent rationsofv ariousel ectrolytesint hebodyf l
uidsandmai ntainingnor mal
pHoft hebl ood.Sev eral bodyor ganscar r
youtexcr etion, butt heki dney saret he
mosti mpor tantexcr etor yorgan.Thepr imar yfunct i
onoft heki dney sisto
mai ntainast abl einternal environment( homeost asi s)f oropt i
mal cellandt issue
met abol i
sm.Theydot hisbysepar ati
ngur ea,mi ner al salts,toxi ns, andot her
wast epr oduct sf r
om t hebl ood.Theyal sodot hej obofconser v ingwat er,salts,
andel ect r
olytes.Atl eastoneki dneymustf unctionpr oper lyforl i
fet obe
mai ntained.Si xi mpor tantrolesoft heki dneysar e: Regul ationofpl asmai oni c
composi ti
on.I onssuchassodi um, potassi um, cal cium, magnesi um, chloride,
bicarbonat e,andphosphat esar er egulatedbyt heamountt hatt heki dney
excretes.

Regul
ati
onofpl
asmaosmol
ari
ty.

Thekidney
sregul
ateosmol
ari
tybecausetheyhav
edi
rectcont
rol
over
howmanyi
onsandhowmuchwat erapersonexcret
es.

Regul
ati
onofpl
asmav
olume.

Yourki
dney sar
esoi mpor t
antt
heyevenhav eanef f
ectonyourblood
pressure.Thekidneyscontrol
plasmav ol
umebycont rol
li
nghowmuchwat era
personexcretes.Theplasmav olumehasadirecteff
ectont hetot
alblood
volume, whi
chhasadi recteff
ectonyourbloodpressure.Salt
(NaCl
)will
cause
osmosi stoHumanPhy si
ology/TheUri
narySyst
em 2happen; thedif
fusionof
wat eri
ntotheblood.

Regul
ati
onofpl
asmahy
drogeni
onconcent
rat
ion(
pH)
.

Theki
dney
spar
tnerupwi
tht
hel
ungsandt
heyt
oget
hercont
rol
thepH.The
ki
dneyshaveamaj orrol
ebecausetheycontroltheamountofbi
carbonat
e
excr
etedorheldonto.Theki
dneyshelpmaintainthebl
oodPhmai nlyby
excr
eti
nghydrogenionsandreabsorbi
ngbicarbonatei
onsasneeded.

Remov
alofmet
abol
i
cwast
epr
oduct
sandf
orei
gnsubst
ancesf
rom t
hepl
asma.

Oneoft hemosti mportantthingsthekidney sexcreteisnitr

ogenouswast e.
Ast heli
v erbr eaksdownami noaci dsitalsoreleasesammoni a.Thelivert
hen
quicklycombi nest hatammoni awi thcarbondi oxi
de,creati
ngur eawhichist he
pri
mar yni trogenousendpr oductofmet abolism inhumans.Thel i
verturnsthe
ammoni ai ntour eabecausei ti
smuchl esstoxic.Wecanal soexcr etesome
ammoni a, creat i
nineandur i
cacid.Thecr eat
ininecomesf rom themet aboli
c
breakdownofcr eat i
nephospate( ahigh-energyphosphat einmuscl es).Ur
icacid
comesf rom t hebr eakdownofnucl eot
ides.Uricacidisinsolubl
eandt oomuch
uri
caci di nt hebl oodwi l
lbui
ldupandf orm cr y
stalsthatcancol l
ectinthejoint
s
andcausegout .

Secr
eti
onofHor
mones

Theendocr inesy stem hasassistancef r

om thekidney'swhenr eleasing
hormones.Reni ni srel easedbyt hekidneys.Reninleadstot hesecreti
onof
al
dosteronewhi chisr eleasedfrom theadr enal
cor t
ex.Aldosteronepr omotesthe
ki
dney storeabsor bt hesodi um (Na+)ions.Theki dneysalsosecr et
e
ery
thropoietinwhent hebl ooddoesn'thavet hecapacitytocar r
yoxy gen.
Eryt
hropoietinstimul atesredbloodcel lpr
oduction.TheVi taminDf rom theskin
i
salsoact i
v atedwi thhel pfrom thekidneys.Calci
um (Ca+)absor pti
onf rom the
di
gestivetractispr omot edbyvitaminD.

CHRONI
CRENALFAI
LURE

Chr onicrenalfail
ur e,orESRD, i
sapr ogr essi v
e, ir
reversibledeter
ior ati
onin
renal funct i
oninwhi cht hebody ’
sabi l
it
ytomai ntai
nmet abol i
candflui dand
electrolytebalancef ail
s, result
inginur emiaorazot emi a(retentionofur eaand
otherni trogenouswast esi nthebl ood).Thei nci denceofESRDhasi ncreasedby
almost8%pery earfort hepast5y ears,withmor et han300, 000pat i
ent sbeing
treatedi nt heUnitedSt ates( USRDS, 2001).ESRDmaybecausedbysy stemic
diseases, suchasdi abet esmel li
tus(leadi
ngcause) ;hypertension;chronic
glomer ulonephri
tis;
py elonephr i
ti
s; obstr
uctionoft heur i
naryt r
act;hereditary
l
esi ons, asi npolycy
sticki dneydi sease;vascul ardi sorders; i
nfecti
ons;
medi cat i
ons; ortoxi
cagent s.Aut osomal domi nantpol ycyst i
ckidneydi sease
account sfor8%t o10%ofcasesofESRDi ntheUni tedSt atesandEur ope
(Perr
one, Ruthazer&Ter ri
n,2001).Comor bidcondi ti
onst hatdev el
opduring
chronicrenalinsufficiencycontributetothehi ghmor bidi
tyandmor t
ali
tyamong
pati
entswi thESRD( Kauszetal .
,2001).Env i
ronment alandoccupat i
onalagent s
thathav ebeenimpl i
cat edinchronicrenalfail
ur eincludelead, cadmium,mer cury,
andchr omi um.Dialysisorkidneyt r
ansplantationev entuall
ybecomesnecessar y
forpatientsurvi
val.Dialysi
sisanef fecti
vemeansofcor r
ect i
ngmet aboli
c
toxi
citi
esatanyage, althoughthemor t
ali
tyrat eininfantsandy oungchil
drenis
greaterthanadult

PATHOPHYSI
OLOGY

Asr enal f
unctiondecl i
nes,t
heendpr oductsofpr oteinmet abol i
sm
(whichar enor mal lyexcretedi nur i
ne)accumul ateinthebl ood.Ur emi adev elops
andadv erselyaf fectsev erysy stem inthebody .Thegr eaterthebui ldupofwast e
product s,themor esev er et hesy mptoms.Ther ear ethreewel l-
recogni zedst ages
ofchr onicr enal disease: reducedr enalreserve, renalinsuffici
ency ,andESRD
(Chart45- 7).Ther ateofdecl i
nei nrenalfunctionandpr ogressionofchr onic
renalfailureisr elatedtot heunder ly
ingdisorder ,theur i
naryexcr et
ionofpr otein,
andt hepr esenceofhy per tension.Thedi seaset endst opr ogressmor er apidlyin
pati
ent swhoexcr et esignificantamount sofpr ot einorhav eelev at
edbl ood
pressuret hani nt hosewi thoutt hesecondi t
ions.

CLI
NICALMANI
FESTATI
ONS

Becausevir
tuall
yeverybodysystem i
saffect
edbytheuremiaofchronic
renalf
ailur
e,pati
entsexhibi
tanumberofsi gnsandsymptoms.Theseveri
tyof
thesesignsandsy mptomsdependsi npartonthedegreeofrenal
impai
rment ,
otherunderl
yingcondit
ions,andthepat
ient’
sage.

CARDI
OVASCULARMANI
FESTATI
ONS

Hy
per
tensi
on

Hypert
ension(duetosodi
um andwat err
etenti
onorfrom act
ivat
ion
ofther
enin–angi
otensin–al
doster
onesystem),hear
tfail
ureandpulmonary
edema(duetofluidov erl
oad),
andperi
cardit
is(
duetoirri
tati
onoftheperi
cardi
al
l
ini
ngbyur emi ctoxins)ar eamongt hecardiovascul
arproblemsmani f
est
edin
ESRD.St ri
ctflui dv olumecont r
ol hasbeenfoundt onormal i
zehyper
tensi
onin
pati
entsr ecei
v i
ngper i
toneal di
alysis(Gunal
, Duman,Ozkahy aetal
.,
2001).
Cardiovasculardiseasei st hepr edominantcauseofdeat hinpati
entswit
hESRD.
I
nchr onichemodi alysi
spat ients,approxi
mat el
y45%ofov eral
lmort
ali
tyi
s
att
ri
butabl etocar diacdisease, andabout20%oft hesecar di
acdeathsar
edueto
acutemy ocar diali
nf ar
ction( USRDS, 2001).

DERMATOLOGI
CSYMPTOMS

Severeit
ching(prur
itus)iscommon.Ur emicfrost
, t
hedeposi
tofurea
crystal
sont heskin,isuncommont odaybecauseofear l
yandaggressi
ve
treat
mentofESRDwi thdi
alysis.DERMATOLOGI CSYMPTOMSSev erei
tchi
ng
(pruri
tus)iscommon.Ur emicf rost,
thedepositofur
eacr ystal
sontheski
n,is
uncommont odaybecauseofear lyandaggressi
vetreatmentofESRDwi t
h
dialy
sis.

St
age1

Reducedr enalreserve,
char acter i
zedbya40%t o75%l ossofnephr on
function.Thepat i
entusual l
ydoesnothav esy mpt omsbecauset heremai ni ng
nephr onsareablet ocarryoutt henor mal f
unctionsoft heki dney .Stage2Renal
i
nsuf ficiencyoccur swhen75%t o90%ofnephr onf unctioni slost.Att hispoi nt,
theser um creati
nineandbl oodur eani t
rogenr i
se, t
heki dneyl osesi t
sabi li
t yto
concent rat
eur i
neandanemi adev el
ops.Thepat ientmayr epor tpolyuriaand
noctur i
a.Stage3End- stagerenal disease( ESRD) ,t
hefinal stageofchr onicr enal
fail
ure,occurswhent her eislesst han10%nephr onf unctionr emaining.Al l ofthe
normal r
egulator
y,excretory,andhor monal functionsoft heki dneyar esev erel
y
i
mpai red.ESRDi sev i
dencedbyel ev atedcreatinineandbl oodur eani t
rogen
l
ev el
saswel laselectrol
yteimbal ances.Oncet hepat ientr eachest hispoi nt,
dialy
sisi susuall
yindicated.Manyoft hesympt omsofur emi aarer eversiblewi th
dialy
sis

OTHERSYSTEMI
CMANI
FESTATI
ONS

GIsignsandsy mptomsar ecommonandi ncludeanorexi

a, nausea,
vomiti
ng,andhiccups.Neurologi
cchanges, incl
udingalt
eredlevelsof
consci
ousness,inabi
li
tyt
oconcent rate,muscletwitchi
ng,andseizures,have
beenobserved.Thepreci
semechani smsf ormanyoft hesediversesignsand
symptomshav enotbeeni denti
fied.Itisgeneral
lythought,howev er,
thatt
he
accumul
ati
onofur
emicwast
epr
oduct
sisthepr
obablecause.Chart45-8
summari
zesthesi
gnsandsy
mpt
omsof t
enseeninchroni
crenalf
ailur
e.

ASSESSMENTANDDI
AGNOSTI
CFI
NDI
NGS

Glomer ularFiltrat
ionRat eDecr easedGFRcanbedet ectedbyobt aininga24-
hourur inal y
si sforcr eat ininecl ear ance.Asgl omer ularfil trati
ondecr eases( due
tononf unct ioninggl omer uli
) ,t
hecr eat i
ni neclearancev al uedecr eases, wher eas
theser um cr eatini
neandBUNl ev elsi ncr ease.Ser um cr eat i
ninei st hemor e
sensi t
ivei ndicat orofr enal funct i
onbecauseofi tsconst antpr oduct i
oni nthe
body .TheBUNi saf fect ednotonl ybyr enal di
seasebutal sobypr oteini ntakei n
thedi et,catabol ism ( t
issueandRBCbr eakdown) , parent eralnut rition, and
medi cationssuchascor ti
cost er oids.SODI UM ANDWATERRETENTI ONThe
kidneycannotconcent rat eordi l
ut et heur i
nenor mal lyinESRD.Appr opr iate
responsesbyt heki dneyt ochangesi nt hedai l
yintakeofwat erandel ect rol
y tes,
therefore, donotoccur .Somepat i
ent sr etainsodium andwat er,incr easi ngt he
ri
skf oredema, heartfai lure, andhy per tension.Hy pertensi onmayal sor esult
from act i
v ationoft her enin–angi otensin–al dosteroneaxi sandt heconcomi tant
i
ncr easedal dost eronesecr etion.Ot herpat i
entshav eat endencyt ol osesal tand
runt her i
skofdev elopinghy pot ensi onandhy pov olemi a.Epi sodesofv omi t
ing
anddi arrheamaypr oducesodi um andwat erdeplet i
on, whi chwor senst he
uremi cst ate.

ACI
DOSI
S

Wit
hadv ancedr enaldi
sease, metaboli
cacidosisoccur
sbecauset he
ki
dneycannotexcreteincreasedloadsofaci d.Decreasedacidsecret
ion
pri
maril
yresult
sfrom inabil
it
yoftheki dneytubulestoexcret
eammoni a(
NH3−)
andtoreabsorbsodium bicarbonate(HCO3−) .Thereisalsodecreasedexcret
ion
ofphosphatesandot herorganicacids.

ANEMI
A

Anemi adev el
opsasar esultofinadequateer ythr
opoieti
npr oducti
on,
theshor t
enedl i
fespanofRBCs, nutrit
ionaldeficienciesandt hepatient’
s
tendencytobl eed,part
icul
arl
yfr
om t heGIt ract
.Erythropoieti
n,asubstance
normal l
ypr oducedbythekidney,st
imul at
esbonemar rowt oproduceRBCs.I n
renalfai
lure,eryt
hropoi
etinpr
oductiondecr easesandpr of
oundanemi aresul
ts,
pr
oduci
ngf
ati
gue,
angi
na,
andshor
tnessofbr
eat
h.

CALCI
UM ANDPHOSPHORUSI
MBALANCE

Anot hermaj orabnor mal i

tyseeni nchr onicr enalfai l
ureisadi sor derin
calcium andphosphor usmet abolism.Ser um cal cium andphosphat el evelshave
ar ecipr ocal relati
onshi pi nthebody :asoner ises,theot herdecr eases.Wi t
h
decr easedfil t
rationt hrought heglomer ulusoft heki dney, therei
sani ncreasein
theser um phosphat el evelandar eciprocal orcor respondi ngdecr easei nt he
serum cal cium l evel.Thedecr easedser um cal cium level causesincr eased
secr etionofpar athor monef rom thepar athyroidgl ands.I nr enalf
ail
ur e,howev er
,
thebodydoesnotr espondnor mallytot hei ncreasedsecr et i
onofpar at hormone;
asar esul t,calcium l eavest hebone, oft
enpr oducingbonechangesandbone
disease.I naddi ti
on, theact i
vemet aboliteofv itami nD( 1,25-
dihydr oxy chol ecalciferol)normal l
ymanuf acturedbyt heki dneydecr easesas
renal failurepr ogr esses.Ur emi cbonedi sease, of t
encal ledr enalosteody str
ophy
,
dev elopsf r
om t hecompl exchangesi ncal ci
um, phosphat e,andparat hor mone
balance( Bar nas, Schmi dt,Seidletal.,2001) .

COMPLI
CATI
ONS

Pot
ential
compl
icat
ionsofchroni
crenal
fai
lur
et hatconcer
nthenur
seand
t
hatnecessi
tat
eacoll
aborat
iveappr
oachtocareincludethef
oll
owi
ng:

•Hyper
kal
emiaduetodecr
easedexcreti
on,met
abol
i
caci
dosi
s,cat
abol
i
sm,
and
ex
cessi
vei
ntake(
diet
,medi
cati
ons,f
luids)

•Per
icar
dit
is,
pericar
dial
eff
usi
on,andperi
car
dial
tamponadeduet
oret
ent
ionof
ur
emicwasteproductsandi
nadequat
edial
ysi
s

Hypert
ensi
onduet osodium andwaterr
etent
ionandmal
funct
ionoft
he
r
enin–angi
otensi
n–aldoster
onesyst
em

•Anemiaduetodecr
easeder
ythropoi
etinproducti
on,
decreasedRBCl
if
espan,
bl
eedi
ngintheGItr
actfr
om i
rr
itat
ingtoxins,andbl
oodlossduri
nghemodi
aly
sis

•Bonediseaseandmetastat
iccal
cificat
ionsduetoret
enti
onofphosphor
us,l
ow
ser
um calci
um l
evel
s,abnormalvi
taminDmet abol
ism,andel
evat
edaluminum
l
evel
s

MEDI
CALMANAGEMENT
 Thegoal ofmanagementi stomai nt
ainki
dneyf uncti
onandhomeost asi
sfor
aslongaspossi ble.Allfact
orsthatcontri
butetoESRDandal lfact
orsthatare
reversibl
e( eg,obstr
uction)areidenti
fiedandt r
eated.Managementi s
accompl ishedpr i
mar i
l
ywi thmedi cat
ionsanddiettherapy,al
thoughdialysi
smay
alsobeneededt odecreasethel evel
ofuremicwast eproductsintheblood( Fi
nk
etal.,2001) .

PHARMACOLOGI
CTHERAPY

Compl i
cat i
onscanbepr event edordel ayedbyadmi ni
steri
ngprescri
bed
ant i
hypertensi ves,erythropoieti
n( Epogen) ,
ironsuppl ement s,phosphate-bi
ndi
ng
agent s,andcal cium suppl ement stoxi ci
tyofal uminum andt heassociati
onof
highal umi num l evelswithneur ologi csympt omsandost eomal aciahaveled
somephy sicianst oprescr ibecalcium car bonat ei
npl aceofhi ghdosesof
alumi num- basedant acids.Thismedi cati
onal sobindsdi etaryphosphorusinthe
i
nt estinaltractandper mitst heuseofsmal lerdosesofant acids.Bothcalci
um
car bonateandphosphor usbindingant aci
dsmustbeadmi nisteredwithfoodto
beef fective.Magnesi um- basedant acidsmustbeav oidedt opreventmagnesium
toxicity.

Ant
ihy
per
tensi
veandCar
diov
ascul
arAgent
s.

Hy pertensi
oni smanagedbyi nt
ravascularv olumecontrolandav ari
etyof
antihypertensiveagent s.Heartf
ail
ureandpul monar yedemamayal sor equi
re
treatmentwi t
hflui dr estri
cti
on,l
ow-sodium diets, diur
eti
cagents,i
not
ropic
agentssuchasdi gitali
sordobut amine,anddialy sis.Themetaboli
cacidosisof
chronicr enal f
ail
ureusual lyproducesnosy mpt omsandr equi
resnotreatment ;
howev er, sodium bicarbonatesupplement sordi alysismaybeneededt ocor rect
theaci dosisifitcausessy mptoms( Tonell
ietal., 2001).

Ant
isei
zur
eAgent
s.

Neur ol
ogicabnormali
tiesmayoccur , sothepatientmustbeobser vedfor
earl
yev i
denceofsl i
ghttwi
tching,headache, del
iri
um, orsei
zureactivi
ty.If
sei
zuresoccur ,t
heonsetoft heseizurei
sr ecordedalongwi t
ht hetype,durati
on,
andgener aleff
ectonthepat i
ent.Thephy sici
anisnot i
fiedimmedi atel
y.
Int
ravenousdiazepam (Val
ium)orpheny t
oi n(Di
lanti
n)isusuall
yadmi nister
edt o
contr
ol sei
zures.Thesider
ai l
soft hebedshoul dbepaddedt oprotectthepatient.

Er
ythr
opoi
eti
n.
 Anemi aassoci at edwi thchr oni cr enal fail
ur ei st reat edwi t
hr ecombi nant
humaner y
t hr opoi etin( Epogen) .Anemi cpat i
ents( hemat ocritlesst han30%)
presentwi thnonspeci ficsy mpt oms, suchasmal aise, gener al fatigabi l
ity,and
decr easedact i
vityt ol erance.Epogent her apyi si nitiatedt oachi ev eahemat ocrit
of33%t o38%, whi chgener allyallev i
at est hesy mpt omsofanemi a.Epogeni s
admi nisteredei theri nt rav enousl yorsubcut aneousl yt hr eet imesaweek.I tmay
take2t o6weeksf ort hehemat ocr i
tt or ise; theref or e, Epogeni snoti ndi catedf or
patient swhoneedi mmedi atecor r ectionofsev er eanemi a.Adv er seef fect sseen
wi t
hEpogent her apyi ncl udehy per tensi on( especi allydur ingear l
yst agesof
treatment ),incr easedcl otti
ngofv ascul araccesssi tes, sei zur es, anddepl eti
onof
bodyi ronst or es( Finketal .,2001) .Thepat i
entr ecei vingEpogenmayexper i
ence
i
nfluenza- l
ikesy mpt omswi thiniti
at ionoft her apy ;t heset endt osubsi dewi th
repeat eddoses.Managementi nvol vesadj ustmentofhepar int opr ev entcl otti
ng
oft hedi alysi slinesdur inghemodi alysist r eatment s, f
requentmoni tor i
ngof
hemat ocr i
t, andper iodi cassessmentofser um i ronandt ransf er rinlev els.
Becauseadequat est or esofi ronar enecessar yf oranadequat er esponset o
erythr opoiet in,suppl ement ar yironmaybepr escr ibed.I naddi t
ion, t
hepat i
ent ’
s
bloodpr essur eandser um pot assi um l ev el aremoni toredt odet ecthy per t
ension
andr i
singser um pot assi um l evels, whi chmayoccurwi tht her apyandt he
i
ncr easi ngRBCmass.Theoccur r
enceofhy per tensi onr equi resi ni t
iationor
adjust mentoft hepat ient ’
sant i
hyper tensi v ether apy .Hy per tensi ont hatcannot
becont r
olledi sacont raindicat i
ont or ecombi nanter y t
hr opoi etint her apy .
Pat i
ent swhohav er ecei vedEpogenhav er epor t
eddecr easedl ev elsoff ati
gue, an
i
ncr easedf eel i
ngofwel l-
bei ng,bet tert oler anceofdi aly sis, higherener gylev el
s,
andi mpr ov edexer ciset olerance.Addi ti
onal l
y ,t
hi st her apyhasdecr easedt he
needf ort r
ansf usi onandi tsassoci at edr isks, i
ncl udi ngbl oodbor neinf ect i
ous
disease, ant ibodyf or mat ion, andi ronov er l
oad

NUTRI
TIONALTHERAPY

Di
etaryinter venti
oni snecessar ywithdet eri
orat
ionofr enal functionand
i
ncludescar eful regulati
onofpr otei
nintake,fluidintaketobal anceflui dlosses,
sodium int
aket obal ancesodi um losses, andsomer estr
ict
ionofpot assium.At
thesamet ime, adequat ecal or
icintakeandv i
taminsuppl ement ationmustbe
ensured.Protei nisrestrictedbecauseur ea,uri
cacid, andorgani cacids—t he
breakdownpr oduct sofdi etaryandt i
ssuepr otei
ns—accumul ater apidlyinthe
bloodwhent her eisimpai redrenal cl
earance.Theal lowedpr oteinmustbeof
highbiol
ogicv alue(dairypr oducts,eggs, meats).Hi
gh- bi
ologic-valuepr otei
nsare
thoset hatarecompl etepr ot einsandsupplytheessenti
alami noaci dsnecessary
forgr owt handcel lrepai r
.Usual ly,
theflui
dal l
owanceis500t o600mLmor e
thant hepr eviousday ’
s24- hourur i
neoutput.Calor
iesaresuppl i
edby
car bohy dr
atesandf attopr ev entwasti
ng.Vitaminsupplement ati
oni snecessar
y
becauseapr otein-
restricteddi etdoesnotprovidethenecessar ycompl ementof
vitami ns.Additionall
y ,
thepat i
entondialysi
smayl osewater-solublev i
tamins
from t heblooddur ingt hedi alysistr
eat
ment .

OTHERTHERAPY:
DIALYSI
S

Hyperkalemi aisusuallypr
ev entedbyensur i
ngadequat edialysi
s
treatmentswi t
hpot assium remov alandcar efulmoni t
ori
ngofal lmedications,
bothor alandintravenous, f
ortheirpotassium cont ent
.Thepat ientisplacedona
potassium-restr
icteddi et
.Occasionally,Kayexalate,acati
on-exchanger esin,
admi ni
steredorally,maybeneeded.Thepat ientwi thi
ncreasi
ngsy mptomsof
chronicrenalfail
urei srefer
redtoadi alysisandt r
ansplantati
oncent erear lyi
n
thecour seofprogr essiverenaldi
sease.Di alysi
sisusuallyini
tiatedwhent he
patientcannotmai ntainar easonableli
f est
ylewithconser vat
ivet r
eatment .

NURSI
NGMANAGEMENT

Thepatientwithchroni
crenal f
ail
urer
equir
esastut
enursingcaretoavoi
d
thecompl
icat
ionsofr educedrenalfunct
ionandthest
ressesandanxieti
esof
deal
ingwi
thal i
fe-t
hreateni
ngil
lness.Examplesofpot
enti
alnursi
ngdiagnoses
fort
hesepati
entsincludethefoll
owing:

•Excessfluidvol
umer el
atedtodecr
easedur
ineout
put
,di
etar
yexcesses,
andret
entionofsodi
um andwat er

•I
mbalancednutr
it
ion:l
essthanbodyrequi
rement
sr el
atedt
oanor
exi
a,
nauseaandvomiti
ng,diet
aryr
estri
cti
ons,
andalter
edoralmucousmembranes

•Defici
entknowl
edger
egar
dingcondi
ti
onandt
reat
mentr
egi
men

•Act
ivi
tyi
ntoler
ancer
elat
edt
ofat
igue,
anemi
a,r
etent
ionofwast
epr
oduct
s,
anddi
aly
sisprocedur
e

•Lowself
-esteem r
elat
edtodependency
,rol
echanges,
changesi
nbody
i
mage,andsexualdysf
uncti
on
 NURSI
NGDI
AGNOSI
S

 Excessfluidvol
umerelat
edtodecreasedurineout
put
,di
etaryexcesses,
andretent
ionofsodi
um andwaterasevidencedbyABGreport

I
mbalancednut
ri
ti
on;l
essthanbodyr
equi
rementsr
elat
edt odiet
ary
r
est
rict
ions,
andal
ter
edoralmucousmembranesasevidencedby
wei
ght

I
mbalancednut
ri
ti
on;l
essthanbodyr
equi
rement
srel
atedt
odi
etar
y
r
est
ri
ctions,
andal
ter
edoralmucousmembranes

 Defici
entknowl
edger
egar
dingcondi
ti
onandt
reat
mentasev
idencedby
quest
ioni
ng

 Dist
urbedsel
f-est
eem r
elat
edtodependency
,rol
echanges,
changei
n
bodyimage,andchangeinsexual
funct
ion

 RiskforHyper
kalemia;
per
icar
dit
is,
peri
car
dial
eff
usi
on,
andpericar
dial
tamponade;hypert
ensi
on;
anemia;bonedi
seaseandmetast
ati
c
calci
ficat
ions
 Heal
theducat
ion

 Keepaheal
thybl
oodpr
essur
e.

 Fol
l
owal
ow-
sal
t,l
ow-
fatdi
et.

 Exer
ciseatl
east30mi
nut
esonmostday
soft
heweek.

 Keepaheal
thywei
ght
.

 Donotsmokeoruset
obacco.

 Li
mital
cohol
.

ki
dney
-fr
iendl
ydi
et
 kidney-f
riendl
ymeal pl
anwheny ouhav echronickidneydisease(CKD).
Wat chi
ngwhaty oueatanddr i
nkwil
lhelpy oustayhealthi
er.Akidney-
fr
iendlydietmayal sohelpprot
ectyourkidneyfrom f
ur t
herdamageby
l
imitingcertainfoodstoprev
entthemi neralsi
nthosef oodsfrom bui
ldi
ng
upinbody

Don'
tsmoke.
 

Cigar
ettesmoki ngcandamageyourki
dneysandmakeexi st
ingkidney
damagewor se.Ifyou'
reasmoker,t
alkt
oyourdoctoraboutst
rat
egiesfor
quit
ti
ngsmoki ng.Supportgr
oups,
counsel
i
ngandmedi cati
onscanallhelpyout
o
stop

THEORY

Or
em’
sSel
f-
Car
eDef
ici
tTheor
yinHomeDi
aly
sisPr
ogr
ams
 
Orem’
ssel
f-
car
edef
ici
ttheor
yasar
efer
encei
ncont
inui
ngsuppor
tofhome
di
aly
sis;

Thesy
mpt
omsassoci
atedwi
thEndSt
ageRenal
Disease(
ESRD)j
ust
pr
iort
othei
nit
iat
ionofr
enal
repl
acementt
her
apyencompasshopel
essnessi
n
manycases.Lossofappet
it
e,l
ethar
gy,
decr
easedment
alcapaci
ty,
lossof
ener
gy,
weakness,
andshor
tnessofbr
eat
har
ecommonsy
mpt
omsof
depr
essi
ony
ett
heyar
eal
sot
hesy
mpt
omsassoci
atedwi
thESRD.Cur
rent
pr
act
icewi
thpr
ogr
essi
ngChr
oni
cKi
dneyDi
sease(
CKD)aswel
laspat
ient
sthat
“
showup”i
nESRDpr
ovi
det
hesepat
ient
sandf
ami
l
ymember
swi
thchoi
ces
whent
heyar
emostv
ulner
abl
epsy
chol
ogi
cal
l
yanddesi
resomeonet
otakeov
er
f
orawhi
l
e.I
nmyexper
ience,
theyhav
eal
readywi
thdr
awnf
rom manyf
ami
l
y
f
unct
ionsorot
herper
sonal
l
yenj
oyabl
eli
feact
ivi
ti
est
hathav
ebr
oughtmeani
ng
t
othei
rli
vesduet
othesl
owonsetofsy
mpt
oms.

Or
em’
stheor
yst
atest
hatsel
f-
car
eanddependentcar
ear
elear
ned
behav
ior
sandi
tisst
eepedi
nthebel
i
eft
hatpeopl
ear
esel
f-
rel
i
antand
r
esponsi
blef
ort
hei
rowncar
e.Theappl
i
cat
ionofef
fect
ivei
ndi
vi
dual
i
zedsel
f-
car
ebehav
ior
sisessent
ial
toov
eral
lheal
th.Asnur
singpr
ofessi
onal
s,wecan
pr
ovi
det
het
ool
spat
ient
sandt
hei
rsuppor
tsy
stemsneedt
opr
omot
esuccessf
ul
sel
f-
car
ebehav
ior
s. 
Orem st
atest
hatnur
singi
sneededwhensel
f-
car
e
r
equi
sit
esexceedt
heper
son’
scapabi
l
iti
es.wi
tht
hepur
poseofnur
singt
ofocus
ont
hepat
ient
’sabi
l
ityt
otakecar
eoft
hemsel
ves.

Cr
it
ical
Anal
ysi
s

Mr
sSar
ojawas76y
ear
sol
dgotadmi
tt
edi
nSav
eet
haMedi
cal
Col
l
egeand
Hospi
tal
wit
hthecompl
aintofv
omi
ti
ngf
or3day
sloosest
ool
sforsev
eral
epi
sodeand
t
her
eisapr
esenceofol
i
gur
iabydoi
ngaphy
sical
exami
nat
ionshehadadul
ll
ook 
dry
ski
nImpr
essi
onsofpedal
edemai
nvest
igat
ionhemogl
obi
nis6mgperDLwhi
ch
i
ndi
cat
eanaemi
a,cr
eat
inel
evel
incr
easesandi
ntakeout
putchar
tshowst
hepr
esence
ofol
i
gur
iapat
ienti
snowundert
reat
mentPhar
macol
ogymanagement,
nur
sing
managementandheal
theducat
ionwasgi
vent
othepat
ient

Concl
usi
on

MrsSar oj
awas76y earsoldgotadmittedinSaveet
haMedicalColl
ege
andHospi talwiththecomplaintsofvomit
ingfor3day sandloosest
oolsfor
severalepisodeandt her
eisapr esenceofal
l oli
guri
asheunderwental
lthe
i
nv est
igati
onsandphy si
ci
andi agnoseddi
agnosedhert ohaveadehydrati
onand
chronickidneydiseasestage5andsheshei saknowncaseofchr oni
ckidney
diseaseanddi abeticmell
it
us.sheisnowundert reat
ment.
Bi
bli
ogr
aphy

Br
unnerAndSuddar
th“
TextBookOfMedi
cal
Sur
gical
Nur
sing12Th
Edi
ti
onByWol
ter
sKl
uwer

Jay
aM.
BlackJuneHokamanMedi
cal
Sur
gical
Nur
sing3RdEdi
ti
on
Publ
i
shedByEl
sev
ier

Pot
terAndPer
ryFundament
alsOfNur
sing6thEdi
ti
onPubl
i
shedBy
El
sev
ier2005

Netr
efer
ence

ht
tp/
/www.
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pedi
a.or
g

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icanassoci
ati
onofki
dney.
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