Chapter 67: Care of Patients with Kidney Disorders

Key Points

The priority concept applied in this chapter is ELIMINATION.

 Kidneys: urinary ELIMINATION, FLUID AND ELECTROLYTE BALANCE, ACID– BASE BALANCE.
 Disorders are congenital, obstructive, infectious, immunologic (glomerular), or degenerative.

Three Functions of the Kidneys: Urine formation, Regulation, Hormonal

 Polycystic Kidney Disease (PKD)

 Polycystic kidney disease (PKD) is an inherited disorder wherein fluid-filled cysts

develop. Genetic Two types:
 Recessive (Childhood): All nephrons turn into cysts, usually die in early
childhood 
 Dominant (Adult 30’s): Few nephrons turn into cysts and gets worst with age
function becomes less affective
 Relentless development and growth of cysts from loss of CELLULAR REGULATION and
abnormal cell division result in progressive kidney enlargement. 

Symptoms:

 Pain is often the first manifestation, and a distended abdomen is common. 

 The patient may have flank PAIN caused by increased kidney size with distention or by
infection within the cyst. 
 Urinalysis shows proteinuria, hematuria, and bacteria, if INFECTION is present. Diagnostic
studies may include renal ultrasonography, computed tomography scan, and magnetic
resonance imaging. H&H (Anemia)
 Sodium, Potassium, Phosphorous elevated Kidneys are not clearing 
 Calcium, Vitamin D Low
 Check weight often because of sodium and water retention
 Don’t take too much of any electrolyte because kidneys are not clearing 
 Comfort strategies include drug therapy and complementary approaches.
 Imagine 

 MRI because it is soft tissue 

 Interventions: 
 include pain management (abdominal and back) and prevention of infection,
constipation, hypertension, and chronic kidney disease. 
 There is no way to prevent this disease, although early detection and management of
hypertension may slow the progression of renal damage and reduce cardiovascular
complications. 
 Check weight because of sodium and water retention 
  Long term the PT Dialysis and Eventually Transplant 
 Refer patients with PKD to a geneticist or a genetic counselor. 
 PKD is nonrevivable BP is a chronic problem 
 On ace inhibitors 
 Antibiotics for UTI
 Pain Meds 

INFECTIOUS DISORDERS 

 PYELONEPHRITIS (Upper UTI)

 Acute pyelonephritis: involves immunity responses leading to acute tissue inflammation, 

local edema, tubular cell necrosis, and possible abscess formation anywhere in the 

kidney. 

 Chronic pyelonephritis: often occurs with structural deformities, urine status, obstruction,
or when urine refluxes from the bladder back into the ureters. 
 PT needs to be hospitalized
 Symptoms 
 abdominal discomfort or repeated, low-grade fevers. Pyelonephritis from an
ascending infection may follow the placement of a catheter, particularly in
patients who have reduced IMMUNITY or who have diabetes. 
 Meds
 Antibiotics, fluid replacement, pain meds, fever antipyretics, urinary analgesics
 In patients with chronic kidney stone disease, stones may retain organisms, resulting in ongoing infection
and kidney scarring. High-dose or long-term use of some drugs can lead to papillary necrosis and reflux. 
 Other causes of kidney scarring contributing to increased risk for pyelonephritis are inflammatory
responses resulting from IMMUNITY excesses with antibody reactions, cell- mediated immunity against
the bacterial antigens, or autoimmune reactions. 
 As a result, filtration, reabsorption, and secretion are impaired and kidney function is reduced. 
 The focus of care for these patients is to manage the structural or functional abnormality that contributes to
recurrent infection and inflammatory fibrosis. 
 Urinalysis shows a positive leukocyte esterase and nitrite dipstick test and the presence of white blood cells
and bacteria. 
 Blood cultures may be obtained to determine the source and spread of infectious organisms. Other blood
tests include the WBC count and differential of the complete blood count, as well as C-reactive protein and
erythrocyte sedimentation (ESR) rate to determine IMMUNITY responses and presence of inflammation. 
 Blood urea nitrogen (BUN) and creatinine are used as baseline and to trend recovery or deterioration.
Estimate of glomerular filtration rate (GFR) also is used to trend kidney function. 
 X-ray of the kidneys, ureters, and bladder and IV urography are performed to diagnose stones or
obstructions. 

 Cystourethrogram is indicated for some patients to define urinary tract structures and identify any defects,
such as stones, obstructions to the outflow of urine, and urine reflux caused by incompetent bladder-ureter
valve closure. 
 Interventions include the use of drug therapy with antibiotics, analgesics if needed, diet and fluid therapy,
and teaching to ensure the patient’s understanding of the treatment. 
  Preventing complications is an important nursing intervention, especially when FLUID AND
ELECTROLYTE BALANCE is disrupted. 
 The success of techniques that crush stones, such as lithotripsy and percutaneous ultrasonic pyelolithotomy,
has decreased the need for surgery. 
 Other procedures to improve lower urinary tract drainage include pyelolithotomy, nephrectomy, ureteral
diversion, or reimplantation of the ureter to restore proper bladder drainage. 

 Glomerulonephritis (Inflammation or injury to the filter of the kidney)

Risk Factors:
 Infection (strep)
 Lupus (auto
immune disorders)
 Diabetes

Acute
Glomerulonephritis 

 Glomerulonephritis is the third leading cause of end-stage kidney disease. Acute

glomerulonephritis (GN) develops suddenly from an excess IMMUNITY response
within the kidney tissues. Usually an infection is noticed before kidney symptoms
of acute GN are present. The onset of symptoms is about 10 days from the time of
infection. 
 Usually patients recover quickly and completely from acute GN. 
 Decrease in GFR
 Passing through in urine: proteinuria, hematuria, decreased glomerular
filtration rate, edema, and hypertension. 
 Backup in fluid that leads to congestion and pulmonary edema in older PT
with heart failure
 Oliguria: not passing enough urine (be careful with dietary and fluid restriction
low)
 Vitals increase BP 
 Mild to moderate hypertension occurs with acute GN as a result of
impaired FLUID AND ELECTROLYTE BALANCE with fluid and sodium
retention. 
 Labs 
 ASO tides increase (children R/T strep)
 BUN Creatinine increase 
 GFR decrease
 Monitor 
 
 Daily weight
 Check passage of the infection (cuts openings)
  Meds
 Antibiotics penicillin, diuretics, antihypertension, steroids for
inflammatory response (not always recommended)
 Prevention
 Handwashing
 Dialysis and Plasma filtration to alleviate the process
 Many causes of primary GN are infectious and secondary glomerulonephritis can be caused by multi-system diseases,
manifested as acute or chronic disease.
 Primary and secondary glomerulonephritis, both demonstrate altered IMMUNITY. Drugs and inherited disorders are also
implicated in glomerulonephritis with an acute or chronic presentation.
 The extent and duration of renal injury, prognosis, and specific cause vary.
 Both antibody and cellular immune responses leading to inflammation are involved.
 The resultant kidney disorder can be systemic or confined to the kidneys.
 Urinalysis demonstrates red blood cells and protein.
 A renal biopsy provides a precise diagnosis of the condition, assists in determining the prognosis, and helps outline
treatment.
 Interventions focus on managing infections, fluid overload, preventing complications, and providing appropriate patient
education.
 Ask about any systemic diseases that alter IMMUNITY such as systemic lupus erythematosus (SLE), which could cause
acute GN.
 Ask about changes in urine ELIMINATION patterns and any change in urine characteristics. Rapidly Progressive

Glomerulonephritis

 Rapidly progressive glomerulonephritis (RPGN), a type of acute nephritis, develops over several weeks or months and causes
loss of renal function.
 Patients become quite ill quickly and have manifestations of kidney impairment (hypertension, oliguria, disturbed FLUID AND
ELECTROLYTE BALANCE, and uremic symptoms).
 The patient may have had previous infection or systemic disease, such as SLE. When associated with SLE, steroid therapy is
recommended.
 Regardless of treatment, RPGN often progresses to ESKD.

Chronic Glomerulonephritis

 Chronic glomerulonephritis, or chronic nephritic syndrome, develops over 20 to 30 years or even longer, yet the exact onset of
the disorder is rarely identified.
 Although the exact cause is not known, changes in the kidney tissue result from infection, hypertension, inflammation from
IMMUNITY excess, or poor blood flow to the kidneys.
 Decreased kidney function causes disturbed FLUID AND ELECTROLYTE BALANCE.
 Disturbances of ACID–BASE BALANCE with acidosis develop from hydrogen ion retention and loss of bicarbonate.
 Management
 consists of diet changes, fluid intake sufficient for renal perfusion, and drug therapy to control the problems from uremia.
 Eventually, the patient requires dialysis or transplantation.

 RENAL CELL CARCINOMA

 Renal cell carcinoma is also known as adenocarcinoma of the kidney is the most common
type of kidney cancer and occurs as a result of impaired CELLULAR REGULATION 
 Occurring more often in patients between 55 and 60 years of age, the 5-year survival rate
for renal cell carcinoma is only 60% in the United States. 
 Renal tumors are classified into four stages, and complications include metastasis and
urinary tract obstruction. 
  Tumors 
 compress tissues underneath, tissue pressure reduces circulation, this alters kidney
function and leads to kidney failure
 Risk Factor 
 Tobacco use, heavy metal exposure
 Symptoms
 Triad of symptoms as tumor grows and compresses tissues: 
 1) Flank mass 2) Flank Pain 3) hematuria 
 Only about 5% to 10% of patients with renal cell cancer have flank pain, obvious
blood in the urine, and a kidney mass that can be palpated. 
 Bloody urine is a late common sign, but urinalysis may show red blood cells. 
 Imaging
 Renal masses may be detected by surgical exploration, IV urogram with
nephrograms, or ultrasonography. 
 CT, MRI to check for masses 
 Stages
 Stage 1) Mass is in renal capsule
 Stage 2) Moves to renal gland
 Stage 3) Affects lymph nodes
 Stage 4) Spreads to other organs
 Interventions
 focus on controlling the cancer and preventing metastasis. 
 Radiofrequency ablation can slow tumor growth and biological response
modifiers have lengthened survival time, but chemotherapy has limited
effectiveness against this cancer type.
 Renal cell carcinoma is usually treated surgically by nephrectomy
(ectomy=removal) (removal of kidney) and, because the kidneys are highly
vascular, blood loss during surgery is a major concern. 

 KIDNEY TRAUMA

 Trauma to one or both kidneys is always a concern with penetrating wounds or blunt
injuries to the back, flank, or abdomen.
 Risks:
 Contact Sports, Motor vehicle accidents (not wearing seatbelts)
 Not wearing protective clothing 
 Minor injuries include contusions, small lacerations, and tearing of the renal parenchyma. 
  Five grades based upon the severity of the injury. 
 Grade 1: Consists of low-grade injury in the
form of kidney bruising 

 Grade 5: the most sever variety associated

with shattering of the kidneys and tearing of
it’s blood supply 
 Traumatic kidney injury can also cause hypertension from changes in perfusion and
activation of the renin–angiotensin–aldosterone system.
 Assess
 Vital signs, signs or bruising, urinary output (absent, increased or decreased),
pain, bloody urine (if they lose a lot of blood they can go into shock), I&O,
Hematocrit level
 Diagnostic 
 procedures include IV urography and computed tomography.
 Interventions
 Goals: Control bleeding Prevent shock, promote urinary drainage
 Shock- replace blood volume / normal saline anf other blood products 
 Drug therapy is aimed at bleeding prevention or control. 
 Nephrectomy or partial nephrectomy may be needed. 
 When major blood vessels are torn, the kidney may be removed, repaired, and
then reimplanted, a process called “bench surgery.” 
 Teach
 the patient and family how to assess for INFECTION and other complications
following kidney trauma.
 Instruct the patient to check the pattern and frequency of urine ELIMINATION. 

 Nephrotic Syndrome (NS)

 Nephrotic syndrome (NS) is an immunologic kidney condition of increased glomerular

permeability that allows massive loss of protein in urine, edema formation, and decreased
plasma albumin. The most common cause of glomerular membrane changes is altered
IMMUNITY with inflammation. 
 Labs 
 Proteinuria: Severe loss of protein albumin (blood protein) over 3.5g in 24 hr. 
 Delayed Clotting: show higher than normal partial thromboplastin time aPTT,
INR and PT
 Elevated BUN & Creatinine: reduced kidney function
 Decreased GFR
 Symptoms
 Foamy frothy urine 
 Severe EDEMA 
  hypoAlbuminemia (helps to retain the fluid in the vessels, without albumen the
fluid leaks out and cause peripheral edema, edema in legs, asities(abs swell),
periorbital edema= (eyes))
 Hyperlipidemia caused by the liver trying to make up for protein loss by making
lipids resulting in PT with high cholesterol 
 Interventions
 Treatment varies depending on the causative change identified by renal biopsy. 
 Diet changes (depending on GFR eat more or less protein) GFR: if you can’t filter
there will be a backflow)
 Meds:
 Heparin (clot prevention), ACE inhibitors: to decrease protein loss, Cholesterol
lowering agents, Mild Diuretic/ sodium restriction: edema and HTN, steroids and
cytotoxic or immunosuppressive agents: For excess immunity.

Nephrosclerosis

 Nephrosclerosis is a problem of thickening in the blood vessels, resulting in narrowing of the vessel lumen and
decreased renal blood flow.
 Nephrosclerosis occurs with hypertension, atherosclerosis, and diabetes mellitus.
 The changes may be reversible or may progress to end-stage kidney disease.
 Treatment aims to control high blood pressure and reduce albuminuria to preserve renal function.
 Use of steroids, cytotoxic or immunosuppressive agents may improve the condition.
 OBSTRUCTIVE DISORDERS
 Hydronephrosis, Hydroureter, and Urethral Stricture: Hydronephrosis and hydroureter are problems of urinary
ELIMINATION with outflow obstruction.
 Prompt recognition and treatment are crucial to prevent permanent renal damage.

 Obtain a history from the patient, including his or her usual pattern of urine ELIMINATION, and ask about recent
flank or abdominal pain. Chills, fever, and malaise may be present with a urinary tract infection.
 In hydronephrosis, the kidney enlarges as urine collects in the pelvis and kidney tissue, damaging the blood vessels
and renal tubules.
 In patients with hydroureter and urethral stricture, obstructions are lower.
 IV urography shows ureteral or renal pelvis dilation.
 Urinary outflow obstruction can be seen with ultrasonography or computed tomography.
 Urinary retention and potential for INFECTION are the primary problems.
 Failure to treat the cause of obstruction leads to infection and end-stage kidney disease (ESKD).
 X-ray of the kidneys, ureters, and bladder and IV urography are performed to diagnose stones or obstructions.
 When a stricture is causing hydronephrosis and cannot be corrected with urologic procedures, a nephrostomy is
performed to divert urine externally.
 Renovascular Disease:
 Processes affecting the renal arteries, such as renal artery stenosis, atherosclerosis, or thrombosis, narrow the
lumen and cause ischemia and atrophy of renal tissue. Patients with renovascular disease often have a sudden
onset of hypertension, particularly in patients older than 50 years of age.
 Diagnosis is made by magnetic resonance angiography, ultrasonography, radionuclide imaging, renal
arteriography, and renal vein renin levels.
 Identifying the type of defect, extent of narrowing, and condition of the surrounding blood vessels is critical for
treatment choice.
 Uncorrected renovascular disease, such as renal vein thrombosis, or renal artery stenosis, atherosclerosis, or
thrombosis, causes ischemia and atrophy of kidney tissue, leading to severe impairment of urinary ELIMINATION
and FLUID AND ELECTROLYTE BALANCE.
 Diabetic Nephropathy: A vascular complication, diabetic nephropathy occurs with type 1 or type 2 diabetes
mellitus related to extent, duration, and effects of atherosclerosis, hypertension, and neuropathy.
 Proteinuria may be mild, moderate, or severe.
 Diabetic patients are always considered to be at risk for renal failure.

IN GENERAL, REMEMBER ...

 Check blood pressure and urine output frequently with any type of kidney problem.
 Urinalysis shows proteinuria once the glomeruli are involved and is the gold standard for detecting early kidney
dysfunction.
 Instruct patients with any type of kidney problem to weigh themselves daily and to notify their health care
provider if there is a sudden weight gain.
 Encourage patients with diabetes to adhere to regimens for glucose control and blood pressure control to prevent
kidney disease.
 Refer patients to community resources, support groups, and information organizations such as the National Kidney
Foundation, the Polycystic Kidney Disease Foundation, and the American Association of Kidney Patients.
 Report immediately to the physician any sudden decrease of urine output in a patient with kidney disease or
kidney trauma. In general, adult urine output expectations are 0.5 to 1 mL/kg/hr.