RENAL SYSTEM

NORMAL ALTERED STATE

1. regulate fluids and electrolytes Water retention = edema
Hyperkalemia = STAT hemodialysis
2. excrete metabolic wastes products Azotemia (Increased BUN and creatinine)
BUN (10-20 mg/dL) Uremic Syndrome (accumulation of nitrogenous
Creatinine (0.6-1.2 mg/dL) wastes)
3. produce erythropoietin ( stimulates Anemia (decreased RBC)
production of RBC in the bone marrow)
4. activate Vitamin D (aids in the absorption of Renal osteodystrophy
Calcium in the GI tract)
5. regulates BP via RAAS Hypertension

DIAGNOSTIC EXAMINATIONS

1. BUN
 Measures kidney`s ability to excrete wastes
 10-20 mg/dL
2. Serum Creatinine
 Measures kidney`s ability to breakdown creatine
 0.6-1.2 mg/dL
 0.5-1.5mg/dL
3. Creatinine Clearance Test (CCT)
 Measures GFR-tubular filtration
 Female: 87-107mL/min
 Male: 107-137 mL/min
4. Urine Specimen
Specimen Indications Volume Instruction
1. Clean catch urine U/A 30-50 mL Midstream
2. 24 hour urine  CCT-renal failure 1500 mL Discard 1st urine and
 Schilling`s test- collect succeeding
Pernicious Anemia ones
 Vanil
3. 2nd voided urine  Benedict`s test- 10 gtts Discard 1st urine
glucosuria (Gestational 5 gtts Offer 1 glass of H20
DM) Collect
 Heat and acetic acid
test-proteinuria
(PIH)
4. Sterile urine C&S 3-5 mL 30 minutes clamp
5 mL syringe
Unclamp
RENAL SYSTEM
5. Specific Gravity
 Measures urine concentration
 1.010-1.025
6. KUB
 X-ray assessment of organs
7. Intravenous Pyelogram (IVP)
 Use of contrast dye
 NPO 8-10 hours
 Forced fluids
 Warm feeling is normal
8. Cystoscopy
 Direct visualization of bladder and urethra
 DBE to prevent bladder spasms
 Pink-tinged or tea-colored urine is normal after 1 week
9. Bladder ultrasound
 Full bladder
10. Renal Arteriography
 Use of radiopaque dye (allergies)
 Sandbags for 4-8 hours
 Assess renal arterial supply
11. Renal Scan
 Assess renal blood flow
 Use of radioisotope
 24 hours-radiation is removed
 Use of gloves
12. Renal Biopsy
 Prone position to prevent bleeding
 No strenuous activities for 2 weeks except sex

RENAL DISORDERS

 DYSFUNCTIONAL VOIDING PATTERN

a) Incontinence
 Involuntary loss of urine
 Loss of tone in the bladder
 Kegel`s exercise
b) Retention
 Incomplete emptying of bladder due to detrussor muscle failure
 Catheterization
c) Neurogenic Bladder Dysfunction
 PNS and CNS lesions
 Syringomyelia and spina bifida
RENAL SYSTEM
 Types:
 Spastic Bladder
o Volume is small or normal
o Involuntary contractions
 Flaccid Bladder
o Volume is large
o Pressure is low
o Contractions are absent
 URINARY TRACT INFECTION
 Urinary stasis and reflux of urine back to the kidneys
 E. coli and pseudomonas
 Types:
 Upper UTI
o Pyelonephritis
o Retroperitoneal
 Lower UTI
o Cystitis (groin)
o Urethritis
 Clinical manifestations


 Dysuria  Urgency
 Hematuria  Pyuria
 Frequency  Retention

 Interventions
 Increase fluid intake
 Acidify urine (citrus fruits, cranberry, Vit. C rich foods)
 3W`s (wash, wipe, wear cotton undies)

 GLUMERULONEPHRITIS
 Inflammation of glomerulus of both kidneys due to antigen-antibody response
Increased permeability-cell hyperplasia-scarring-damage
 Clinical Manifestation
 Fever
 Edema
 Dark, smoky, cola colored urine
 Proteinuria –foamlike urine
 Treatment
 Antibiotics (cephalosporins), anti-HPN
RENAL SYSTEM
 Weigh daily (same time, same scale)
 Diet (high calorie, low CHON)

 RENAL FAILURE
I. ACUTE RENAL FAILURE
 Types
a) Pre-renal (blood flow)
b) Intra-renal (damage to nephrons)
c) Post-renal (mechanical obstructions to tubules and urethra)
 Phases

Phases Physiologic Effects Findings Signs and Symptoms

OLIGURIC  Inability to excrete  Increased BUN and  Confusion,
metabolic wastes Creatinine drowsiness,
products  Hyperkalemia, restlessness
 Regulate hyponatremia,  Cardiac
electrolytes acidosis dysrhythmias,
 Excrete fluids  Fluid overload Kussmaul`s
breathing
 Weight gain, neck
vein distention,
edema
DIURETIC Hypovolemia Weight loss Hypertension
Hypokalemia UO (4-5 L/day)
hyponatremia Tachycardia
Constipation
RECOVERY 1-2 years recovery

II. CHRONIC RENAL FAILURE

 Gradual onset, irreversible
 Phases

Phases GFR BUN and Creatinine Signs and Symptoms

Decreased Renal 40-50 Normal Asymptomatic
Reserve
Renal Insufficiencey 20-40 Starts to increase Oliguria

Renal Failure 10-20 Increased Anuria

End Stage Renal <10 Severely Increased Azotemia
Disease (ESRD) Anemia
Hyponatremia/hypocalcemia
Hyperkalemia/hyperphosphatemia
RENAL SYSTEM

INTERVENTIONS
a) Medications
 Erythropoietin
 Amphogel
b) Diet
 Low salt, Low CHON
c) Monitor for early signs of uremia (Confusion, Drowsiness, Restlessness)
d) Monitor skin integrity for uremic frost
e) Mannitol
 12.5 g of 25% solution given in 3 minutes
 40 mL/hr=reversible
 100mL/hr=normal
f) Hemodialysis
 Hemodialysis
 Dialyzer
 Dialysate
 Access
1. External Arteriovenous Shunt
o 2 silastic cannula shunt
o U-shaped
o Complication: Exsanguination
2. Internal Arteriovenous Fistula
o Mature (1-2 weeks)
o Maturity is caused by arterial blood flow to the vein
3. External Arteriovenous Graft
g) Peritoneal Dialysis
 Peritoneal membrane
 ``Exchange``
 Complications: pain (normal)
DOB (slow rate of infusion - stop)
 Auscultate for bruits / Palpate for thrill
 Assess for arterial steal syndrome
S/S: pain
Pallor
RENAL SYSTEM
(-) pulse
h) Renal Transplant
 Identical twin
 Outflow of brown (bowel perforation) & yellow (bladder perforation) &cloudy
(peritonitis)
 UROLITHIASIS
 Uric stones
 Acidic
 From purine rich foods
 Calcium stones
 Alkali
 From milk and dairy products
 Cysteine stones
 Acidic
 From protein rich foods
 Oxalate stones
 From tea, cola, chocolates
 Signs and Symptoms
 Sudden, intermittent pain
 Hematuria
 Interventions
 Medications
o Calcium stones- Hydrodiuril
o Oxalate stones- Vitamin C to promote oxalate excretion
 Diet
o Acid ash diet
o Alkaline ash diet
All milk and milk products except cheese
All vegetables except corn and lentils
All fruits except cranberry, prunes, plums
 ESWL
o Disintegration of shock waves for application of UTZ and sound waves
for 2-3 days
o Use of fluoroscopy as a visual guide
 NEPHROTIC SYNDROME
 Excessive excretion of CHON due to diffused glomerular damage
 Diet: High calorie, Low CHON
 Proteinuria : 3.5 grams /day
 Treatment: plasma expanders to increase osmotic pressure
 HYDRONEPHROSIS
RENAL SYSTEM
 ``water in the kidneys``
 Distention of renal pelvis due to obstruction of normal urine flow
 Hydroureter
Tx: nephrostomy tube

RENAL SYSTEM DRUGS

A. URINARY TRACT ANTISEPTICS (UTI)

o Nitrofurantoin (Macrodantin)
 Pulmonary reaction – refer
 Contraindication: renal failure ----Crystalluria
o Metheramine Mandelate (Mandelamine)
 Gram (+) UTI
 Contraindication: Renal or Hepatic Disorder
o Nalidixic Acid (Negram)
 Gram (-) UTI
 Contraindication: history of convulsive disorder
o CInoxacin (Cinobac)
 Gastric irritants ( with meals/ after meals/ with milk)

B. FLUROQUINOLONES
o AB for UTI
o Only Enoxacin can be taken on an empty stomach
o Monitor for signs and symptoms of CNS toxicity (confusion, drowsiness, restlessness,
headache, lightheadedness)--------refer
o Maintain increased high fluid intake
C. SULFONAMIDES
o ``sulfa``drugs
o Inhibit folic acid synthesis
o Maintain high fluid intake
o ADVERSE EFFECT: Steven`s Johnsons Syndrome
 Severe hypersensitivity reaction, disc shaped, non painful, non-itchy, red
papules
 Stop and refer
D. CHOLINERGIC MEDICATIONS
o Non obstructive urinary retention (urinary stimulator)
o Obstruction: bladder rupture
 Bethanecol
RENAL SYSTEM
 Never IM
 Ready Atropine SO4
E. ANTI SPASMODIC DRUGS
o Oxybutinin Chloride (Ditropan)
 Relaxes smoothemuscles
o Propantheline Bromide (Probantin)
 Prevents bladder spasms
No to narrow angled glaucoma & myasthenia gravis
F. URINARY ANALGESICS
o Phenazopyridine (Pyridium)
Normal (orange or red urine)
G. HEMATOPOEITIC GROWTH FACTOR
o Epoeitin alfa (Epogen)
Initial effect: after 1-2 weeks
Therapeutic effect: after 2-3 months
H. ANTIREJECTION MEDICATIONS
o Cyclosporine (Sandimmune, Neoral)
 Prevent injection of allogeneic kidney transplant
 Prednisone
 No grapefruit juice – increase toxicity of cyclosporine
o Tacrolimus (Prograf)
o Azathioprine (Imuran)
o Mycophenolate Mofetil (Ellcept)
o Muromonab (Orthoclone)
o Daclizumab(Zepanax)
Basiliximab (Simulet)