Chapter 30

Alterations in Renal and

Urologic Function
 Learning outcomes and key terms
Learning Outcomes Key Terms

1. Differentiate between common bladder disorders. • Anuria

2. Distinguish between the stages of chronic kidney disease. • Azotemia
3. Identify the systemic effects of chronic kidney failure. • Bladder calculi
4. Discuss the etiology, pathogenesis, and clinical • Costovertebral angle
• Cystitis
manifestations of selected renal disorder. • Dermatome
• Enuresis
• Incontinence
• Lithotripsy
• Nephralgia
• Oliguria
• Renal calculi
• Renal colic
• Acute kidney injury
• Chronic kidney
disease
• urinalysis
Structures of the Renal System

From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby.

Copyright © 2017, Elsevier Inc. All rights reserved. 3

Kidney

From Solomon E: Introduction to human anatomy and physiology, ed 4, St Louis, 2016, Saunders.

Copyright © 2017, Elsevier Inc. All rights reserved. 4

Nephron

• 1.2 million nephrons per kidney

• Cortical nephrons
• Midcortical nephrons
• Juxtamedullary nephrons
• Functional unit of the kidney

Copyright © 2017, Elsevier Inc. All rights reserved. 5

Nephron (Cont.)

• Renal corpuscle
• Glomerulus
• Bowman capsule
• Mesangial cells
• Bowman space/capsule

Copyright © 2017, Elsevier Inc. All rights reserved. 6

 Nephron (Cont.)

From Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy & physiology, St Louis, 2012, Mosby; Damjanov I: Pathology for the health professions, ed 4, St Louis,
2012, Mosby.

Copyright © 2017, Elsevier Inc. All rights reserved. 7

Nephron (Cont.)

• Glomerular filtration membrane

• Inner capillary endothelium
• Basement membrane
• Outer capillary epithelium
• Contains podocytes
• Filtration slits
• Filtrate passes through the three layers and forms the primary urine

Copyright © 2017, Elsevier Inc. All rights reserved. 8

Nephron (Cont.)

• Juxtaglomerular apparatus
• Juxtaglomerular cells
• Renin releasing
• Macula densa
• Sodium sensing

Copyright © 2017, Elsevier Inc. All rights reserved. 9

Juxtaglomerular Apparatus

Copyright © 2017, Elsevier Inc. All rights reserved. 10

Nephron

• Renal tubules
• Proximal convoluted tubule
• Loop of Henle
• Distal convoluted tubule
• Collecting duct
• Principal cells
• Intercalated cells

Copyright © 2017, Elsevier Inc. All rights reserved. 11

Structures of the Kidney

Copyright © 2017, Elsevier Inc. All rights reserved. 12

Urinary Structures
• Ureters
• Peristaltic activity
• Contraction of the bladder during
micturition compresses the
lower end of the ureter to avoid
urine reflux
• Bladder
• Detrusor muscle
• Trigone
• Urethra
• Innervation of the bladder & the
internal sphincter is controlled by
the parasympathetic fibers of the
ANS

Copyright © 2017, Elsevier Inc. All rights reserved. 13

Hormones and Renal Function

• Antidiuretic hormone (ADH)

• Aldosterone
• Natriuretic peptides
• Atrial natriuretic peptide
• Brain natriuretic peptide
• Diuretics
• Increases urine output

Copyright © 2017, Elsevier Inc. All rights reserved. 14

Renal Hormones

• Vitamin D
• Necessary for the absorption of calcium and phosphate
• Erythropoietin
• Released when decreased oxygen to the kidney
• Stimulates RBC production

Copyright © 2017, Elsevier Inc. All rights reserved. 15

Renal Blood Flow

• Receive 1000 to 1200 mL of blood per minute

• Glomerular filtration rate (GFR)
• The filtration of the plasma per unit of time
• Autoregulation
• Tubuloglomerular feedback

Copyright © 2017, Elsevier Inc. All rights reserved. 16

Renal Blood Flow (Cont.)

• Neural regulation
• Sympathetic fibers regulate size of afferent and efferent arterioles, thus renal
blood flow
• No significant parasympathetic regulation
• Hormones
• Renin-angiotensin-aldosterone system
• Natriuretic peptides
• Urodilantin

Copyright © 2017, Elsevier Inc. All rights reserved. 17

Tests of Renal Function

• Creatinine clearance and glomerular filtration rate (GFR)

• GFR – 90mL/min
• Blood tests
• Plasma creatinine concentration - 0.7-1.2 mg/dL
• Blood urea nitrogen (BUN) - 10-20 mg/dL
• Urinalysis

Copyright © 2017, Elsevier Inc. All rights reserved. 18

Age Related Renal Alterations

Pediatric Renal Function Aging and Renal Function

• Decreased ability to remove
excess water and solutes
• Decreased urine concentrating
ability
• Narrow margin for fluid and
electrolyte balance
• Increased risk of drug toxicity
• Decrease in renal blood flow and
GFR
• Altered sodium and water balance
• Number of nephrons decrease
due to renal vascular and
perfusion changes
• Response to acid-base changes
delayed
• Increased risk for drug toxicity
• Alterations in thirst and water
intake

Copyright © 2017, Elsevier Inc. All rights reserved. 19

 Urinary Tract Obstruction
 Upper
 Kidney Stones
 Lower
 Neurogenic bladder
 Overactive bladder syndrome
(OBS)
• Frequency, urgency,
nocturia
 Obstruction
• Urethral stricture, prostate
enlargement, pelvic organ
prolapse

Copyright © 2017, Elsevier Inc. All rights reserved. 20

Urinary Tract Obstruction

Copyright © 2017, Elsevier Inc. All rights reserved. 21

 Nephrolithiasis (kidney stones)

 What is it?

 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 22

Nephrolithiasis

Copyright © 2017, Elsevier Inc. All rights reserved. 23

 Bladder

From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby.

Copyright © 2017, Elsevier Inc. All rights reserved. 24

 Acute cystitis
 What is it?
 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 25

 Pyelonephritis

 What is it?
 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 26

 Nephron

From Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy & physiology, St Louis, 2012, Mosby; Damjanov I: Pathology for the health professions, ed
4, St Louis, 2012, Mosby.

Copyright © 2017, Elsevier Inc. All rights reserved. 27

 Nephron Function

 Filters plasma
 Reabsorbs and secretes
 Tubular reabsorption and secretion
 Forms a filtrate of protein-free fluid
 Regulates the filtrate to maintain fluid volume,
electrolytes, and pH

Copyright © 2017, Elsevier Inc. All rights reserved. 28

 Nephron Function (Cont.)

 Glomerular filtration
 Permeable to water; impermeable to large
molecules (proteins)
 Tubular reabsorption vs. tubular secretion
 Net filtration pressure
• Glomerular capillary oncotic/hydrostatic pressure
 Filtration rate
• 180 L/day

Copyright © 2017, Elsevier Inc. All rights reserved. 29

Glomerular Filtration

Modified from Hockenberry MJ et al: Wong’s nursing care of infants and

children, ed 8, St Louis, 2007, Mosby

Copyright © 2017, Elsevier Inc. All rights reserved. 30

 Nephron Function (Cont.)

 Tubular transport
 Proximal convoluted tubule
• Active reabsorption of sodium
 Glomerulotubular balance
• Adjustment of reabsorption of sodium and water
 Loop of Henle and distal tubule
• Concentration or dilution of urine
 Countercurrent exchange system
• Production of uromodulin

Copyright © 2017, Elsevier Inc. All rights reserved. 31

Nephron Function (Cont.)

Copyright © 2017, Elsevier Inc. All rights reserved. 32

 Glomerulonephritis

 What is it?

 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 33

Glomerulonephritis

Copyright © 2017, Elsevier Inc. All rights reserved. 34

 Nephrotic Syndrome
 What is it?
 Etiology
 Same as glomerulonephritis
 Pathophysiology
 Glomerular basement
membrane injury causing
protein excretion
 Clinical manifestations
 Hypoalbuminemia
 Edema
 Hyperlipidemia
 Vitamin D deficiency
 HTN
 Decreased GFR
 Lipiduria- Foamy urine

Copyright © 2017, Elsevier Inc. All rights reserved. 35

 Acute Kidney Injury (AKI)
What is it?
 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 36

 Acute Kidney Injury (AKI)
Categories & Pathophysiology
 Prerenal
 Most common cause of AKI
 Caused by impaired renal
blood flow
 GFR declines because of
the decrease in filtration
pressure
 Intrarenal
 Acute tubular necrosis
(ATN) is the most common
cause of intrarenal renal
failure
 Postrenal
 Occurs with urinary tract
obstructions that affect the
kidneys bilaterally

Copyright © 2017, Elsevier Inc. All rights reserved. 37

Copyright © 2017, Elsevier Inc. All rights reserved.

38
RIFLE criteria for acute kidney injury

 R= risk
 I= injury
 F= failure
 L= loss
 E= end stage kidney disease

Copyright © 2017, Elsevier Inc. All rights reserved. 39

 Chronic Kidney Disease (CKD)
 What is it?
 5 Stages:
 Normal (GFR >90 mL/min)
 Mild (GFR 60-89 mL/min)
 Moderate (GFR 30-59 mL/min)
 Severe (GFR 15-29 mL/min)
 End stage (GFR less than 15)

Copyright © 2017, Elsevier Inc. All rights reserved. 40

 Chronic Kidney Disease (CKD)
 Etiology

 Pathophysiology

 Clinical Manifestations

Copyright © 2017, Elsevier Inc. All rights reserved. 41

 Chronic Kidney Disease (CKD)
Clinical Manifestations
 Alterations seen in following
systems
 Cardiovascular
 Pulmonary
 Hematologic
 Immune
 Neurologic
 Gastrointestinal
 Endocrine and reproduction
 Integumentary

Copyright © 2017, Elsevier Inc. All rights reserved. 42

 Chronic Renal Failure

 Clinical Manifestations of ESRD GFR <15 ml/min

 Increased BUN 180 – 200 mg/dL

 FVE decreased GFR and activation of RAAS

 Electrolyte imbalance- retention of K, Mg, Phos

 Uremic Syndrome -confusion, anorexia, N/V, pruritis,

43
Signs and Symptoms of Kidney Failure

From Goldman L, Schafer AI: Goldman’s Cecil medicine, ed 24, Philadelphia, 2012, Saunders; redrawn from
Forbes CD, Jackson WF: Color atlas and text of clinical medicine, ed 3, London, 2003, Mosby.

Copyright © 2017, Elsevier Inc. All rights reserved. 44