RENAL DISEASES

Terms:
1. aldosterone – hormone synthesized and released cortex; causes the kidneys
to absorb Na
2. antidiuretic hormone(ADH) – hormone secreted by the posterior pituitary
gland; causes the kidneys to reabsorb more water
3. anuria – total urine output less than 50mL in 24hrs.
4. bacteriuria - bacteria in the urine; bacterial count higher than 100,000
colonies/mL
5. clearance – vol. of plasma that the kidneys can clear of specific solute(eg,
creatinine); expressed in milliliters per minute
6. dysuria – painful or difficult urination
7. frequency – voiding more frequently than every 3hrs.
8. Glomerular filtration rate(GFR) – vol. of plasma filtered at the glomerulus into
the kidney tubles each minute; normal rate is approximately 120mL/min
9. hematuria – red blood cells in the urine
10. nocturia –awakening at night to urinate
11. oliguria - total urine output less than 400mL in 24hrs.
12. proteinuria – protein in the urine
13. pyuria – pus in the urine
14. Valsalva Leak Point Maneuver (VLPP) – amount of abdominal pressure
against the urethra to open and leak urine
15. vesicoureteral reflux – back flow of urine from the bladder into the ureters

Anatomy of the Upper and Lower Urinary Tracts

• Kidneys
-retroperitoneal organs
-120 – 170g
-12cm long, 6cm wide and 2.5cm thick
-with 8 – 18 pyramids
-with 4 -13 minor calyces
-with 2 – 3 major calyces
-with protective structures:
a. Pararenal fat
b. Gerota’s fascia
c. Perirenal fat
d. Renal capsule
• Nephron
-basic structural and functional unit of the kidney
• Ureter, Bladder, and Urethra
Ureter- narrow, muscular tubes, each 24 to 30 cm long that originates at
the lower proton of the renal pelvis
- connects each kidney to the bladder
Bladder- temporary storage of urine
Urethra- where the urine comes out
3 Processes of Urine Formation
1. Glomerular Filtration- this where H2O,electrolytes other substance are
filtered
2. Tubular Reabsorption- some of these substances are reabsorb
3. Tubular Secretion- some of these substances are secreted in form of urine

Test of Urine Specific Gravity:

1. Osmolality- no. of particles(electrolytes and other molecules) dissolved per
kilogram of the urine
2. Specific gravity- 1.010 to 1.025
Renal function begins to decrease at a rate of 1% each year at 30.

URINARY DISORDERS
A. Acute Pyelonephritis
-bacterial infection of the renal pelvis, tubules and interstitial tissue
-an ascending infection
-predisposing factors:
a. vesico-ureteral reflux
b. urinary tract obstruction
-enlarged kidney
-with abscess on the renal capsule and at the cortico-medullary junction
-s/sx:
fever and chills costo-vertebral angle
leucocytosis tenderness
bacteriuria and pyuria dysuria
flank pain inc urinary frequency
-dx:
UTZ Nuclear scan
CT scan Urine Culture and Sensitivity Test
IVP

-medical management:
a. Acute uncomplicated Pyelonephritis
-no dehydration, no nausea and vomiting, no sepsis
>2 weeks of oral antibiotics
Trimethoprim-Sulfamethoxazole
Ciprofloxacin
Gentamicin with or without Ampicillin
Third Generation Cephalosporins
>6 weeks of oral antibiotics if with relapse
*urine culture 2 weeks after antibiotic therapy
b. complicated
-pregnant patients
>hospitalization (antibiotics from IV to oral)
B. Chronic Pyelonephritis
-repeated acute pyelonephritis > chronic pyelonephritis
-no s/sx unless there’s an acute exacerbation
-kidneys scarred, contracted and non functional
-commomn cause of end stage renal disease (ESRD)
-s/sx:
fatigue polyuria
headache excessive thirst
anorexia weight loss
-diagnosis:
creatinine and BUN clearance
creatinine levels
intravenous pyelography
-complications:
a. ESRD
b. hypertension
c. formation of renal stones
-may be due to the presence of urea splitting
microorganisms
-medical management:
urine culture and sensitivity guided antibiotic therapy if the urine cannot
be made bacteria free
-Nitrofurantoin to suppress
-TMP-SMZ bacterial growth
-nursing management:
a. monitoring
-I&O
b. oral fluids (3-4L/day)- to dilute urine, dec,. burning on urination, and
prevent dehydration
-unless contraindicated
c. monitor temp.every 4hrs
-antipyretics
d. education
-advise bed rest
-prevention of UTI
C. Acute Glomerulonephritis
-Inflammation of the glomerular capillaries
-primarily a disease of children older than 2 years old
-may affect any age
-causes:
>autoimmune
SLE
>streptococcal
Acute Post Streptococcal Glomerulonephritis
-most common
D. Acute Post Streptococcal Glomerulonephritis
-2 to 3 weeks after
>impetigo
>sore throat
-s/sx:
hematuria hypertension
tea colored urine headache, malaise, flank pain
proteinuria (+) kidney punch
inc serum BUN and creatinine congestion
anemia confusion, somnolence and seizures
edema

Group A Beta-Hemolytic Streptococcal Infection

Antigen-Antibody Reaction

Deposition in the Glomerulus

Increased Production of Epithelial Cells in the Glomerulus

WBC Infiltration

Thickening

Scarring

Decreased GFR
-diagnosis:
a. kidney biopsy
b. electron microscopy
c. immunoflourescence analysis
d. Anti-Streptolysin O Titer
Anti-DNAse B Titer
e. Serum Complement Determination
-decreased
-will normalize in 2 – 8 weeks
E. Chronic Glomerulonephritis
-repeated acute glomerulonephritis
-components:
repeated acute glomerulonephritis
hypertensive nephrosclerosis
hyperlipidemia
chronic tubulo-interstitial injury
hemodynamically mediated glomerular sclerosis
-contraction of the kidneys to 1/5 of its original size
 -deformed kidneys
-may result to ESRD
-s/sx:
may be asymptomatic
hypertension or inc BUN and Creatinine
edema
Routine eye exam. (ophthalmoscopy):
retinal hemorrhages
papilledema
Gen. symptom:
weight loss
weakness and irritability
nocturia
GIT disturbances
anemia
heart failure
peripheral neuropathy, decreased DTR
pulsus paradosus
-diagnosis:
1. Urinalysis- fixed sp. Gravity at 1.010
proteinuria; urinary casts(protein plugs secreted by damaged
kidney tubules)
GFR falls below 50mL/min
2. electrolyte imbalances
-hyperkalemia due to dec. potassium excretion/excessive intake
-hypoalbuminemia with edema secondary to protein
loss(damaged glomerlar membrane)
-hyperphosphatemia due to dec.renal excretion of phosporus
-hypocalcemia (cal. Binds tophosporus tocompensate for
elevated serum phosporus level)
-hypermagnesemia dec exceretion inadvertent ingestion of
antacids containing magnesium
3. CBC
-anemia
4. Chest X-Ray
-cardiomegaly
-pulmonary edema
5. ECG
-left ventricular hypertrophy
-management:
1. treatment of hypertension
2. weight monitoring
3. give proteins of high biologic value
4. adequate calories
5. dialysis
-nursing management:
1. monitoring

F. Acute Renal Failure

-sudden and almost complete loss of renal function
-Dec. in GFR
-s/sx:
-oliguria -normal urine vol.(not as common)
-anuria -rising serum creatinine and BUN

Categories of ARF
1. Prerenal
-ocuur as a result of impaired blood flow
-shock
2. Intrarenal
-the result of actual parenchymal damage to the kidney tubules
-use of nephrotoxic drugs (NSAIDs and ACE inh)
3. Postrenal
-obstruction somewhere in distal kidney

Four Clinical Phases of ARF

1. Initiation
-begins with the initial insult and ends when oliguria develops
2. Oliguria
-rise in the serum of waste products of metabolism
-rise in serum potassium and magnesium
3. Diuresis
-with gradually increasing urine output
-renal function may still be markedly abnormal
4. Recovery Period
-improvement of renal function
-may take 3-12 months
-with normal laboratory values
-with permanent 1-3% reduction in GFR

-assessment and diagnostic finding

-changes in urine (scanty to normal)
-changes in contour(Utz)
-Azotemia
-Hyperkalemia
-metabolic acidosis
-hyperphophatemia and hypocalcemia
-anemia
-prevention:
-prevention of exposure to nephrotoxic drugs
-aminoglycosides, cyclosporine, amphotericin B
-serum BUN and creatinine monitoring

-management:
a. restore chemical balance and prevent complications
b. Any possible casue is identified
c. maintain fluid balance
-BP, CVP, serum and urine electrolyte. Fluid loses
d. monitoring for over hydration
-dyspnea, crackles, distended neck veins
-Furosemide, Ethacrynic Acid
e. dialysis
-to prevent serious complications
*hyperkalemia
*severe metabolic acidosis
*pericarditis
*pulmonary edema
f. pharmacologic
-cation exchange resin
(sodium polystyrene sulfonate-kayexalate)
-retention enema
-diuretic therapy
-low dopamine dose (1-3g/kg)
-phosphate binding agents (AlOH)
g. nutritional therapy
-give additional proteins (1g/kg/day during the oliguric phase)
-high potassium and phosphate foods are restricted (banana,
citrus and coffee)
-potassium restricted to 20-40mEq/day
-sodium restricted to 2g/day
-may require parenteral nutrition

-nursing management:
a. monitoring fluid and electrolyte balance
b. reducing metabolic rate
-bed rest, prevention of fever and infection
c. promoting pulmonary function
-assistance in changing positions
-advise to cough and deep breath
d. preventing infection
-asepsis
-avoid inserting an indwelling urinary
catheter
 e. providing skin care
f. providing support

G. Chronic Renal Failure (END-STAGE RENAL DISEASE)

-is a progressive irreversible deterioration in renal function
-maintain metabolic and fluid and electrolyte balance fails resulting in uremia
or azotemia (retention of urea and other nitrogenous wastes in the blood)
-prognosis will be determined by the presence or absence of hypertension and
proteinuria
-causes:
diabetes mellitus- most common
hypertension
chronic glomerulonephritis
obstruction of the urinary tract
polycystic kidney disease
infections
nephrotoxic medications

- stages:
Stage 1
-Reduced Renal Reserve
-40%-75% loss of nephron function
-usually asymptomatic
Stage 2
-Renal Insufficiency
-75%-90% loss of nephron function
-increase in serum BUN and creatinine
-inability to concentrate urine
-anemia may develop
-with polyuria and nocturia
Stage 3
-End Stage Renal Disease
-<10% of nephron function remaining
-regulatory, excretory and hormonal functions are lost
-requires dialysis

-s/sx:
cardiovascular
hypertension pulmonary edema
heart failure pericarditis
dermatologic
*pruritus
*uremic frost (deposit of urea crystals)
 GI and Neurologic s&sx
-assessment and diagnosis
a. glomerular filtration rate
creatinine clearance
b. Na retention and water
c. Acidosis
d. Anemia
-complications
a. Hyperkalemia
b. Pericarditis, Pleural Effusion and Cardiac Tamponade
c. Hypertension
d. Anemia
e. Bone Disease
-medical management:
a. maintain kidney function and homeostasis
b. treat the underlying cause and contributory factors
-medications >dialysis
-diet therapy
• Pharmacologic Therapy
a. antihypertensives
-includes intravascular volume control
*fluid restriction
*sodium restriction
b. sodium bicarbonate
c. erythropoietin
-therapy Epogen(recombinant erythropoietin) IV or
subcutaneous, may take 2-6 weeks to increase Hct.
d. iron supplementation
e. antiseizure agents
>Diazepam
>Phenytoin
f. antacids
for hyperphosphatemia and hypocalcemia
-aluminum based antacids
Toxicity my result to:
-neurologic symptoms
-osteomalacia
-calcium carbonate
• Nutritional Therapy
-regulation of protein intake
-regulation of fluid intake
(500-600ml more than the previous day’s 24 hour UO)
-regulation of sodium intake
-regulation of potassium
-adequate calories and vitamins
3. Dialysis
-to prevent hyperkalemia
-nursing management:
a. avoid the complications of reduced renal function
b. assess fluid status
c. identify potential sources of the imbalance
d. implement a dietary program
e. encourage self care and independence