ADULT HEALTH

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Renal anatomy

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The renal anatomy

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Renal anatomy

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The physiology …

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The physiology …

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Renal physiology
Function
❖Regulation of the volume and composition of blood

❖Gluconeogenesis

❖Production of hormones

❖Metabolizing vitamin D to its active form

❖ Excretion of metabolic waste products & foreign chemicals

❖ Regulation of arterial pressure

Regulation of acid-base balance

❖ 10/3/2023 8
 Glomerular Diseases
(GD)

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 GD…
A variety of diseases affecting the glomerulus
◼ Glomerulonephritis (GN)

Acute

Chronic

◼ Nephrotic syndrome

Are primary glomerular diseases

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 GD…
◼ The major manifestations of GD
Proteinuria

Hematuria

Anemia

Decreased GFR (azotemia)

Alteration in excretion of Na (edema and HPN)

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 ACUTE GLOMERULONEPHRITIS (AGN)
Inflammatory reaction of the glomeruli

It is not an infection of the kidney

Is the result of the immune mechanisms of the body like SLE…

It is also called Acute Nephritis, GN or PSGN

Predominantly affects children from ages 2 to 12yrs

But it can affect any age group

Incubation period is 2 to 3 weeks

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 AGN…

Etiology
◼ Immune-complex glomerulonephritis may be
Idiopathic

Part of a multisystem immune-complex disorder

◼ Genetic

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 AGN…
◼ Poststreptococcal glomerulonephritis

Leading cause of acute nephritic syndrome

10 days after pharyngitis or 2 wks after a skin infection

GA-BHSC is the inducer

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 AGN…
Pathophysiology
◼ Infection (pharyngitis, impetigo)

◼ Atn-Abd reaction

◼ Immune complexes

◼ Deposition of antigen–antibody complex in glomerulus

◼ Increased production of epithelial cells lining the glomerulus

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 AGN…
◼ Thickening of glomerular basement membrane (vasculature,
interstitium, and tubular epithelium may also be affected)

◼ Activation of complement pathways

◼ Leukocytes infiltrate the glomerulus

◼ affect vascular tone and permeability, resulting in tissue injury

◼ Scarring and loss of filtering surface may lead to renal failure

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 AGN…
Clinical Manifestations
◼ Hematuria (major) may be macro/microscopic

◼ Proteinuria (primarily albumin)

◼ Oliguria: urine output is < 400 ml/day

◼ Edema

◼ Hypertension
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 AGN…
General Symptoms
◼ Fever, and malaise

◼ Anorexia, nausea and vomiting

◼ Headache, Lethargy and Confusion

◼ Anemia

◼ Enlargement of the liver

◼ Flank
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 AGN…
The clinical course of AGN proceeds as follows

◼ Diuresis starts 1 to 2 weeks after onset of symptoms

◼ Renal clearances and BUN return to normal

◼ Edema decreases, and hypertension lessens

◼ Proteinuria or hematuria may persist many months

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 AGN…

Complications;

◼ CHF, hypertension , Pulmonary edema

◼ Acute renal failure

◼ Sever hypertension with hypertensive encephalopathy

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 AGN…
Diagnostic Evaluation
◼ Urinalysis for
 Blood cells

 Proteinuria…

◼ RFT

◼ Elevated BUN and serum creatinine levels

◼ Needle biopsy of the kidney (definitive)

◼ Serology: circulating antibodies in >90% of pts

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 AGN…
Management
◼ Is symptomatic

◼ Preserve kidney function

◼ Treating complications promptly

◼ If streptococcus is cause, penicillin is the agent of

choice
Corticosteroids and immunosuppressant may be used
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 AGN…
◼ Cephalexin
◼ Erythromycin, Azithromycin

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 AGN…
◼ Antihypertensives

◼ Drugs for management of hyperkalemia

◼ Fluid intake is restricted

◼ Protein is restricted moderately

◼ Increase CHOs intake

Dialysis
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 AGN…
◼ Promoting Renal Function
Monitor vital signs, intake and output,

Maintain dietary restrictions during acute phase

Encourage rest during the acute phase

Administer medications

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 AGN…
◼ Improving Fluid Balance
Carefully monitor fluid balance

Replace fluids according to the patient's fluid losses

Monitor for signs and symptoms of heart failure

Observe for hypertensive encephalopathy

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 AGN…
❑ Patient Education
Explain the disease process

Follow up evaluation

Rx of infection promptly

Reporting any sign of complications

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 CHRONIC GLOMERULONEPHRITIS

Chronic glomerulonephritis may be due to:

◼ Repeated episodes of AGN.

◼ Hypertensive nephrosclerosis

◼ Hyperlipidemia.

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 Pathophysiology

The kidneys are reduced to as little as one-fifth their normal size

(consisting largely of fibrous tissue).

The cortex shrinks to a layer 1 to 2 mm thick or less.

Bands of scar tissue distort the remaining cortex, making the

surface of the kidney rough and irregular.

Scarring & thickening of numerous glomeruli and their tubules

The result is severe glomerular damage that results in ESRD

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 Clinical Manifestations

Mostly no symptoms at all for many years.

But sometimes:

◼ Hypertension

◼ Elevated BUN and serum creatinine levels

◼ Sudden, severe nosebleed, a stroke or a seizure

◼ Feet are slightly swollen at night.

◼ Renal insufficiency and chronic renal failure may develop.

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◼ General symptoms:
Loss of weight and strength

Increasing irritability

Increased need to urinate at night (nocturia).

Headaches and dizziness

Digestive disturbances are common

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 Assessment and Diagnostic Findings
Urinalysis reveals:
◼ A fixed specific gravity of about 1.010

◼ Variable proteinuria

◼ Urinary casts (protein plugs)

As renal failure progresses:
◼ GFR falls below 50 mL/min (normal for adult 90-120ml/min)

◼ Hyperkalemia due to decreased potassium excretion.

◼ Anemia secondary to decreased erythropoiesis

◼ Hypo-albuminemia secondary to protein loss

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 Medical Management
Symptoms guide the course of treatment:
Hypertension:
◼ Sodium and water restriction

◼ Anti-hypertensive agents

Weight is monitored daily

Proteins of high biologic value:
◼ Dairy products, eggs, meats are provided to promote good nutritional

status.
◼ Adequate calories are also important to spare protein for tissue growth

and repair.
Initiation of dialysis = minimize the risk of complications of renal failure.

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 …..
◼ Daily weight control.

◼ Accurate record of intake and out.

◼ Observation of edema (facial, extremities, abdomen etc).

◼ High protein diet (frequent small meal).

◼ Protect from infection.

◼ Psychological treatment.

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 NEPHROTIC SYNDROME (NS)

Is a clinical complex characterized by

◼ Proteinuria

◼ Hypoalbuminemia

◼ Edema

◼ Hyperlipidemia and lipiduria

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 NS…
◼ The syndrome is apparent in any condition that
Seriously damages the glomerular capillary membrane
and

Results in increased glomerular permeability

◼ Results from a defect in the permeability of glomerulus

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 NS…
Etiology

◼ Idiopathic GN (75%)

◼ Metabolic disorders (DM)

◼ Collagen vascular diseases (SLE)

◼ Amyloidosis
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 NS…
◼ Chronic GN

◼ Myelomas

◼ Infections (TB, enteritis)

◼ Circulatory diseases (HF, anemia)

◼ Renal vein thrombosis

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 NS…
Pathogenesis
Clinical Manifestations

◼ The major manifestation of NS is pitting edema occurring at

 Periorbital

 In dependent areas (sacrum, ankles, and hands), and

 In the abdomen (ascites)

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 NS…
◼ Edema occurs insidiously

◼ Weight gain

◼ Fatigue, headache, malaise

◼ Iron-resistant microcytic hypochromic anemia

◼ Hypocalcemia

◼ An increased susceptibility to infection

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Diagnosis
◼ Quantify 24 hours urine protein
◼ Measure urinary protein by a dipstick (+3 or +4 Dx)
◼ Renal biopsy ( if available )

◼ Creatinine clearance (decreased)

◼ Serum chemistry
 Decreased total protein and albumin,

 Increased creatinine,

 Increased triglycerides, and

 Altered lipid profile

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 NS…
Complications
◼ Infection (due to a deficient immune response).

◼ Thromboembolism (especially of the renal vein)

◼ Pulmonary emboli

◼ Acute renal failure (due to hypovolemia).

◼ Accelerated atherosclerosis (due to hyperlipidemia).

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 NS…
Management
◼ Treatment of causative glomerular disease

◼ Specific treatment of the underlying morphologic entity

Minimal change disease : Steroids

Immunosuppressants: azathioprine, Chlorambucil…

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 NS…
No specific treatment exists.
Diuretic agents may be prescribed for the patient with severe edema.

The use of angiotensin-converting enzyme (ACE) inhibitors in

combination with diuretics often reduces the degree of proteinuria but
may take 4 to 6 weeks to be effective.

Dietary protein restriction

Corticosteroids

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 General measurements:

Prevent infection.

Diet with protein 19mg/kg/day depending on glomerular filtration

rate.

Sodium restriction(1 to 2 g/day) and fluid restriction

Controlling hypertension (keeping BP below 130/80)

Potassium supplementation with diuretics.

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 NS…
◼ Cholesterol and fat restriction.

◼ Bed rest.

◼ Thromboembolism: Anticoagulants

◼ Hyperlipidemia : may need lipid lowering agents

◼ Vit-- D supplementation

◼ Low-saturated-fat diet

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 NS…
…
◼ Increasing Circulating Volume and Decreasing Edema
 Monitor daily weight, intake and output

 Monitor V/S

 Monitor BUN and serum creatinine

 Administer diuretics, and fluid and Na restriction

 Encourage bed rest

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 NS…
◼ Preventing Infection
 Monitor for signs and symptoms of infection

 Check laboratory values for neutropenia

 Use aseptic technique for all invasive procedures

 Restrict contact

 Strict hand washing by patient and all contacts

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 NS…
◼ Patient Education
Adherence to medications

Adverse effects of medications

Dietary and fluid restrictions

Life style modification

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 Renal failure (RF)
◼ Renal failure is a partial or complete impairment of kidney
function.
Results when the kidneys can not remove the body’s metabolic
wastes or perform their regulatory functions.
◼ Is a final common pathway of many different kidney and UTDs

◼ Classified in to
 Acute renal failure

 Chronic renal failure

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 ACUTE RENAL FAILURE/INJURY
(ARF/ARI)
Acute renal failure (ARF) is a sudden and almost complete loss of
kidneys function (decreased GFR) over a period of hours to days.

Has a rapid onset and reversible although mortality rate is about 50%.

Is a syndrome characterized by
◼ Rapid decline in GFR

◼ An increase in BUN and creatinine

◼ Oliguria (less than 0.5 mL/kg/h )

◼ Hyperkalemia, and Sodium retention

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 Chronic renal failure (CRF)
Is a progressive deterioration

◼ Progressive, irreversible deterioration in renal function

◼ The body’s ability to maintain metabolic and fluid and electrolyte

balance fails, resulting in uremia or azotemia (retention of urea
and other nitrogenous wastes in the blood).

◼ Over a period of > 6 months

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 Pathophysiology

As renal function declines

The end products of protein metabolism (which are normally

excreted in urine) accumulate in the blood.

Uremia develops and adversely affects every system in the body

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 CRF …
Etiologies
◼ Prerenal causes
 Sever long standing renal artery stenosis

 Bilateral renal artery embolism

◼ Renal causes
 Chronic glomerulonephritis

 Diabetic nephropathy (leading cause)

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 CRF …
Chronic tubulointerstitial disease: - vesicouretral reflux, and
chronic pyelonephritis

Vascular disease: - hypertensive nephrosclerosis

Connective tissue diseases : SLE , scleroderma

Hereditary disease: -polycystic kidney disease

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 CRF …
◼ Post renal cause
Obstructive nephropathy: -which lead to congestion of the
filtration system leading to a shift in the filtration driving
forces

Urolithiasis(renal/ureteral calculi,, or any urethral

obstruction) tumors, blood clots
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 CRF …
Stages of Chronic Renal Disease

◼ Stage 1: Reduced renal reserve:

◼ Characterized by a 40% to 75% loss of nephron function.

◼ No symptoms because the remaining nephrons are able to carry out the
normal functions of the kidneys.

 GFR may be normal or even elevated (hyperfiltration)

 BUN and creatinine are normal or slightly elevated

 GFR >90ML/minute/1.73m2
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 CRF …
Stage 2: Renal insufficiency-MILD

◼ Occurs when 75% to 90% of nephron function is lost.

◼ GFR=60-89ML/MIN

◼ The serum creatinine and BUN rise

◼ The kidneys loses its ability to concentrate urine and anemia develops.

◼ The patient may report polyuria and nocturia.

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▪ Stage 3: Renal insufficiency-moderate

▪ GFR=30-59ML/MIN/1.73m2

▪ Stage 4: Severe decreased GFR

▪ GFR=15-29ML/MIN/1.73m2

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 CRF …
Stage 5: End-stage renal disease (ESRD)—kidney failure,GFR<15ML/Min
The final stage of chronic renal failure occurs when there is less than 10%
nephron function remaining.
All of the normal regulatory, excretory, and hormonal functions of the
kidneys are severely impaired.

ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as

well as electrolyte imbalances.

Once the patient reaches this point, dialysis is usually indicated.

Many of the symptoms of uremia are reversible with dialysis

Survival without transplantation is impossible

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 CRF …
Consequences of Decreasing Renal Function
◼ Retention of Na and water: edema, HF, Hptn…

◼ Hypoperfusion: stimulation of R-A-A axis

◼ Metabolic acidosis

◼ Decreased erythropoietin production: profound anemia

◼ Decreased GFR: Azotemia

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 CRF …
Complications: Death
The rate of ESRD is related to
◼ Underlying disorder,

◼ Urinary excretion of protein,

◼ Presence of hypertension

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 CRF …
Clinical manifestations
◼ Neurologic
Confusion; inability to concentrate

Tremors; Seizures

Restlessness of legs

Burning of soles of feet

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 CRF …
◼ Integumentary
Gray-bronze skin color;

Dry, flaky skin;

Pruritus; Ecchymosis

Thin, brittle nails;

 thinning hair
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 CRF …
◼ Cardiovascular
Hypertension; Pitting edema

Pericardial friction rub

Engorged neck veins

Pericardial effusion

 Pericardial
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 CRF …
◼ Pulmonary
Crackles; Thick, tenacious sputum; Depressed cough reflex

Pleuritic pain

Shortness of breath; Tachypnea

Kussmaul-type respirations

Uremic pneumonitis; “uremic lung”; uremic fetor

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 CRF …
◼ Gastrointestinal
 Mouth ulcerations and bleeding

 Anorexia, nausea, and vomiting

 Hiccups

 Constipation or diarrhea

 Bleeding from gastrointestinal tract

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 CRF …
◼ Hematologic
 Anemia; Thrombocytopenia

◼ Reproductive
 Amenorrhea; Infertility

 Testicular atrophy

 Decreased libido

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 CRF …
◼ Musculoskeletal
 Muscle cramps; fatigue

 Loss of muscle strength

 Renal osteodystrophy

 Bone pain

 Bone fractures

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 CRF …
Diagnostic Evaluation
◼ CBC: anemia (a characteristic sign)

◼ Elevated serum creatinine, BUN, phosphorus

◼ Decreased serum Ca, HCO-3, and albumin

◼ ABG: low blood pH, low CO2

◼ Reduced kidney size on ultrasonography

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 CRF …
Management
◼ Goal: conservation of renal function as long as possible

◼ Detection and treatment of reversible causes of RF

◼ Diet: low-protein diet supplemented with essential aa

◼ Maintenance dialysis or kidney transplantation

◼ Slowing the rate of progression of renal diseases
ACE inhibitors or angiotensin II receptor blockers

Blood pressure control: target BP

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 CRF …
◼ Treatment of the complications
Volume overload
◼ Dietary sodium restriction

◼ Diuretic therapy, usually with a loop diuretic

Hyperkalemia:
◼ Low-potassium diet
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 CRF …
◼ Calcium gluconate (Ca antagonizes the cardio toxicity of
hyperkalemia)
◼ Glucose plus insulin

◼ Correction of acidosis: administration of bicarbonate

◼ Potassium exchange resins: kayaxalate (sodium polystyrene

sulfate) to help exchange sodium for potassium in colon and
thus excrete potassium fro body
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 CRF …
◼ Metabolic acidosis

Maintain the plasma HCO3 concentration above 22 mEq/L

NaHCO3(in a daily dose of 0.5 to 1 mEq/kg/d)

◼ Anemia:

Blood transfusion

Recombinant Erythropoietin (Epo-gene/epoetin)

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 CRF …
◼ Preparation for renal replacement Therapy
Education
Informed choice of renal replacement therapy
Hemodialysis
◼ Maintaining Fluid and Electrolyte Balance

Same as ARI

◼ Maintaining Adequate Nutritional Status

Same as ARI
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 CRF …
◼ Maintaining Skin Integrity
Keep skin clean while relieving itching and dryness
◼ Sodium bicarbonate added to bath water

◼ Bath oil added to bath water

Apply ointments or creams

Administer antihistamines for relief of itching

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 CRF …
◼ Preventing Constipation
Encourage high-fiber diet

Use stool softeners

Increase activity as tolerated

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 CRF …
◼ Ensuring a Safe Level of Activity
 Monitor serum calcium and phosphate levels

 Inspect patient's gait, ROM, and muscle strength

 Administer analgesics

 Administer medications (Calcium supplements, Vit D)

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 CRF …

◼ Pt and family education

Assess pt's understanding of Rx regimen

Importance of adherence to Rx

Self monitoring of wt

Dietary modification
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 Urolithiasis
◼ Urolithiasis

◼ Nephrolithiasis

◼ Men are more often affected than women

◼ Chance of recurrence is about 50%

◼ Has familial tendency

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 Urolithiasis…
◼ Formed due to high urinary concentrations of substances

Calcium oxalate

Calcium phosphate

 Uric acid

◼ This is referred to as supersaturation

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 Urolithiasis…
◼ They can also form when there is a deficiency of substances
Citrate-reduces urinary super saturation of calcium salts
by forming it soluble

Magnesium,

Uropontin – inhibit calcium oxalate

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 Urolithiasis…

◼ Calculi may be found anywhere from the kidney to

the bladder
◼ They vary in size from
Minute granular deposits, called sand or gravel

Bladder stones as large as an orange

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10/3/2023 84
 Urolithiasis…
Types and their causes
◼ Calcium oxalate and phosphate
Account for about 75% to 85% of urolithiasis

Calcium oxalate is more common than phosphate

Certain factors favor the formation of stones, including

◼ Infection, urinary stasis, and immobility
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 Urolithiasis…
◼ Increased Ca concentrations in blood and urine due to
 Hyperparathyroidism

 Excessive intake of vitamin D

 Excessive intake of milk

 Dehydration…

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 Urolithiasis…
◼ Magnesium Ammonium Phosphate:
 15-20% of stones

 Caused by urea-splitting MOs (Proteus, Staphylococcus)

 Form the Stag-horn calculi

 Alkaline urine (antacids, laxative…)

 Dehydrated patients

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 Urolithiasis…
◼ Uric acid: 5-10% of stones
 Purine metabolism

◼ High turnover of protein metabolism( Gout, Leukemias & Lymphomas)

◼ Cystine: Only 1-2% of stones

 Caused by genetic defects in renal reabsorption of amino acids

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 Urolithiasis…
Ethiology
◼ Hypercalcemia and hypercalciuria

◼ Chronic dehydration

◼ Abnormal purine metabolism

◼ Chronic infection with urea-splitting bacteria

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 Urolithiasis…
◼ Chronic obstruction with stasis of urine

◼ Urinary retention

◼ Excessive intake of vitamin D

◼ Excessive intake of milk and alkali

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 Urolithiasis…
◼ Most stones migrate downward
◼ Spontaneous stone passage can be anticipated in 80% of pts

◼ They may lodge in renal pelvis, ureters, or bladder

 Obstruction

 Infection

 Damage to the nephrons

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 Urolithiasis…

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 Urolithiasis…

Clinical Presentation: depends on

◼ Obstruction: producing

An increase in hydrostatic pressure and

Distending the renal pelvis and proximal ureter--> renal

colic

Pain relief is immediate after stone passage

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 Urolithiasis…
◼ Infection: pyelonephritis and cystitis
 Chills,

Fever, and

Dysuria

Urinary urgency or frequency

◼ Edema
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Pain : depends on site of calculi formation

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 Urolithiasis…
◼ Hematuria (micro)

◼ Pyuria

◼ Nausea and vomiting

◼ Pt spontaneously passes stones 0.5 to 1 cm in diameter

◼ Silent

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 Urolithiasis…
Diagnostic Evaluation
◼ KUB radiography
Will reveal calculus in up to 80% of cases

Disadvantages include
◼ Stones must generally be at least 2mm in diameter

◼ Stones must contain calcium to be visible

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Nephrolithiasis
◼ Intravenous Pyelography (IVU)
 Classic diagnostic test
 Disadvantages includes
◼ Bowel preparation

◼ Reactions to contrast

◼ Can take a really long time

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 Nephrolithiasis…
◼ CT scan
Requires no preparation and is noninvasive

Takes only 10 minutes; can replace IVU

◼ Urinalysis
Hematuria and pyuria

Urine culture and drug sensitivity studies to detect infection

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 Nephrolithiasis…
Management
◼ General Principles
If small stone (< 4 mm)
◼ 80% will pass stone spontaneously

◼ Hydration,

◼ Pain control; and reassurance

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 Nephrolithiasis…
◼ Hospitalized for
Intractable pain

Persistent vomiting

High-grade fever

Obstruction…

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 Nephrolithiasis…
Non-surgical mgt
◼ Pain relief
 Morphine sulfate IV (PCA)

 NSAIDS – Toradol

◼ Spasmolytic drugs:
 Dicyclomine hydrochloride, Pro- Banthine, Detrol LA

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 Nephrolithiasis…
◼ Allopurinol to
 Reduce serum uric acid levels and

 Increase urinary uric acid excretion

◼ Avoid dehydration

◼ Strain all urine to monitor for stone passage

◼ Send any stone passed to the laboratory for analysis

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 Nephrolithiasis…
◼ Extracorporeal Shock Wave Lithotripsy

 Noninvasive technique

 Rx of choice for stones <2 cm in dm (80% fall into this category)

 The stone should be located in the ureter above the iliac crest

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Nephrolithiasis

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Nephrolithiasis

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 Nephrolithiasis…
◼ Ureteroscopy
 Used for distal ureteral calculi

 Flexible/rigid ureteroscopes are used with graspers

 Electrohydraulic, ultrasonic, or laser is used to fragment

stone

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10/3/2023 108
 Nephrolithiasis…

Minimally Invasive Surgical Procedures

◼ Percutaneous Nephrostolithotomy
 For stones in renal collecting system or upper portion of ureter, &

 Larger than 2.5 cm in diameter

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 Nephrolithiasis…

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 Nephrolithiasis…
Open Surgical Procedures
◼ Indicated for only 1% to 2% of all stones

◼ Used when other attempts have failed

◼ Pyelolithotomy- surgical incision of renal pelvis for stone removal

◼ Ureterolithotomy- laparoscopic surgical removal of stone from the

ureter

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 Nephrolithiasis…

◼ Cystolithotomy – surgical removal of stone from

bladder

◼ Nephrectomy : indicated when kidney is

Extensively and irreparably damaged and

No longer a functioning organ

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 Nephrolithiasis…
……..
◼ Preoperative Care

 Explain the procedure

 NPO

 Preoperative bowel preparation

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 Nephrolithiasis…
◼ Controlling Pain
 Give opioid analgesic (usually I.V. or I.M.)

 Encourage pt to assume comfortable position

 Reassess pain frequently using pain scale

 Administer antiemetics (I.M. or suppository) for nausea

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 Nephrolithiasis…
◼ Maintaining Urine Flow
 Administer fluids orally or I.V.

 Monitor urine output and patterns of voiding

 Strain all urine

 Help pt to walk, b/c ambulation may help move the stone

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 Nephrolithiasis…
◼ Controlling Infection
Administer parenteral or oral antibiotics
◼ Broad spectrum antibiotics (Gentamicin, Cephalexin)

Assess urine

Monitor V/S, and S+S of infection

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 Nephrolithiasis…
◼ Patient Education
 Encourage fluids (2-3L/d)

 Ambulation, and Adequate caloric intake

 Avoid excesses of Ca and phosphorus

 Increase consumption of fiber

 Save any stone passed for analysis

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