URINARY TRACT & RENAL MANAGEMENT Assessment: History ( changes in voiding; unexplained anemia; pain; n&v) Physical Examination

(Abdominal assessment, palpation of kidneys, bladder percussion, prostate palpation, inspection of urinary meatus)

Diagnostic Tests Urinalysis (specific gravity, color, pH, RBC, WBC, ketones) Urine culture and sample Creatinine clearance (collect urine 24hrs on ice bath) Cytoscopy Serum electrolytes BUN (nitrogen fraction of urea) reflects CHON intake Serum creatinine: MOST SENSITIVE MEASURE OF RENAL DAMAGE IV Pyelogram (inject dye to visualize urinary tract) Specific gravity (urine concentration) OTHERS: o KUB o CT scan/MRI o Retrograde Pyelography o Voiding cystourethrography o Renal angiography

o burning on urination o frequency, urgency, nocturia o incontinence o suprapubic or pelvic pain o hematuria, back pain Dx: urinalysis, urine culture(recurrent infections), gram stain, CT scan Management: o Antibiotics o Pain meds o Hygiene o Fluid intake o Voiding habits o Sexual activities: void after o Minimize catheterization o Acidify urine

Upper Urinary PYELONEPHRITIS *infection: renal pelvis, tubules, interstitial tissue of the kidneys *causes: ascending infection, incompetent ureterovesical valve or obstruction ACUTE: Enlarged kidneys, interstitial infiltrations of inflammatory cells Abscesses on/within renal capsule and corticomedullary junction Atrophy and destruction of tubules and glomeruli s/sx: chills, fever, pain, n&v, headache, malaise, painful urination dx: UTZ & CT (for locating obstructions), IVP, radionuclide imaging, Urine culture and sensitivity tests Management: o 2-week course antibiotics o Follow-up urine culture after atb therapy o Hydration with oral and parenteral fluids (flushing)

Physiologic Responses: Pain: dull/constant Hematuria: RBC casts Uremia: presence of urea & nitrogenous products in blood seizures, confusion Fluid imbalance Electrolyte and acid-base imbalance Integumentary Neurologic, GI, CV symptoms

Urinary Tract Disorders Risk Factors: 1. 2. 3. 4. 5. 6. Inability/failure to completely empty bladder Obstructed urinary flow Decrease natural host defenses or immunosuppresion Instrumentation Inflammation/abrasion Associated medical conditions

CHRONIC: Kidneys scarred, contracted, non-functioning May result to CKD s/sx: asymptomatic infection (unless for acute exacerbations), fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss COMPLICATIONS: end-stage renal disease, hypertension, kidney stones Management: o Long-term prophylactic antimicrobial therapy o Careful monitoring of renal function o Careful I&O monitoring o 3-4L fluid per day (dilute urine, decrease burning sensation, prevent dehydration) o Monitor temp q4hrs o Bed rest for symptomatic patients

Lower Urinary CYSTITIS, PROSTITIS, URETHRITIS Bacterial invasion of urinary tract (GAG & IgA) Reflux: urethrovesical, ureterovesical Uropathogenic bacteria: E. coli, Pseudomonas, Enterococcus Routes of infection: transurethral, hematogenous, direct extension s/sx:un/complicated o asymptomatic bacteriuria

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Administer antipyretic and antibiotic as ordered Patient teachings -

URINARY INCONTINENCE Stress involuntary; intact urethra; results from sneezing, coughing, or changing position Urge involuntary; strong urge to void but cannot be suppressed. Functional lower urinary tract function intact but other factors such as severe cognitive impairment make it hard for pt to identify the need to void or physical impairments make it hard to reach the toilet in time Iatrogenic involuntary; due to extrinsic medical factors (medications) Mixed involuntary; urgency, with exertion, sneezing, coughing, or effort Dx:history, extensive urodynamic tests, urinalysis, urine culture Management: o Behavioral therapy (pelvic floor muscle exercises, voiding diary, biofeedback, verbal instruction and physical therapy) o ANTICHOLINERGIC agents o TRICYCLIC ANTIDEPRESSANTS o Hormone therapy o ANTISPASMODIC agents o Pseudoephedrine sulfate o Surgical correction o Provide support and encouragement o Patient teaching

renal pelvis: intense deep ache in the CVA radiating anteriorly and downward o ureter: acute, excrutiating, colicky pain o bladder: hematuria, urinary retention dx: KUB, UTZ, IV urography, retrograde pyelography management: o eradicated stones o determine type o prevent nephron destruction o control infection o relieve any obstruction o pain meds o increase fluid intake o diet restrictions: decrease Ca, Na, CHON, uric, purine, cystine, oxalate o interventional procedures: ESWL (shockwave) o endourologic removal? o Surgery: nephrolithotomy, pyelolithotomy

RENAL CANCER Risk factors: 1. 2. Increase BMI Cigarette smoking Management: o Eradicate the tumor before metastasis o Surgery: Radical nephrectomy Renal artery embolization (impede blood supply to kill tumor cells o Pharmacotherapy: biological response mod?; vaccine

Urinary Calculi: NEPHROLITHIASIS, UROLITHIASIS, URETEROLITHIASIS Types: free, staghorn o Acid: cystine, uric acid o Alkaline: Calcium oxalate, CaPO4, struvite o Mixed Risk Factors: o Supersaturation of urine with poorly soluble crystals o Infection o Stasis o Bone demineralization o Metabolic diseases o Meds (Vit. D and Steroids) o High urine concentration Prevents crystallization: citrate, potassium, magnesium s/sx: o pain: colic o renointestinal reflex: n&v, diarrhea and constipation o hematuria, fever, chills, frequency, altered urine pH

BLADDER CANCER Risk factors: 1. 2. 3. Old males Smoker Stones Metastatic form PAINLESS HEMATURIA, UTI s/sx Dx: cytoscopy Management: o Surgery: simple/radical cystectomy o Chemotherapy o Radiotherapy o Removal of bladder with diversions Ureterosigmoidostomy implantation of the ureters into the sigmoid colon. Cutaneous ureterostomy ureters are directed through the abdominal wall and attached to an opening in the skin.

Urinary Diversions ILEAL CONDUIT

Oldest and most common Urine is diverted by implanting the ureter into a 12cm loop of ileum that is led out through the abdominal wall Ileostomy bag to collect urine Complications: o Wound infection or dehiscence o Urinary leakage o Ureteral obstruction, contraction, narrowing of the stoma o Hyperchloremic acidosis o Small bowel obstruction o Ileus o Gangrene of the stoma o Renal deterioration Management: o Urine volumes monitored q1hr (<30mL/hr dehydration or obstruction o Stoma and skin care o Testing urine and care for ostomy o Encourage fluids and relieve anxiety o Patient teaching on home care o Monitor closely for complications

Kidney Disorders RENAL TRAUMA prone: retroperitoneal structure ureteral: surgical repair, STENTS bladder complications: bleeding, shock, sepsis urethral: acute onset of blood management: o CONTROL HEMORRHAGE, PAIN AND INFECTION o blood transfusion o monitor VS and I&O o pain medication o antibiotics: quinolones floxacin, beta lactam o w/o shock: peritonitis o surgery o adequate fluid intake

Glomerular Disorders capillaries most common cause of CKD antigen-antibody reaction IgG seen in membrane HALLMARK: PROTEINURIA, HEMATURIA, DECREASED GFR AND EXCRETION OF Na, EDEMA, HYPERTENSION TYPES: o Post Strep Glomerulonephritis o Rapidly Progressive Glomurelonephritis

PROSTATE CANCER Risk factors: 1. 2. 3. 4. Increasing age >50yrs Familial predisposition/genetics Excessive amounts of red meat or dairy products that are high in fat in diet Endogenous hormones s/sx: (later periods) o urinary obstruction (difficulty and frequency of urination, retention, decreased size and force of the urinary stream) o blood in urine or semen, painful ejaculation o hematuria in invasion of bladder and urethra o sexual dysnfunction o metastases: backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, oliguria, spontaneous pathologic fractures dx: routine repeated DRE, serum PSA, UT-guided TRUS w/ biopsy, TURP, open prostatectomy, UTguided transrectal needle biopsy management: o radical prostatectomy o radiation therapy: teletherapy external beam radiation therapy brachytherapy internal implants o androgen deprivation therapy o luteinizing hormone-releasing hormone o chemotherapy docetaxel based o cryosurgery

GLOMURELONEPHRITIS Cause: immune reactions (GABHS) forming an antigen-antibody complex Complexes are deposited in the glomerulus forming anti-GBM antibodies Inflammation and activation of chemical mediators: migrate to area and attack the GBM Altered membrane permeability: allows RBCs and protein to pass thru glomerulus and into urine Can lead to ARF or CRF

Sequence: 1. 2. 3. 4. 5. 6. 7. 8. Antigen exposure Antigen-antibody product Deposition of complexes in the glomerulus Proliferation of epithelial cell lining in the glomerulus leukocyte infiltration of the glomerulus Thickening of the glomerular filtration membrane Scarring and loss of glomerular filtration membrane Decreased GFR s/sx: o hematuria o proteinuria, RBC casts o 24hr urine: decreased Creatinine clearance, impaired GFR o Oliguria o Increase BUN AZOTEMIA o Increase creatinine, anemia

Hypertension, edema, hyperlipidemia increase synthesis of cholesterol in the liver (increase Ca, decrease Phosphorus) hypoalbuminemia o Elevated ASO titers o Biopsy o EM: complements Management: o Symptomatic management o Preserve kidney function, treat complications o Assess and monitor renal function, serum creatinine and BUN o Observe for infection o LOW Na, K, FLUID and CHON INTAKE o Weigh daily o ATB, antihpn, diuretics o Dialysis: uremia o

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Proteins with high biologic value (DAIRY PRODUCTS, EGGS, MEATS) ARE PROVIDED to promote good nutritional status Treat UTIs Dialysis Prevent fluid and electrolyte imbalances Minimize risk for RF Report to the physician changes in fluid and electrolyte status and cardiac and neurologic status Emotional support Promoting home and community based care

NEPHROTIC SYNDROME PROTEINURIA, HYPOALBUMINEMIA, EDEMA, LIPIDURIA, HYPERLIPIDEMIA, HYPERCOAGULABILITY Plasma CHON loss >3.5g/day Decrease muscle mass Edema (feet, legs, sacrum, periorbital) Sequence of events: o Damaged glomerular capillary membrane o Loss of plasma protein A. Stimulates synthesis of lipoproteins HYPERLIPIDEMIA B. HYPOALBUMINEMIA decreased oncotic pressure generalized edema(fluid moves from vascular space o extracellular compartment) activation of RAAS Na retention EDEMA Management: o Treatment of underlying morphologic entity o Measures to control proteinuria o Measures to control nephrotic complications o Dietary CHON restriction o Use of ACE inhibitors, NSAIDs, statins o Anticoagulants o Monitor for complications: thrombosis, protein malnutrition, anemia, decreased calcium, secondary hyperparathyroidism, depressed thyroxine, susceptibility to infection

CHRONIC GLOMERULONEPHRITIS: Causes: repeated episode of nephritic(*with HPN) syndrome Hypertensive nephrosclerosis Hyperlipidemia CITN Glomerular sclerosis SLE s/sx: o same as acute o weight loss, strength loss o increase irritability, nocturia o headache, dizziness, digestive disturbances o signs of RF and CKD may develop o poorly nourished, yellow-gray skin pigmentation o periorbital peripheral dependent edema o BP normal to severely elevated o Retinal hemorrhage exudate, narrowed tortuous arterioles, papilledema o Anemia o Cardiomegaly (gallop rhythm, distended neck veins) o Crackles at the bases of the lungs o Peripheral neuropathy, neurosensory changes o Diminished DTRs o Pericarditis Dx: urinalysis (fixed spgr of 1.010, variable proteinuria, urinary casts) CXR (cardiac enlargement), ECG GFR <50mL/hr: o Hyperkalemia o Metabolic acidosis o Anemia o Hypoalbuminemia with edema o Increased serum phosphorus o Decreased serum calcium o Mental status changes o Impaired nerve conduction Management: o Symptomatic treatment

ACUTE RENAL FAILURE Rapid loss of renal function due to kidney damage Treatment aimed at replacing renal function temporarily to minimize potentially lethal complications and reduce potential causes of increased renal injury Oliguria, nonoliguria, anuria Hypovolemia, hypotension, reduced cardiac output and heart failure, obstruction of the kidney or lower UT by tumor, blood clot, stone, bilateral obstruction of renal arteries or veins reduced blood flow to kidneys impaired kidney function Increased BUN, creatinine levels

PHASES: o Initiation starts with initial insult to onset of oliguria o Oliguria increase in serum concentration of urea, crea, uric acid, K, Mg; uremic s/sx: hyperkalemia o Diuresis gradual increase in urine output, recovery of GFR; renal function still abnormal, observe closely for dehydration > uremic sx may increase o Recovery improvement of renal function (3-12 months); Nonoliguric form: decreased renal function, increasing nitrogen retention, excrete normal amts of urine s/sx: lethargic, critically ill, skin and mucus membrane dry due to dehydration, drowsiness, headache, muscle twitching, seizures DX: o Low spgr; EARLISET MANIFESTATIONS: inability to concentrate urine o Decreased sodium in urine less than 20mEq/L and normal urinary sediment: prerenal azotemia o Urinary s Na greater than 40mEq/L with urinary casts and other debris: intrarenal azotemia o ULTRASONOGRAPHY: CRITICAL COMPONENT o BUN lvl increases o