Chapter 38: Alterations of Renal and Urinary Tract Function

Which mineral accounts for the most common type of renal stone?

Calcium oxalate Calcium stones (calcium phosphate or calcium oxalate) account for 70% to 80% of all stones requiring treatment. (1343)

Bladder cancer is associated with the gene mutation of which gene?

TP53 Oncogenes of the ras gene family and tumor-suppressor genes including TP53 mutations and the inactivation of the retinoblastoma gene (pRb) are implicated in bladder cancer. This process is not associated with the other options. (1348)

Which statement is false concerning the skeletal alterations caused by chronic renal failure when the glomerular filtration rate (GFR) declines to 25% of normal?

The parathyroid gland is no longer able to secrete sufficient parathyroid hormone. Bone and skeletal changes develop with alterations in calcium and phosphate metabolism (see Table 38-16). These changes begin when the GFR decreases to 25% or less. The combined effect of hyperparathyroidism and vitamin D deficiency can result in renal osteodystrophies (e.g., osteomalacia, osteitis fibrosa with increased risk for fractures). Other consequences of secondary hyperparathyroidism include soft-tissue and vascular calcification, cardiovascular disease, and, less commonly, calcific uremic arteriolopathy. The other options are true. (1368 | Table 38-16)

Which statements are true concerning struvite stones? (Select all that apply.)

They are more common in women than in men. They grow large and branch into a staghorn configuration in renal pelvis and calyces. Struvite stones are closely associated with urinary tract infections caused by urease-producing bacteria, such as Pseudomonas. Women are at greater risk for developing struvite stones, but the risk is greater because women have an increased incidence of urinary tract infections not because of chronic laxative use. Such stones grow large and branch into a staghorn configuration and are associated with Pseudomonas. (1343-44)

Detrusor hyperreflexia develops from neurologic disorders that originate where?

Above the pontine micturition center Neurologic disorders that develop above the pontine micturition center result in detrusor hyperreflexia, also known as an uninhibited or reflex bladder. This selection is the only option responsible for detrusor hyperreflexia. (1345)

In glomerulonephritis, what damages the epithelial cells resulting in proteinuria? (Select all that apply.)

Activated complement Altered membrane permeability Activated complement, inflammatory cytokines, oxidants, proteases, and growth factors attack epithelial cells, alter membrane permeability, and cause proteinuria. None of the other options are responsible for this process. (1353-57)

Which renal disorders are considered causes of intrarenal renal failure? (Select all that apply.)

Acute glomerulonephritis Allograft rejection Tumors Acute tubular necrosis (ATN) Intrarenal (intrinsic) acute kidney injury (AKI) may result from ischemic ATN, nephrotoxic ATN, acute glomerulonephritis, vascular disease, allograft rejection, or interstitial disease (drug allergy, infection, tumor growth). Prostatic hypertrophy is not associated with intrarenal renal failure. (1360-61)

Goodpasture syndrome is an example of which of the following?

Antiglomerular basement membrane disease Antiglomerular basement membrane disease (Goodpasture syndrome) is associated with immunoglobulin G (IgG) antibody formation against pulmonary capillary and glomerular basement membranes. Goodpasture syndrome is not an example of any of the other options. (1355 | Table 38-5)

Pyelonephritis is usually caused by which type of organism?

Bacteria Pyelonephritis is usually caused by the bacteria Escherichia coli, Proteus, or Pseudomonas. (1351-52)

Which conditions related to the bladder would result from the effects of lesions of the sacral segments below S1? (Select all that apply.)

Bladder distension Urinary retention Lesions that involve the sacral micturition center (below S1; may also be termed cauda equina syndrome) or peripheral nerve lesions result in detrusor areflexia (acontractile detrusor), a lower motor neuron disorder. The result is an acontractile detrusor or atonic bladder with retention of urine and distention. The other options are associated with neurologic lesions that occur between C2 and S1 (1345)

What are considered risk factors for developing bladder and kidney cancers? (Select all that apply.)

Cigarette smoking Hypertension Exposure to aniline dyes Risk factors for renal cancer include cigarette smoking, obesity, and hypertension. The risk of primary bladder cancer is greater among people who smoke or those who are exposed to metabolites of aniline dyes or other aromatic amines or chemicals and with heavy consumption of phenacetin. Gender is not a recognized risk factor. (1347-49)

Which clinical manifestations of a urinary tract infection may be demonstrated in an 85-year-old individual?

Confusion and poorly localized abdominal discomfort

Which clinical manifestations of a urinary tract infection may be demonstrated in an 85-year-old individual?

Confusion and poorly localized abdominal discomfort Older adults with cystitis may demonstrate confusion or vague abdominal discomfort or otherwise be asymptomatic. (1351)

Which abnormal laboratory value is found in glomerular disorders?

Elevated creatinine concentration Elevated creatinine concentration is an abnormal laboratory value found in glomerular disorders. Reduced glomerular filtration rate during glomerular disease is evidenced by elevated plasma urea, creatinine concentration, or reduced renal creatinine clearance. Glomerular disorders are not associated with the other options (1357)

Anemia of chronic renal failure can be successfully treated with which element?

Erythropoietin Anemia of chronic renal failure can be successfully treated with erythropoietin. Reduced erythropoietin secretion and reduced red cell production are evident in anemia resulting from chronic renal failure. The other options are not relevant to this condition. (1365 | Page 1369 | Table 38-13)

What is the most common cause of uncomplicated urinary tract infections?

Escherichia coli The most common infecting microorganisms are uropathic strains of E. coli (80% to 85%). (1350)

Movement of organisms from the urethra into the bladder with infection and retrograde spread to the kidney

Female sexual trauma Female sexual trauma can result from the movement of organisms from the urethra into the bladder with infection and retrograde spread to the kidney. (1352 | Table 38-4)

Which antibiotics are considered "major culprits" in causing nephrotoxic acute tubular necrosis (ATN)?

Gentamicin and tobramycin Although numerous antibiotics can produce nephrotoxic ATN, the aminoglycosides (gentamicin, tobramycin) are the major culprits. (1361)

A patient exhibits symptoms including hematuria with red blood cell casts and proteinuria exceeding 3 to 5 g/day, with albumin as the major protein. These data suggest the presence of which disorder?

Glomerulonephritis The data suggest the patient has the disorder known as glomerulonephritis. Two major changes distinctive of more severe glomerulonephritis are (1) hematuria with red blood cell casts and (2) proteinuria exceeding 3 to 5 g/day with albumin as the major protein. These symptoms do not support the diagnosis of the other options. (1357)

Considering host defense mechanisms, which element in the urine is bacteriostatic?

High urea Dilute urine washes out bacteria, and urine with higher urea concentrations (high osmolarity) is more bacteriostatic. (1350)

When the right kidney is obstructed, how will the glomeruli and tubules in the left kidney compensate?

Increase in size These processes cause the contralateral (unobstructed) kidney to increase the size of individual glomeruli and tubules. (1342)

Hypercalciuria is primarily attributable to which alteration?

Intestinal hyperabsorption of dietary calcium Hypercalciuria is usually attributable to intestinal hyperabsorption of dietary calcium and less commonly to a defect in renal calcium reabsorption. Hyperparathyroidism and bone demineralization associated with prolonged immobilization are also known to cause hypercalciuria but too a much lesser degree. (1343)

How does progressive nephrons injury affect angiotensin II activity?

It is elevated. Angiotensin II activity is elevated with progressive nephron injury. This selection is the only accurate identification of the effect of progressive nephron injury on angiotensin II activity. (1364. 1366)

Obstruction and stasis of urine, contributing to bacteremia and hydronephrosis; irritation of epithelial lining with entrapment of bacteria

Kidney stones Kidney stones result in the obstruction and stasis of urine, contributing to bacteriuria and hydronephrosis and causing irritation of epithelial lining with entrapment of bacteria.

Which glomerular lesion is characterized by thickening of the glomerular capillary wall with immune deposition of immunoglobulin G (IgG) and C3?

Membranous The thickening of the glomerular capillary wall characterizes only membranous lesions. (1355 | Table 38-6)

Creatinine is primarily excreted by glomerular filtration after being constantly released from what type of tissue?

Muscle Creatinine is constantly released from only muscle tissue to be excreted by glomerular filtration. (1366)

Hypothyroidism, edema, hyperlipidemia, and lipiduria characterize which kidney disorder?

Nephrotic syndrome Symptoms of nephrotic syndrome include edema, hyperlipidemia, lipiduria, vitamin D deficiency, and hypothyroidism. These symptoms do not support the other options. (1359)

What medical term is used to identify a functional urinary tract obstruction caused by an interruption of the nerve supply to the bladder?

Neurogenic bladder Neurogenic bladder is a general term for bladder dysfunction caused by neurologic disorders. The types of dysfunction are related to the sites in the nervous system that control sensory and motor bladder function (see Figure 38-3). None of the other options correctly identify the described condition. (1344-45)

Impairment to the bladder, interfering with normal bladder contraction and causing residual urine and ascending infection

Neurogenic bladder Neurogenic bladder, caused by neurologic impairment, results in the interference of normal bladder and urethral sphincter contraction and causes residual urine and ascending infection.

Which statements are true regarding renal colic? (Select all that apply.)

Pain originates in the flank area. Renal colic indicates the presence of renal stones. Pain radiated to the groin. Renal colic indicates obstruction of the renal pelvis or proximal ureter. Renal colic is described as moderate-to-severe pain often originating in the flank and radiating to the groin. It usually indicates obstruction by renal stones of the renal pelvis or proximal ureter (1344)

skeletal alterations evelop with alterations in calcium and phosphate metabolism caused by chronic renal failure when the glomerular filtration rate (GFR) declines to 25% of normal

Parathyroid hormone is no longer effective in maintaining serum phosphate levels. The synthesis of 1,25-vitamin D3, which reduces intestinal absorption of calcium, is impaired. The synthesis of 1,25-vitamin D3, which impairs the effectiveness of calcium and phosphate resorption from bone by parathyroid hormone, is impaired.

Dilation and relaxation of the ureter with hydroureter and hydronephrosis

Pregnancy Pregnancy causes the dilation and relaxation of the ureter with hydroureter and hydronephrosis.

Renal cell carcinoma, classified as clear cell tumors, arises from epithelial cells in which structure?

Proximal tubule Renal cell carcinoma, classified as clear cell tumors according to cell type and extent of metastasis, arises from the proximal tubular epithelium. These tumors are not associated with the other options. (1347)

Prerenal injury from poor perfusion can result from which condition? (Select all that apply.)

Renal vasoconstriction Renal artery thrombosis Hemorrhage Hypotension Poor perfusion can result from renal artery thrombosis, hypotension related to hypovolemia (dehydration, diarrhea, fluid shifts) or hemorrhage, renal vasoconstriction and alterations in renal regional blood flow, microthrombi, or kidney edema that restricts arterial blood flow. Bilateral ureteral obstruction is not associated with prerenal injuries. (1360)

Regarding the formation of renal calculi, what function does pyrophosphate, potassium citrate, and magnesium perform?

They inhibit crystal growth. Stone or crystal growth inhibiting substances, including potassium citrate, pyrophosphate, and magnesium, are capable of crystal growth inhibition. They are not capable of the functions stated by the other options. (1343)

Which differentiating sign is required to make the diagnosis of pyelonephritis from that of cystitis?

Urinalysis confirmation of white blood cell casts Clinical assessment, alone, is difficult to differentiate the symptoms of cystitis from those of pyelonephritis. Urine culture, urinalysis, and clinical signs and symptoms establish the specific diagnosis. White blood cell casts indicate pyelonephritis, but they are not always present in the urine. This selection is the only option that is considered a required sign of pyelonephritis. (1351-52)

Which urine characteristics are indicative of acute tubular necrosis (ATN) caused by intrinsic (intrarenal) failure?

Urine sodium >30 mEq/L Urine sodium >30 mEq/L is the only option indicative of ATN. (1363 | Table 38-11)

Chronic reflux of urine up the ureter and into the kidney during micturition, contributing to bacterial infection

Vesicoureteral reflux Vesicoureteral reflux results in the chronic reflux of urine up the ureter and into the kidney during micturition, contributing to bacterial infection.

How are glucose and insulin used to treat hyperkalemia associated with acute renal failure?

When insulin transports glucose into the cell, it also carries potassium with it. This selection is the only option that accurately describes glucose metabolism, causing potassium to move to the intracellular fluid; insulin infusions therefore can be effective in shifting potassium from the extracellular to intracellular space, along with the transport of glucose. (1363)

Considering the innervation of the circular muscles of the bladder neck, which classification of drug is used to treat bladder neck obstruction?

α-Adrenergic blocking medications Because the bladder neck consists of circular smooth muscle with adrenergic innervation, detrusor sphincter dyssynergia may be managed by α-adrenergic blocking (antimuscarinic) medications. (1346)