Unit 4: Alterations of the Renal/Urinary System

Disequilibrium syndrome

*Headache, confusion, restless, N/V* - Also hypertension, agitation, muscle weakness... - Symptoms are due to the rapid changes in BUN, pH, and electrolye levels during dialysis that may lead to cerebral edema and increased intracranial pressure (resulting in the syndrome)

Reservoir

- A section of small bowel is used to create a "neobladder" or Kock's Pouch - Continent ostomy - Client performs irrigation & self-catheterization to empty it Teaching - Won't feel urge to void, so must irrigate and drain at regular intervals (e.g. q4h or q6h)

Ileal conduit

- A section of the small bowel (ileum), or, colon (colon conduit) is used to create a conduit from the ureters to the opening on the skin - Incontinent ostomy - The portion of the bowel which is used to form the ileal conduit produces mucus, so cloudy urine is an expected finding Teaching Same as for ureterostomy

Hemodialysis

- Arteriovenous (AV) fistula is created - Fistula is the access point: Guard it with your life! - No BPs, venipunctures, or laying on the fistula arm - Treatment several times per week - Electrolytes, waste products, and excess water are removed - Blood is pumped to the dialyzer and through a semipermeable membrane - Takes hours - Very serious decision - Fluid imbalance = hypotension - Electrolyte imbalance = cramping - Heparin: Check for bleeding at site Potential complications - Disequilibrium syndrome - Bleeding r/t heparin administration and altered platelet function due to uremia - Hypotension: Hold sedatives and antihypertensives before dialysis to prevent

Urine production

- Blood filtered in porous glomeruli - Hydrostatic "pushing" pressure of water filters blood in to the Bowman's capsule (keeps blood cells, platelets, and large plasma proteins) - Glomerular filtration rate (GFR): The amount filtered each minute by the glomeruli, normally around 125 mL/min - Glomerular filtrate passes down the tubule, and much of it is reabsorbed, leaving ~1 mL/min to become urine

Antibiotics for pyelonephritis

- Fluroquinolines: ciproflaxacin (Cipro) - ofloxacin - gatifloxacin Broad-spectrum - ampicillin, vancomycin combined with an aminoglycoside Sensitivity-guided - trimethoprim/sulfamethoxazole (Bactrim) when C&S results are available

Potassium

- Normal 3.5-5.0 mEq/L - Retained or increased, which can cause hyperkalemia Symptoms Cardiac dysrhythmias and asystole Treatment Kayexalate, PO or rectal, regular IV insulin with 5-50 percent dextrose, IV calcium gluconate, and dialysis

Magnesium

- Normal: 1.5-2.5 mEq/L - Retained or increased Treatment Avoid magnesium-containing antacids and laxatives

Sodium

- Normal: 135-145 mEq/L - Normal or increased with renal failure - Patient retains sodium, however, there is water retention (d/t clogged kidney filters) which causes hemodilution of sodium Symptoms Fluid volume excess, HTN, heart failure, pulmonary edema, and generalized edema Treatment Diuretics, dialysis, fluid restriction and sodium restriction

Blood urea nitrogen (BUN)

- Normal: 6-20 mg/dL - Increases in renal failure - Can be managed by decreasing or limiting protein intake - Protein is limited to 0.6-1 g/kg/day to limit the amount of azotemia (increased nitrogen waste products in blood) - Complete protein is recommended: Milk, eggs, cheese, meats, poultry, fish and soy. - Check for sepsis, GI bleed and dehydration.

Calcium and phosphorus

- Phosphorus is mostly excreted through the kidney, and with an impaired kidney, serum phosphate levels increases - Calcium will decrease due to a decrease activated vitamin D, impairing absorption of calcium from the gut (acute!) - Calcium and phosphorus are inversely related, so the the imbalance of hyperphosphatemia an hypocalemia is accentuated - With hypocalcemia and hyperphosphatemia, parathyroid hormone is released so that the bones can undergo demineralization and release calcium. Now the person is experiencing hyperphosphatemia and hypercalcemia (chronic!) - Phosphorus and calcium can bind creating an insoluble product, and over time, this will lead to vascular complications (osteomalacia, osteitis fibrosa) and soft tissue calcifications (CV problems, uremic red eye, intracardiac calcification disrupting the conduction of the heart leading to MI)

Intravenous pyelogram (IVP)

- The patient is injected with radiopaque dye and X-rays are taken as the dye travels through the urinary tract - Used to diagnose kidney stones Before the test: - Assess patient's knowledge and understanding - Schedule the IVP before any ordered barium test and gallbladder studies using contrast material (it may take days to eliminate barium/contrast material from the body) - Ask about allergies: seafood, iodine, radiologic contrast dye; inform MD/radiologist - Verify the presence of a signed consent for the procedure - Assess renal/fluid status: serum osmolality, creatinine and BUN levels before IVP; notify MD of abnormal values - Instruct patient to complete ordered pretest bowel preparation (prescribed laxative or cathartic the evening before the test, enema or suppository the morning of the test - Withhold food 8 hours before the test (clear liquids are allowed) - Obtain baseline vital signs - Instruct the patient that they may feel some momentary effects when the dye is injected into the IV line: flushing sensation, a salty or metallic taste in the mouth, a brief headache, itching, or nausea and/or vomiting After the test: - Monitor vital signs and urine output - Report signs and symptoms of delayed reaction to the contrast media: Dyspnea, tachycardia, itching, hives, or flushing - Patient should drink more fluids to help flush the contrast dye from their body

Sigmoidostomy

- The ureters are attached to the large intestine and no stoma is created - Supposed to be a continent diversion,m but the increased liquid in stool may cause rectal incontinence Teaching - Skin and anal care to prevent excoriation - Avoid foods that produce gas if the diversion uses the intestinal tract - Steps to take if bowel incontinence is developed

Peritoneal dialysis

- Tube is surgically inserted into the body - A sterile clear solution (dialysate) is instilled - Waste products and electrolytes diffuse into the dialysate while it's in the abdomen - Excess water is drawn into the dialysate by osmosis- Fluid is then drained by gravity out of the peritoneal cavity into a sterile bag - Can be done in the home, with the dwell time being at night, causing less of an interruption - No need for vascular access or anticoagulant therapy - Less effective at removing wastes Potential Complications - High glucose in dialysate may cause weight gain and hyperglycemia; infection - Peritonitis: Abdominal tenderness, distended abdomen, nausea and vomiting, chills, and fever; always assess the catheter site and fluid for S/S of infection (red, tender, swelling, or purulent drainage at exit site, and/or, cloudy or foul smelling dialysis fluid exiting the body) - Herniation, bloating, respiratory distress, bowel perforation, overfilling of the abdomen

Ureterostomy

- Ureter tube taking urine from the kidney is attached to the surface of the skin - Incontinent ostomy Teaching - Appearance of a healthy stoma: Reddish pink and moist (darkening may indicate ischemia) - Should protrude from abdomen about 3/4" and slight bleeding is normal, observe for signs of the stoma detaching from the skin - Cut the wafer 1/8" larger than the stoma itself, use the measuring tool provided in your start up kit (stoma will shrink after surgery so it will have to measured more than one time) - Empty the pouch when it is 1/3 to 1/2 full - If malodorous, likely from leakage - Encourage positive self-image by building confidence in looking at the stoma and pouch application - Refer to support groups as needed - If performed, cystectomy causes impotence in men

Urinary diversion procedures

- Ureterostomy - Ileal Conduit - Reservoirs - Sigmoidostomy

Kidney anatomy

20-25% of all cardiac output goes to the kidneys Functions - Filtration, reabsorption, secretion, and excretion of water, electrolytes, and metabolic waste products - Regulation blood pressure via RAA system - Regulation acid-base balance - Erythropoietin production in response to hypoxia to stimulate production of RBCs - Activation of vitamin D to enhance calcium absorption

Polycystic kidney disease (PKD) (pp. 1051-1052)

A genetic disorder characterized by the growth of numerous cysts in the kidneys Autosomal dominant PKD is the most common inherited form. Symptoms usually develop between the ages of 30 and 40, but they can begin earlier, even in childhood. About 90 percent of all PKD cases are autosomal dominant PKD. Autosomal recessive PKD is a rare inherited form. Symptoms of autosomal recessive PKD begin in the earliest months of life, even in the womb. Signs & Symptoms - Protuding abdomen Diagnosis Clinical manifestations, family history, ultrasound, CT Treatment - Currently, no treatment can prevent the cysts from forming or enlarging because it is a genetic predisposition - Reduce symptoms and prevent complications - Control BP! Low sodium diet, antihypertensive medications (ACE inhibitors, calcium channel blockers, beta blockers and vasodilators), diuretics - Check BP weekly and weigh daily - 2 liters fluid per day - Cipro for infected cysts - Pain management: Avoid NSAIDs (harsh on kidneys) and aspirin (increased risk of bleeding) - Heat - Percutaneous needle aspiration of painful cysts - Constipation: Fluids, fiber, physical activity - Kidney failure: Dialysis, transplant

Nephrotic syndrome (pp. 1043-1044)

A group of symptoms rather than a specific disorder; results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema Causes - About 1/3 of patients with nephrotic syndrome have a systemic disease, e.g. diabetes or lupus - Primary glomerular disease - Multisystem disease - Allergens (e.g. bee stings, pollen) - Infections - Neoplasms - Drugs (NSAIDs, captopril heroin) Signs & Symptoms - Peripheral edema, massive proteinuria, hypertension, hyperlipidemia, hypoalbuminemia, and foamy urine - When albumin levels drop, fluid may collect in the ankles (pedal edema), lungs (pulmonary edema), or belly (ascites) Treatment - Treat the cause! Plus... - Reduce high cholesterol - Reduce blood pressure - Reduce protein loss in the urine through diet and/or medications (protect the kidneys and reduce protein loss; ACEs & ARBs) - Reducing BP and proteinuria will reverse edema - Albumin used short-term - Daily weights, strict I&O, and measurement of abdominal girth or extremity size - Edematous skin needs careful cleaning and trauma should be avoided - Diuretic therapy should be monitored - Small, frequent meals in a pleasant setting can encourage better dietary intake as the client may be anorexic and has the potential to become malnourished from proteinuria - Prevent infection: Nephrotic syndrome alters the immune response - Loss of anticoagulant proteins: Increased risk for thromboembolism

Renal artery stenosis (pp. 1050-1051)

A partial occlusion of one or both renal arteries and their major branches Causes - Atherosclerotic narrowing - Fibromuscular hyperplasia Signs & Symptoms - If hypertension develops abruptly, renal artery stenosis may be the cause Diagnosis Renal ultrasound, CT scan, MRI, and renal arteriogram (the best tool!) Treatment - Control BP - Restore perfusion to the kidney - Percutaneous transluminal renal angioplasty (best procedure) - Surgical revascularization of the kidney - If only one kidney is affected, unilateral nephrectomy may be considered

Renal calculi: Diet modifications based on stone composition

Calcium oxalate: Avoid spinach, black tea, and rhubarb and other oxalate sources. Diets high in salt, or sodium, can increase the excretion of calcium into the urine and thus increase the risk of calcium-containing kidney stones. Reducing salt intake is preferred to reducing calcium intake in most cases. Calcium phosphate: Limit high intake of animal protein to 5-7 servings/week, never more than 2/day. Similar diet recommendations as calcium oxalate, but the client does not have to worry about high oxalate levels in the urine. These stones thrive in alkaline conditions (high pH), so acidify the urine with cranberry juice. Drink lots of water! Struvite: Linked to UTI's. Treat the infection. Uric acid: Decrease intake of purines (organ meats, poultry, fish, gravies, red wine, and sardines). Meats and other animal proteins such as eggs and fish contain purines, which break down into uric acid in the urine. Clients who form uric acid stones should limit their meat consumption to 6 ounces each day. Cystine stones <1-2%: Result from a genetic disorder that causes cystine to leak through the kidneys into the urine, forming crystals that accumulate to form stones. Increase fluids!

Urinary tract infections (pp. 1033-1038)

Causes - E. coli is most common - Also Enterococcus, Klebsiella, Enterobacter, Proteus, Psuedomonas, Stapholococcus, Seratia, and Candida albicans Risk factors - Female - Wiping back to front; incontinence - Dehydration - Holding urine too long - Use of douches, bubble baths, harsh soaps, or powders in the perineal area Diagnostics - Clean catch urine specimen, refrigerate - Urinalysis: WBCs, leukocyte esterase, nitrites - C&S to determine the pathogen Clinical manifestations - Emptying symptoms: Hesitancy, intermittency, retention, dribbling, dysuria - Storage symptoms: Frequency, urgency, incontinence, nocturia, nocturnal enuresis - Hematuria - Cloudy, foul-smelling urine - Tender, enlarged kidney Treatment - Antibiotic therapy (Fluoroquinolones) - Trimethoprim/Sulfamethoxazole (Bactrim) - Nitrofurantoin (Macrodantin): Avoid sunlight and notify MD of fever, chills, cough, chest pain, dyspnea, rash, or numbness or tingling of fingers or toes develops - Fosfomycin (Monurol) - Urinary tract analgesic: Phenazopyridine (Pyridium) causes urine to become red/orange; monitor renal function, blood sugar, and watch for yellow sclera

Kidney transplants (pp. (Notes on rejection: pp. 208-211)

Contraindications - Disseminated malignancies - Refractory or untreated cardiac disease - Chronic respiratory failure - Extensive vascular disease - Chronic infection - Nonadherence to medical regimens - Alcoholism - Drug addiction - Not HIV or hepatitis B/C! - Some programs won't allow donors who are obese or who continue smoking Donors - Living - Dead (brain dead, then allowed to die) - Can have a donor change to get organs where they're needed Rejection - Hyperacute: Occurs within 24 hours r/t rapid blood vessel destruction; need to remove organ - Acute: Within 6 months r/t cell-mediated immunity against the tissue/organ; usually reversible with additional immunosuppressive therapy (creates increased risk for infection through...) - Chronic: Occurs over months or years; irreversible Immunosuppressive Therapy - Requires a lifeling balance between rejection and infection - calcineurin inhibitors, e.g. cyclosporine (Gengraf), tacrolimus (Prograf): Avoid grapefruit - corticosteroids - mycophenolate (CellCept): Must be reconstituted in D5W; incompatible with all other solutions - sirolimus (Rapamune)

Acute renal failure (pp. 1069-1075)

Formerly known as acute renal failure (ARF), acute renal disease (ARD), and acute kidney disease (AKD) Prerenal: Problem is before the kidneys - Hypoperfusion from problems that decrease cardiac output, systemic vascular resistance, or vascular volume - Causes: Cardiogenic shock, congestive heart failure, anaphylaxis, vasoactive drugs, sepsis, burns, wounds, excess fluid loss from GI tract, hemorrhage, and dehydration - Cells swell and die - Treatment: Restore BP and bloodflow to the kidneys Intrarenal: Problem is inside the kidneys - Glomerular/microvascular injury, acute tubular necrosis (ATN), or interstitial nephritis - Causes: Glomerulonephritis, DIC, HTN, toxemia (in pregnancy), hemolytic uremic syndrome (usually caused by E. coli infection), vasculitis, nephrotoxic drugs, heavy metals, rhabdomyolysis, conditions associated with prerenal ARF resulting in ischemia, acute pyelonephritis, idiopathic, and metabolic imbalances - Treatment: All drugs that are nephrotoxic, such as NSAIDs, nephrotoxic antibiotics, or those that may interfere with renal perfusion, such as potent vasoconstrictors, are discontinued Postrenal: Problem lies after the kidneys - Any condition which obstructs the outflow of urine, increasing pressure within the kidney - Ureteral or urethral obstruction impairs renal perfusion, decreasing GFR, which results in oliguria, azotemia, electrolyte imbalances, and tissue injury - Causes: Calculi, tumor edema, external compression, structural abnormalities, stricture, blood clot, neurogenic bladder, and prostatic enlargement - Treatment: Remove the obstruction; lithotripsy, TURP

Functions of nephron segments

Glomerulus Selective filtration Proximal tubule - Reabsorption of 80% of electrolytes and water, glucose, amino acids, HCO3 - Secretion of H+ and creatinine Loop of Henle - Reabsorption of Na+ and Cl- in ascending limb, and water in descending loop - Concentration of filtrate Distal tubule - Secretion of K+, H+, ammonia - Reabsorption of water (regulated by ADH) and HCO3- - Regulation of Ca2+ and PO4- by parathyroid hormone - Regulation fo Na+ and K+ by aldosterone Collecting duct - Reabsorption of water (ADH required)

Treating calcium/phosphorus imbalances

Hyperphosphatemia - Phosphate binding agents - Limiting phosphorus intake - Vitamin D Hypocalcemia - Calcium supplements - Vitamin D

Acid-base balance

In acidosis, when excess hydrogen ions are present and the pH falls, the kidney excretes hydrogen ions and retains bicarbonate In alkalosis, the kidney retains hydrogen ions and excretes bicarbonate to restore acid-base balance - In renal failure, the imbalances are treated with bicarb supplements and dialysis - The lungs will compensate for what the kidneys aren't doing (retained CO2 causes vasodilation)

Glomerulonephritis (pp.

Inflammation of the glomeruli Causes - Infections: Poststreptococcal glomerulonephritis (GN) may develop 1-2 weeks after a strep infection. This happens because immune complexes deposit in the glomeruli and cause inflammation. Other infections may include infective endocarditis and viruses. - Immune Diseases: Goodpasture syndrome is an example of an autoimmune condition that attacks the glomeruli and lungs. - Vasculitis - Conditions causing scarring of glomeruli: These include diabetic neuropathy and hypertension Illicit drug use increases the risk for GN Signs & Symptoms - Abrupt generalized body edema r/t decreased GFR (initially periorbital, then spreading to critical areas such as the lungs) - Hypertension r/t decreased GFR - Oliguria r/t decreased GFR - Hematuria r/t bleeding in the upper urinary tract (smoky/rusty appearance) - Proteinuria, the degree of which is r/t the severity of glomerular damage - Elevated BUN and creatinine r/t retention of nitrogenous wastes Diagnosis - History and physical - Antistreptolysin-O (ASO) titer to determine immune response to (presence of) strep - Urinalysis for protein and RBCs - BUN and creatinine to assess degree of renal impairment - Monitor electrolytes Treatment - Treat the cause! Acute Poststreptococcal GN: - Antibiotics if strep is still present; take full course as prescribed - Encourage early diagnosis of sore throats and skin lesions Goodpasture Syndrome: - Corticosteroids - Immunosuppressive drugs - Plasmapheresis - Dialysis Generally: - Rest until signs of inflammation and hypertension subside - Antihypertensive drugs - Diuretics and sodium and water restrictions to prevent edema - Protein restriction if elevated BUN (azotemia); protein ingested should be complete to maximize nutrition - Avoid nephrotoxic drugs - Monitor for excess fluid volume

Pyelonephritis (pp. 1038-1039)

Inflammation of the renal parenchyma and collecting system Causes - Bacterial infection ascending from the lower urinary tract - Infection may also be related to fungi, protozoa, or viruses - Acute or chronic; chronic can lead to CKD and failure Signs & Symptoms Fatigue, chills, fever, vomiting, flank pain, malaise, dysuria, urgency, frequency, costovertebral angle tenderness Diagnosis H&P, urinalysis, urine C&S, CBC, blood cultures, CVA tenderness, ultrasound, CT Treatment - Fluids, NSAIDs, antipyretic medications - Antibiotics (broad, then based on sensitivity) - Hospitalization if severe - Monitor VS closely for sepsis - Prevent UTIs (wipe front-to-back, void before and after intercourse, avoid sprays and powders, avoid bubble baths)

Bacterial cystitis (bladder infection)

Inflammation of the urinary bladder Interstitial cystitis: Occurs with repeated, chronic, inflammation of the bladder wall and is very painful Risk factors - Female: Short, straight urethra, proximity of urinary meatus to vagina and anus, sexual intercourse, use of diaphragm and spermicidal compounds for birth control, pregnancy. - Male: Uncircumcised, prostatic hypertrophy, anal intercourse - Both: Aging, urinary tract obstruction, neurogenic bladder dysfunction, vesicoureteral reflux, genetic factors and catheterization Signs & symptoms - Dysuria, urgency, nocturia, frequency, pyuria, hematuria and suprapubic discomfort - Older adults may not present with the classic symptoms of cystitis! Confusion, behavior changes, nocturia, incontinence, lethargy, anorexia, or just not feeling right may be present - Neonate: Fever or hyperthermia, change in urine odor or color, poor weight gain, and feeding difficulties. - Children: May c/o abdominal or suprapubic pain Treatment - Same as a for a UTI

Readings

Lewis Chapter 44: Assessment of the Urinary System Chapter 45: Renal and Urologic Problems Chapter 46: Acute Kidney Injury and Chronic Kidney Disease Chapter 54: Male Reproductive and Genital Problems McKinney Chapter 44: The child with a Genitourinary Alteration

Kidney, ureter, bladder (KUB)

No special prep except for removing metal and a bowel prep - It's an X-ray!

Renal biopsy

Obtains renal tissue for examination to determine type of kidney disease or to follow progress of kidney disease Uses - Identify glomerular or interstitial pathologies - Diagnosis of renal masses and malignancies (most common is renal cell carcinoma) - With a transplanted kidney, used to diagnose graft rejection when serum creatinine increases and helps guide treatment Procedure - Usually done by inserting a needle through the skin into the lower lobe of the kidney - May be CT or ultrasound guided Before the procedure - Informed consent - Answer questions and provide additional information as needed and appropriate to your scope - Maintain NPO status from midnight before the procedure - Note H/H and coagulation values prior to the procedure. Risk for bleeding! - Local anesthesia is used at the injection site - The procedure may be uncomfortable but should not be painful - When the needle is inserted, patient is instructed not to breathe to prevent kidney motion - The entire procedure takes approximately 10 minutes After the procedure - Apply a pressure dressing and position on the affected side to help maintain pressure on the biopsy site (30-60 min) - Bedrest for 24 hours - Monitor closely for bleeding during the first 24 hrs after the procedure - Avoid coughing during the first 24 hrs after the procedure - Avoid strenuous activity and heavy lifting (may be prohibited for approximately 2 weeks after the procedure) - No anticoagulants until allowed by MD - Report any signs and symptoms of complications such as hemorrhage or urinary tract infection - Potential complication for renal biopsy is bleeding (Has it been mentioned enough times for you?)

Assessment of urinary system

Past health history - Medications - Surgeries, particularly pelvic surgeries or urinary tract instrumentation - Any previous hospitalizations related to renal or urologic diseases and all urinary problems during past pregnancies - Review of systems using functional health patterns. Physical exam - Height and weight - Inspection of the skin (integrity, color, and peripheral edema) - Examination of the abdomen - Examination of the costoverterbal area (percussion) Labs - BUN: Concentration of urea in blood is regulated by rate at which kidney excretes urea (Reference: 6-20 mg/dL) - Creatinine: More reliable than BUN as an assessment of renal function, creatinine is the end product of muscle and protein metabolism and is released at a constant rate (Reference: 0.6-1.2 mg/dL) - Creatinine clearance: 24-hour urine specimen test to estimate GFR (no preservatives; refrigerate or keep on ice; instruct patient to avoid meat and excessive exercise during test) - Sodium: 135-145 mEq/L - Potassium: 3.5-5.0 mEq/L - Urine specific gravity: 1.005-1.030

Renal calculi/colic

Stones form in the renal pelvis and are most painful as they move down the ureter Causes - Recent reduction in fluid intake - Increased exercise with medications that cause hyperuricemia (high uric acid) and a history of gout - Stone composition: calcium oxalate and calcium phosphate (75% of all stones), struvite (15%), uric acid (8%), or cystine Signs & Symptoms - Pain: Sudden onset, very severe and colicky (intermittent), not improved by changes in position, radiating from the back, down the flank, and into the groin - Nausea, vomiting Treatment - Pain relief - Hydration (>2 L/day) - If there is concurrent urinary infection, antibiotics - The majority of stones pass spontaneously within 48 hours (passage dependent on size of the person, prior stone passage, prostate enlargement, pregnancy, and the size of the stone) - Stones <4 mm can generally be passes - Strain for stones before and after surgical intervention - Endourology, lithotripsy or an open surgical procedure - Knowing the composition can help treat/prevent future stones - Nursing dx = Pain!

AKI Treatment: Greater details!

Restore renal perfusion IV fluids, blood volume expanders, dopamine (Intropin), a catecholamine, in low doses by IV infusion, to cause renal vasodilation Improve urinary output/to reduce toxin concentration/to decrease edema Loop diuretic such as furosemide (Lasix) or an osmotic diuretic such as mannitol To manage HTN ACE inhibitors or other hypertensive medications To prevent GI hemorrhage Regular doses of antacids, histamine H2-receptor antagonists (-tidine) or a PPI (-prazole) To correct electrolyte imbalances - For hyperkalemia: IV bicarbonate, glucose, and insulin to bring circulating K+ levels down and prevent further acidosis; polystyrene sulfonate (Kayexalate) - For metabolic acidosis: Sodium bicarb or calcium carbonate to increase alkaline levels in blood. - For hypocalcemia and hyperphosphatemia: Phosphorus binding agents such as calcium carbonate or calcium acetate are used to increase calcium levels and reduce high phosphorus levels. - For acute hyperphosphatemia: Aluminum hydroxide is used to decrease phosphate levels. - To increase calcium absorption and utilization: Vitamin D To promote RBC development Folic acid, iron, and erythropoetin To replace renal function Dialysis, either hemodialysis or peritoneal dialysis, is used to remove excess fluid and metabolic waste products in renal failure. A newer form of dialysis is continuous renal replacement therapy (CRRT), where blood is continuously circulated through a highly porous hemofilter

Uric acid

Rises; uric acid is an end product of nucleic acid breakdown. PC: Gout, worsening kidney failure. Gout pain is treated with colchicine. Increased uric acid is treated with allopurinol ;)

Chronic kidney disease (pp. 1075-1084)

Risk Factors - Diabetes mellitus, hypertension, and glomerulonephritis Early S&S Sluggishness, fatigue, and mental dullness Later S&S - Weight gain r/t fluid retention - Anorexia (leading to malnutrition) r/t uremic syndrome - Peripheral neuropathy, tremors, twitching, jerky movements, seizures - Irregular patterns, S3 sounds, pericardial friction rub, cardiomyopathy, anemia - Congestive heart failure and hypertension may occur as the result of hypervolemia - Pulmonary edema, pleural effusion - Polyuria and nocturia r/t inability to concentrate urine - Skin may turn yellow-brown. Diagnosis - BUN & creatinine - Urinalysis: RBCs, WBCs, protein, and glucose - Ultrasound Treatment - Controlling blood pressure is the key to delaying further kidney damage - Restriction of water, protein, sodium, and potassium intake, along with the use of diuretics and antihypertensives - Will progress to end-stage renal disease (ESRD) - Daily weights - Monitor BUN, creatinine, and electrolytes

Bladder cancer (pp. 1053-1055)

Risk Factors - Male - Age 60-70 - Cigarette smoking (smokers have twice the risk) - Exposure to dyes used in rubber and cable industries - Chronic abuse of phenacetin- containing analgesics (Saridon) - Diet high in fried meats and animal fats - History of bladder cancer - Chronic, recurrent renal calculi - Chronic UTIs - Long term use of an indwelling catheter - Women who have been treated with radiation for cervical cancer Signs & Symptoms - Hematuria: Gross or microscopic, chronic or intermittent, and initially painless - Change in bladder habits such as bladder irritability with dysuria, frequency, and urgency Diagnosis - Cystoscopy with biopsy (most reliable for detecting bladder tumors - most are superficial) - Urinalysis - Urine cytology Treatment - Instillation of intravesical chemotherapy - Transurethral resection of the bladder tumor (TURBT) - When tumors are invasive, but free from metastasis, partial or radical cystectomy with urinary diversion is the treatment of choice - Radiation if the tumor is inoperable, with metastasis, or with a cystectomy (

Kidney cancer (Renal cell carcinoma) (pp. 1052-1053)

Risk Factors - Obesity - Smoking - Male - Age 50-70 - Occupational exposure to petroleum products, heavy metals, solvents, or asbestos - Cystic disease secondary chronic renal insufficiency - Renal dialysis - Hereditary renal cancer - Associated malignancy such as lymphoma Signs & Symptoms - Usually causes no symptoms until it has grown large enough to interfere with other tissues, or until it metastasizes - Hematuria, painless - Flank pain that will not subside (later sign in small percent of patients) - Noticeable lump in the flank area - Only about 5-10% of clients with renal cell cancer have flank pain, gross hematuria, and a palpable renal mass - Weight loss - Fatigue - Malaise - Night sweats - Anemia - Bone pain, which is deep and achy, can result from metastatic renal cell to the bones Diagnosis - Intravenous pyelogram (IVP) is clearer than X-ray - Ultrasound to differentiate between cysts and tumors - CT to show normal vs. abnormal tissue, enlarged lymph nodes - MRI is more detailed than CT and shows vessels - PET shows cancers metabolizing increased amounts of glucose - Biopsy - Bone scan if bone pain is present - CXR to look for metastasis to lungs - Associated with lung and breast cancer, melanoma, and malignant lymphoma Treatment - Radical nephrectomy if not metastasized - Radiation for palliative, inoperable cases - Resistant to chemotherapy

Nephrosclerosis (p. 1050)

Sclerosis of the small arteries and arterioles of the kidney; leads to ischemia and necrosis of parts of the kidney - Benign or accelerated (malignant) - Caused by hypertension and resultant atherosclerosis - Treatment for benign is the same as for essential hypertension - Treatment for malignant is more aggressive (diastolic BP may be as high as 130 mm Hg!) - May lead to kidney disease and subsequent failure

End-stage renal disease

The complete, or almost complete failure of the kidneys to function (<15% of function remains) Signs & Symptoms - Increase in serum creatinine - Potein in the urine - HTN r/t fluid overload and production of vasoactive hormones, increasing one's risk of developing hypertension and/or suffering from congestive heart failure - Urea accumulates, leading to azotemia and ultimately uremia; urea is excreted by sweating and crystallizes on skin ("uremic frost") - Hyperkalemia - Erythropoietin ↓ = anemmia = fatigue - Fluid volume overload: Mild edema to life-threatening pulmonary edema - Hyperphosphatemia r/t reduced phosphate excretion; associated with hypocalcemia (Later this progresses to tertiary hyperparathyroidism, with hypercalcemia, renal osteodystrophy and vascular calcification that further impairs cardiac function) - Metabolic acidosis r/t ↓ excretion of H+ an impaired retention of bicarbonate by the kidney; may cause altered enzyme activity by excess acid acting on enzymes, and also increased excitability of cardiac and neuronal membranes by the promotion of hyperkalemia due to excess acid (acidemia); Kussmaul breathing is respiratory compensation for this - Accelerated atherosclerosis and cardiovascular disease

AKI Nutrition

The goal of nutritional management is to provide adequate calories to prevent catabolism despite restrictions that prevent electrolyte and fluid disorders Protein - Non-catabolic patients: Protein intakes of 0.8 - 1.0 g/kg/day - Catabolic patients: Protein intakes up to 1.5 g/kg/day Carbohydrates - Carbohydrates (30 to 35 kcal/kg) are increased to maintain adequate caloric intake and provide a protein-sparing effect Fluids Restricted to minimize fluid retention and avoid complications related to Fluid Volume Excess (600 mL plus their urine output from the previous day)

Tubular secretion

The passage of a substance from the capillaries through the tubular cells into the lumen of the tubule

Tubular reabsorption

The passage of a substance from the lumen of the tubules through the tubule cells and into the capillaries

Cystoscopy

Visualization of the inner lining of the bladder; usually outpatient Uses Find causes of bleeding, blockage (such as calculi), and obtain specimens of bladder lesions or any abnormalities of the bladder or bladder lining Prep - Empty bladder - Lithotomy position - Local or general anesthesia Procedure - A cystoscope (a thin, bendable lighted tube with lenses) will be inserted into the urethra and slowly advanced up into the bladder - Water and or saline is used to fill the bladder which stretches the bladder wall allowing clear visualization of the bladder wall - Takes about 30-45 minutes Before the procedure - Total NPO for 8 hours before the test - Verify signed consent has been obtained - Explain the procedure to the patient - Give any preoperative medication After the procedure - Burning with urination, pink tinged urine and frequency are expected - Watch for bright red urine, this is not normal - Assist with ambulation as orthostatic hypotension may occur - A warm sitz bath, heat, and or mild analgesics may be needed to relieve discomfort

How are renal disease and heart disease connected?

Which came first: The chicken or the egg? - Heart failure can decrease the fluid output to the kidneys and cause kidney failure - If the kidneys cannot filter and excrete, then the fluid has no where to drain. It backs up and floods the heart or lungs. Fluid volume excess! - Heart failure and kidney failure are usually found together in end stages of both diseases (now called the "cardio-renal syndrome' in newer journals)