Chapter 25 Alterations in Renal Function

Microalbuminuria

urinary albumin excretion 30-300mg in 24 hours

Hydronephrosis

urine-filled dilation of renal pelvis and calyces and progressive atrophy of kidney due to obstruction of urine flow

Calcium stones (i.e., oxalate or phosphate)

• 70-80% of all kidney stones • Excess serum Ca2+ (hyperparathyroidism) • Too much iced tea

Manifestations of Acute Pyelonephritis

• Abrupt onset • Shaking, chills, fever, constant ache in lower back • Pain can be unilateral or bilateral • Malaise, may have N/V, abdominal pain • Also, will have lower urinary tract symptoms • Dysuria, increased urinary frequency and urgency

Acute Pyelonephritis

• Acute inflammation of the kidney caused by bacterial infection • E. coli most common cause 2 routes bacteria can take to kidney: • Ascending infection form lower urinary tract - most common route • Through the blood stream - septicemia or infective endocarditis Pathophysiology: outflow obstruction plus incompetence of vesicoureteral orifice -- Vesicoureteral reflux

Urinary stasis

infection and kidney stone formation

An adult client has been diagnosed with polycystic kidney disease. Which of the client's following statements demonstrates an accurate understanding of this diagnosis? "I suppose I really should have paid more attention to my blood pressure." "I've always been prone to getting UTIs, and now I know why." "I suppose I should be tested to see if my children might inherit this." "I had a feeling that I was taking too many medications, and now I know the damage they can do."

"I suppose I should be tested to see if my children might inherit this." Autosomal dominant polycystic kidney disease is the most common of all inherited kidney diseases. The disorder is characterized by multiple expanding cysts of both kidneys that ultimately destroy the surrounding kidney structures and cause renal failure. The etiology of polycystic kidney disease (PKD) is not infective, and it is not caused by nephrotoxic drugs or uncontrolled hypertension.

Describe the use of angiotensin-converting enzyme inhibitor medications with autosomal recessive polycystic kidney disease (ARPKD)

ACE inhibitors may interrupt the renin-angiotensin-aldosterone system to reduce renal vasoconstriction.

If a client with a kidney stone has the "classic" ureteral colic, the client will describe his pain as: Select all that apply. Acute, intermittent Diffuse over the entire lower back and legs Excruciating In the flank and upper outer quadrant of the abdomen

Acute, intermittent Excruciating In the flank and upper outer quadrant of the abdomen The symptoms of renal colic are caused by stones 1 to 5 mm in diameter that can move into the ureter and obstruct flow. Classic ureteral colic is manifested by acute, intermittent, and excruciating pain in the flank and upper outer quadrant of the abdomen on the affected side. The pain may radiate to the lower abdominal quadrant, bladder area, perineum, or scrotum in the man. The pain is usually not described as diffuse and over the entire low back and legs.

The physician suspects that a client with kidney stones has developed magnesium ammonium phosphate (struvite) stones based on which of the following urinalysis results? Select all that apply. Elevated uric acid levels Alkaline urine pH High urine phosphate level High bacterial count Presence of cystine particles

Alkaline urine pH High urine phosphate level High bacterial count Magnesium ammonium phosphate stones, also called struvite stones, form only in alkaline urine and in the presence of bacteria that possess an enzyme called urease, which splits the urea in the urine into ammonia and carbon dioxide. The ammonia that is formed takes up a hydrogen ion to become an ammonium ion, increasing the pH of the urine so that it becomes more alkaline. Because phosphate levels are increased in alkaline urine and because magnesium always is present in the urine, struvite stones form.

What Renal Disorder are Polyuria (excess urine output) and Nocturia (voiding at night) typically associated with?

Chronic pyelonephritis Severe hypertension is often also a contributing factor in the progress of the disease.

Clinical Manifestations of Nephrotic Syndrome occur from what?

Decreased plasma colloidal osmotic pressure.

Diabetic Glomerulosclerosis

Diabetic Nephropathy (type 1 and 2) --> chronic kidney disease --> renal failure Lesions generally in glomeruli -- Non-nephrotic proteinuria, nephrotic syndrome, or renal failure Possible mechanisms: -- Improper synthesis of glomerular basement membrane -- Increased blood glucose --> increased GFR and glomerular pressure (mediated by our old friend angiotensin II) Microalbuminuria

Inflammatory process damages the capillary wall.

Hematuria with red cell casts, decreased GFR This is a Nephritic Syndrome

What Renal Disorder is flank and upper outer quadrant pain typically associated with?

Kidney stones

Following the diagnosis of nephrotic syndrome, the nurse knows the clinical manifestations occur as a result of a decreased plasma colloidal osmotic pressure. Therefore, the nurse should assess the client for: Select all that apply. Moist crackles in both lung fields Areas of diminished breath sounds due to pleural effusions Liver enlargement Kidneys palpable to deep palpation Increased circumference in the abdomen related to fluid excess

Moist crackles in both lung fields Areas of diminished breath sounds due to pleural effusions Increased circumference in the abdomen related to fluid excess Generalized edema, which is a hallmark of the nephrotic syndrome, results from a decrease in the plasma colloidal osmotic pressure due to the hypoalbuminemia that develops as albumin is lost from the vascular compartment. Initially, the edema presents in dependent parts of the body such as the lower extremities, but becomes more generalized as the disease progresses. Dyspnea due to pulmonary edema, pleural effusions, and diaphragmatic compromise due to ascites (increase fluid in the abdominal cavity) can develop in persons with nephrotic syndrome. Live enlargement is not associated with nephrotic syndrome, but increased synthesis of lipoproteins in the liver secondary to a compensatory increase in albumin production may occur. Palpable kidney mass is associated with cancer.

Renal Calculi (Kidney stones, Nephrolithiasis)

Most common cause of upper urinary tract obstruction Why do kidney stones develop? -- Supersaturation -- Crystal aggregation

Crystal aggregation

Organic materials act as a nucleus that facilitates crystal aggregation leading to stone formation

Dilation of collecting ducts

renal tissue destruction and atrophy

Which of the following assessment findings would lead the nurse to suspect the client has nephrotic syndrome? Hematuria and anemia Proteinuria and generalized edema Renal colic and increased serum sodium Increased creatinine with normal blood urea nitrogen

Proteinuria and generalized edema The nephrotic syndrome is characterized by massive proteinuria and lipiduria, along with an associated hypoalbuminemia, generalized edema, and hyperlipidemia.

While taking a client history, which of the following assessments lead the nurse to suspect the client may have polycystic kidney disease? Select all that apply. Massive proteinuria on dipstick urine specimen Renal colic with flank pain Bright red blood in urine sample Elevated blood pressure of 180/94 Shortness of breath (SOB) with loud rhonchi and wheezes heard on auscultation

Renal colic with flank pain Bright red blood in urine sample Elevated blood pressure of 180/94 The manifestations of ADPKD include pain from the enlarging cysts that may reach debilitating levels, episodes of gross hematuria from bleeding into a cyst, infected cysts from ascending UTIs, and hypertension resulting from compression of intrarenal blood vessels with activation of the renin-angiotensin mechanism. Renal colic caused by nephrolithiasis, or kidney stones, occurs in about 20% of persons with ADPKD. One type of pain associated with kidney stones is renal colic, described as colicky pain that accompanies stretching of the collecting system or ureter. Nephrotic syndrome is characterized by massive proteinuria. SOB with abnormal respiratory sounds is not usually associated with ADPKD.

An infant has been diagnosed with autosomal recessive polycystic kidney disease (ARPKD). Which of the following treatment goals would be considered the priority in the care of this child? Rehydration therapy Total parenteral nutrition Prophylactic antibiotics Respiratory support

Respiratory support Aggressive ventilatory support is often necessary for neonates with ARPKD, due to the presence of pulmonary hypoplasia and hypoventilation. Hydration, nutrition, and infection prevention are relevant aspects of care, but respiratory interventions are the priority.

Goodpasture syndrome

• Aggressive form of glomerulonephritis • Antibodies to glomerular basement membrane causing inflammation • These antibodies also cross-react with pulmonary basement membrane • Pulmonary hemorrhage + renal failure

Loss of proteins in urine

• Albumin --> edema • Immunoglobulins and complement --> immune suppression • Binding proteins --> low ions and hormones • Clotting and anticlotting factors --> thrombosis

Cystine stones

• Children with cystinuria - genetic defect in renal transport of cystine

Systemic lupus erythematosus

• Common complication of SLE - lupus nephritis • Deposition of immune complexes within glomerular wall

Nephrotic Syndrome

• Excretion of 3.5 g or more of protein in urine per day (proteinuria) • Characteristic of glomerular injury - glomerular basement membrane disturbed --> increased permeability to protein • Filtration of proteins > tubular reabsorption

Consequences of Dilation of the Renal Tubules

• Expansion of the kidney with urine (hydronephrosis) -- Increased pressure inside the renal capsule -- Compartment syndrome compresses blood vessels inside kidney -- Renal ischemia • Stasis of urine -- Risk of infection -- Stones

Magnesium ammonium phosphate stones

• Form in alkaline urine or with certain bacteria that split urea into ammonia and CO2

Uric acid stones

• Gout or high concentrations of uric acid (high purine diet)

Nephritic Syndromes

• Inflammatory process damages the capillary wall. • Acute postinfectious glomerulonephritis.

Clinical Manifestations of Kidney Stones

• Primary manifestation: PAIN! • Renal colic - acute, intermittent, and excruciating pain in flank (and sometimes upper abdominal quadrant) • Non-colicky pain - dull, deep ache in flank or back that can be mild to severe in intensity

Acute postinfectious glomerulonephritis

• Proliferative inflammatory response after certain strains of group A β-hemolytic streptococci. Deposition of immune complexes • Azotemia (presence of nitrogenous wastes in the blood), oliguria, cola-colored urine This is a Nephritic Syndrome

Rapidly Progressive Glomerulonephritis

• Signs of severe glomerular injury without a specific cause • Often caused by immunologic disorders, such as systemic lupus erythematosus (SLE) Goodpasture Syndrome

Systemic causes of Glomerulonephritis

• Systemic lupus erythematosus • Diabetic Glomerulosclerosis

Supersaturation

• Urine is supersaturated with stone components -- Solutes precipitate and form stones -- Examples: Calcium salts, uric acid, oxalate, etc.