Professor

Dr. Moreen Areh RN, MSN, FNP, DNP

Email mareh@herzing.edu
Phone: 404 816-4533 EX: 15141
1
 Chapter 29
Alterations of Renal and
Urinary Tract Function

Copyright 2017, Elsevier Inc. All rights reserved. 2

Copyright 2017, Elsevier Inc. All rights reserved. 3
 URINARY TRACT
OBSTRUCTION
URINARY TRACT SEVERITY BASED ON:
OBSTRUCTION IS AN LOCATION
INTERFERENCE WITH THE COMPLETENESS
FLOW OF URINE AT ANY INVOLVEMENT OF URETERS
AND/OR KIDNEYS
SITE ALONG THE URINARY
DURATION
TRACT
CAUSE
THE OBSTRUCTION CAN BE
CAUSED BY AN ANATOMIC
OR FUNCTIONAL DEFECT
OBSTRUCTIVE UROPATHY

Copyright 2017, Elsevier Inc. All rights reserved. 4

 UPPER URINARY TRACT OBSTRUCTION
URINARY
HYDROURETER
TRACT
ACCUMULATION OF
OBSTRUCTION
URINE IN THE URETER
HYDRONEPHROSIS
ENLARGEMENT OF
THE RENAL PELVIS
AND CALYCES
URETEROHYDRONEPH
ROSIS
DILATION OF BOTH
THE URETER AND THE
PELVICALICEAL
SYSTEM 5
 UPPER URINARY TRACT
OBSTRUCTION
KIDNEY STONES
COMPENSATOR CALCULI OR URINARY STONES
MASSES OF CRYSTALS, PROTEIN, OR
Y OTHER SUBSTANCES THAT FORM
HYPERTROPHY WITHIN AND MAY OBSTRUCT THE
URINARY TRACT(FORMATION OF
AND HYPER- RENAL CALCULI)
FUNCTION RISK FACTORS
GENDER AND AGE
OBLIGATORY
RACE
GROWTH GEOGRAPHIC LOCATION
COMPENSATO SEASONAL FACTORS
RY GROWTH FLUID INTAKE
DIET
POST-
OCCUPATION
OBSTRUCTIVE KIDNEY STONES ARE CLASSIFIED ACCORDING
TO THE MINERALS THAT MAKE UP THE STONE
DIURESIS 6

NEPHROGENI
 KIDNEY STONE FORMATION

SUPERSATURATION OF
OTHER FACTORS
ONE OR MORE SALTS AFFECTING STONE
PRESENCE OF A SALT IN A FORMATION
HIGHER CONCENTRATION CRYSTAL GROWTH-
THAN THE VOLUME ABLE INHIBITING
TO DISSOLVE THE SALT SUBSTANCES
PRECIPITATION OF A SALT PARTICLE RETENTION
FROM LIQUID TO SOLID MATRIX
STATE STONES
TEMPERATURE AND PH CALCIUM OXALATE
OR CALCIUM
GROWTH INTO A STONE VIA
PHOSPHATE
CRYSTALLIZATION OR 7
STRUVITE STONES
AGGREGATION URIC ACID STONES
 KIDNEY STONES
MANIFESTATION
RENAL COLIC
EVALUATION
IMAGING STUDIES
24-HOUR URINALYSIS

TREATMENT
HIGH FLUID
INTAKE
DECREASING
DIETARY INTAKE
OF STONE-
FORMING 8

SUBSTANCES
 LOWER URINARY TRACT
OBSTRUCTION
NEUROGENIC BLADDER
DYSSYNERGIA
TUMORS
DETRUSOR HYPERREFLEXIAD--- RENAL TUMORS
OVERACTIVE
DETRUSOR AREFLEXIA--- RENAL ADENOMAS
UNDERACTIVE RENAL CELL CARCINOMA
OVERACTIVE BLADDER (RCC)
SYNDROME (OBS)
BLADDER TUMORS
FREQUENCY, URGENCY,
NOCTURIA TRANSITIONAL CELL
OBSTRUCTION CARCINOMA (MOST
URETHRAL STRICTURE, COMMON)
PROSTATE ENLARGEMENT, GROSS, PAINLESS
PELVIC ORGAN PROLAPSE
HEMATURIA
PARTIAL OBSTRUCTION OF
BLADDER OUTLET OR URETHRA MOST COMMON IN MALES
LOW BLADDER WALL OLDER THAN 60 YEARS
COMPLIANCE AND SMOKERS 9
 URINARY TRACT
INFECTION (UTI)
UTI IS INFLAMMATION OF THE
URINARY EPITHELIUM
MOST COMMON
CAUSED BY BACTERIA PATHOGENS
ESCHERICHIA COLI
ACUTE CYSTITIS
VIRULENCE OF URO-
PAINFUL BLADDER
PATHOGENS
SYNDROME/INTERSTITIAL
CYSTITIS
HOST DEFENSE
MECHANISMS
ACUTE AND CHRONIC
PYELONEPHRITIS

10
URINARY TRACT INFECTION (UTI)
(CONT.)
ACUTE CYSTITIS PAINFUL BLADDER
CYSTITIS IS AN SYNDROME/INTERSTITIAL
INFLAMMATION OF THE CYSTITIS
BLADDER
NONBACTERIAL INFECTIOUS
MANIFESTATIONS CYSTITIS; NONINFECTIOUS
FREQUENCY
MANIFESTATIONS
DYSURIA
MOST COMMON IN WOMEN 20
URGENCY TO 30 YEARS OLD
LOWER ABDOMINAL BLADDER FULLNESS,
AND/OR SUPRAPUBIC PAIN, FREQUENCY, SMALL URINE
LOW BACK PAIN VOLUME, CHRONIC PELVIC PAIN
TREATMENT TREATMENT
ANTIMICROBIAL THERAPY NO SINGLE TREATMENT
INCREASED FLUID INTAKE EFFECTIVE, SYMPTOM RELIEF
AVOIDANCE OF BLADDER
IRRITANTS
URINARY ANALGESICS
11
URINARY TRACT INFECTION (UTI)
(CONT.)
PYELONEPHRITIS
ACUTE PYELONEPHRITIS
ACUTE INFECTION OF THE URETER, RENAL PELVIS,
INTERSTITIUM
VESICOURETERAL REFLUX, E. COLI, PROTEUS,
PSEUDOMONAS
CHRONIC PYELONEPHRITIS
PERSISTENT OR RECURRING EPISODES OF ACUTE
PYELONEPHRITIS THAT LEAD TO SCARRING
RISK OF CHRONIC PYELONEPHRITIS INCREASES IN
INDIVIDUALS WITH RENAL INFECTIONS AND SOME
TYPE OF OBSTRUCTIVE PATHOLOGIC CONDITION

Copyright 2017, Elsevier Inc. All rights reserved. 12

 GLOMERULAR DISORDERS
MECHANISMS OF INJURY
GLOMERULONEPHRI DEPOSITION OF CIRCULATING SOLUBLE
TIS ANTIGEN-ANTIBODY COMPLEXES, OFTEN
WITH COMPLEMENT FRAGMENTS (TYPE III
INFLAMMATION OF HYPERSENSITIVITY)
THE GLOMERULUS ANTIBODIES REACTING IN SITU AGAINST
PLANTED ANTIGENS WITHIN THE
IMMUNOLOGIC GLOMERULUS (TYPE II HYPERSENSITIVITY
ABNORMALITIE CYTOTOXIC)
NONIMMUNE (DRUGS, TOXINS, ISCHEMIA)
S (MOST
COMMON) MANIFESTATIONS
TWO MAJOR SYMPTOMS IF SEVERE
DRUGS OR
HEMATURIA WITH RED BLOOD CELL
TOXINS CASTS
VASCULAR PROTEINURIA EXCEEDING 3 TO 5
DISORDERS G/DAY WITH ALBUMIN (MACRO-
ALBUMINURIA) AS THE MAJOR PROTEIN
SYSTEMIC
OLIGURIA
DISEASES
HYPERTENSION
(SECONDARY)
EDEMA
VIRAL CAUSES 13
NEPHROTIC SEDIMENT
NEPHRITIC SEDIMENT
GLOMERULONEPHRITIS (CONT.)

TYPES
MEMBRANOUS
NEPHROPATHY/GLOMERULONEPHRITIS
RAPIDLY PROGRESSING
GLOMERULONEPHRITIS
ANTIGLOMERULAR BASEMENT
MEMBRANE DISEASE
(GOODPASTURE SYNDROME)
CHRONIC GLOMERULONEPHRITIS

Copyright 2017, Elsevier Inc. All rights reserved. 14

 NEPHROTIC SYNDROME
EXCRETION OF 3.5 G OR MORE MEMBRANOUS
OF PROTEIN IN THE URINE PER GLOMERULONEPHRITIS
DAY FOCAL SEGMENTAL
THE PROTEIN EXCRETION IS GLOMERULOSCLEROSIS
CAUSED BY GLOMERULAR MINIMAL CHANGE
INJURY NEPHROPATHY (LIPOID
NEPHROSIS)
FINDINGS NEPHRITIC SYNDROME
HYPOALBUMINEMIA
EDEMA
COMMON SYMPTOM IS
HEMATURIA WITH RBC
HYPERLIPIDEMIA AND LIPIDURIA
CASTS
VITAMIN D DEFICIENCY
MILD PROTEINURIA
IMMUNE INJURY

15
 ACUTE KIDNEY INJURY (AKI)

RENAL INSUFFICIENCY INTRARENAL

RENAL FAILURE
END-STAGE RENAL FAILURE
(ESRF)
PRERENAL
MOST COMMON CAUSE OF ARF
CAUSED BY IMPAIRED RENAL
BLOOD FLOW
GFR DECLINES BECAUSE OF THE
DECREASE IN FILTRATION
PRESSURE
ACUTE TUBULAR
NECROSIS (ATN) IS THE
MOST COMMON CAUSE OF
INTRARENAL RENAL
FAILURE
POST-ISCHEMIC OR
NEPHROTOXIC
OLIGURIA
POST-RENAL
OCCURS WITH URINARY
TRACT OBSTRUCTIONS
THAT AFFECT THE
KIDNEYS BILATERALLY
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 ACUTE KIDNEY INJURY (AKI) (CONT.)

INITIATION PHASE
KIDNEY INJURY IS EVOLVING
PREVENTION OF INJURY IS POSSIBLE
MAINTENANCE (OLIGURIC) PHASE
ESTABLISHED KIDNEY INJURY AND DYSFUNCTION
URINE OUTPUT IS LOWEST DURING THIS PHASE, AND
SERUM CREATININE AND BLOOD UREA NITROGEN BOTH
INCREASE
RECOVERY (POLYURIC) PHASE
INJURY REPAIRED AND NORMAL RENAL FUNCTION
REESTABLISHED
DIURESIS COMMON
DECLINE IN SERUM CREATININE AND UREA
INCREASE IN CREATININE CLEARANCE 17
 CHRONIC KIDNEY DISEASE (CKD)

PROGRESSIVE LOSS OF
RENAL FUNCTION THAT
AFFECTS NEARLY ALL ORGAN
SYSTEMS
ASSOCIATED WITH HTN,
DIABETES, INTRINSIC KIDNEY
DISEASE
STAGES:
NORMAL (GFR >90 ML/MIN)
MILD (GFR 60-89 ML/MIN)
MODERATE (GFR 30-59
ML/MIN)
SEVERE (GFR 15-29 ML/MIN) 18

END STAGE (GFR LESS THAN

15)
CHRONIC KIDNEY DISEASE (CKD)
(CONT.)
PROTEINURIA AND FLUID AND ELECTROLYTE
UREMIA BALANCE
DUE TO SODIUM AND WATER BALANCE
GLOMERULAR SODIUM EXCRETION
HYPERFILTRATION INCREASES WITH OBLIGATORY
WATER EXCRETION LEADING
DAMAGES TO SODIUM DEFICIT AND
INTERSTITIAL VOLUME LOSS
TISSUE OF KIDNEY CONCENTRATION AND
VIA INFLAMMATION DILUTION ABILITY DIMINISHES
CREATININE AND POTASSIUM BALANCE
UREA CLEARANCE TUBULAR SECRETION
INCREASES EARLY
GFR FALLS
ONCE OLIGURIA SETS IN,
PLASMA
POTASSIUM RETAINED
CREATININE
ACID-BASE BALANCE
INCREASES 19

METABOLIC ACIDOSIS WHEN

GFR 30%-40%
 CHRONIC KIDNEY DISEASE (CKD) (CONT.)

FLUID AND ELECTROLYTE Alterations seen in following

BALANCE (CONT.) systems
CALCIUM, PHOSPHATE,
Cardiovascular
BONE
REDUCED RENAL
Pulmonary
PHOSPHATE EXCRETION, Hematologic
DECREASED RENAL Immune
SYNTHESIS OF 1,25-(OH)2
Neurologic
VITAMIN D3 AND
HYPOCALCEMIA Gastrointestinal
FRACTURES Endocrine and reproduction
PROTEIN, CARBOHYDRATE, FAT
Integumentary
METABOLISM
ANEMIA
LETHARGY, DIZZINESS, AND
LOW HEMATOCRIT ARE 20

COMMON
SIGNS AND SYMPTOMS OF KIDNEY FAILURE

21

From Goldman L, Schafer AI: Goldmans Cecil medicine, ed 24, Philadelphia, 2012, Saunders; redrawn from
Forbes CD, Jackson WF: Color atlas and text of clinical medicine, ed 3, London, 2003, Mosby.
 Question/Case Study

1. WHICH OF THE FOLLOWING IS A RISK

FACTOR FOR POST-OBSTRUCTIVE DIURESIS?

A. DEHYDRATION
B. HYPERTENSION.
C. UNILATERAL OBSTRUCTION
D. NEUROGENIC DIABETES INSIPIDUS
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2. A PATIENT PRESENTS WITH FLANK PAIN AND
ANURIA FOLLOWED BY POLYURIA AFTER
UNDERGOING CATHETERIZATION OF THE URETERS.
WHAT IS THE MOST LIKELY CAUSE OF THIS
CONDITION?

A. ACUTE TUBULAR NECROSIS

B. PRERENAL ACUTE RENAL FAILURE
C. POSTRENAL ACUTE RENAL FAILURE.
D. INTRARENAL ACUTE RENAL FAILURE
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 Question/Case Study
3. WHICH OF THE FOLLOWING IS A SYMPTOM OF
CHRONIC RENAL FAILURE?

A. HYPOTENSION
B. HYPOKALEMIA
C. HYPOCALCEMIA.
D. HYPERNATREMIA

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