Renal & Urologic Problems
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Risk factors for UTI?
- 1. pregnancy
- 2. medical conditions: DM, gout
- 3. immunosuppression: HIV
- 4. urinary retention/obstructed urinary flow
- 5. procedures: catheterization, cytoscopic
- 6. Aging
3 things that might cause urinary obstruction?
calculi, congential anomalies, & neurologic abnormalities
5 reasons older adults are at increased risk for UTI?
- 1. chronic illnesses
- 2. antimicrobial agents used fequently
- 3. presence of infected pressure ulcers
- 4. immobility
- 5. bedpans
2 types of UTI by location?
upper & lower urinary tract infections
Upper UTI's include _____, _____ ______, & ____ _____.
- interstitial nephritis
- renal abscesses
S/S of upper UTIs?
- 1. fever
- 2. chills
- 3. flank pain
- s/s of lower UTI may occur but lower UTI does not usually include system s/s like upper
inflammation of the renal parenchyma & collecting system - usually r/t infection
inflammation of the bladder wall
inflammation of the urethra
UTI that has spread into the systemic circulation
Complicated & uncomplicated UTI?
Uncomplicated occurs in a normal urinary tract
Complicated UTI occurs with coexisting conditions: stones, catheters, DM, neuro disease, etc
Person with a complicated UTI is at risk for ____, ______, & ____ ____.
- renal damage
Urinary system's defenses against UTI?
- 1. voiding with complete emptying of the bladder
- 2. ureterovesical junction competence
- 3. peristaltic activity pushing urine toward bladder
- 4. acidic pH of urine (<6.0) & high urea conc.
- 5. glycoproteins that interfere with bacterial growth
Why may women have increased UTI after menopause?
decrease in estrogen -> vaginal atrophy, decreased vaginal flora, & increased vaginal pH -> colonized with other organisms
May give estrogen replacement intravaginally to acidify the vagina
Effect of sexual intercourse on UTIs?
may increase incidence
How does urosepsis occur?
must be prior injury to the urinary tract: obstruction of the ureter, damage caused by stones, renal scars
Cause of most HAI's of urinary tract?
What complications may occur?
- 1. renal abscesses
- 2. arthritis
- 3. epididymitis
- 4. periurethral gland infections
- 5. bacteremia
S/S of lower urinary tract infection?
- 1. dysuria
- 2. frequent urination (>q2h)
- 3. urgency
- 4. suprapubic discomfort or pressure
- 5. grossly visible blood or sediment
Important consideration about temperature in older adult with a UTI?
may not have a fever with UTI & may have a temp decrease
Dx of UTI?
- 1. dipstick UA: shows nitrites (indicates bacteria), WBC, & leukocyte esterase (enzyme present in WBC indicating pyuria)
- 2. microscopic analysis to confirm dipstick UA
- 3. C&S
- 4. IVP or CT to look for obstructions
- 5. renal ultrasound for recurrent infections
How is urine collected for a UA with C&S?
How is it done in F & M?
- Clean catch: collect urine midstream & refrigerate immediately
- F: spread labia & wipe periurethral area front to back using a moistened clean gauze sponge. Keep labia spread & collect specimen 1 to 2 seconds after voiding starts
- M: Wipe glans penis around the urethra. Collect urine same way.
When should cultures be done on clean catch urine sample?
within 24 h
Why is antiseptic not used to clean urethra before clean catch sample is collected?
can contaminate the specimen & cause false positives
Tx of UTI?
Meds: ABX & analgesics
ABX most commonly used for UTI?
Other ABX/anti-fungals used?
- 1. sulf/trim: Bactrim, Septra
- 2. nitrofurantoin: Macrodantin
- 1. fluoroquinolone: Cipro, Floxin, Levaquin, Noroxin
- 2. fungus meds: amphotericin or fluconazole
Admin of sulfa/trim & nitrofurantion?
- * uncomplicated UTI: bid X 1 to 3 days
- * complicated UTI: bid X 7 to 14 days
nitrofurantoin: 3 to 4 times per day or has long lasting (macrobid) that may be taken bid
AE of nitrofurantoin/Macrodantin?
Long term use:pulmonary fibrosis & neuropathies
sensitivity to sunlight
Education of pt taking nitrofurantoin/Macrodantin?
- 1. avoid sunlight, use sunscreen, & wear protective clothing
- 2. Notify health care provider of s/s of pulmonary fibrosis or neuropathies: fever, chills, cough, chest pain, dyspnea, rash, numbness or tingling of fingers or toes
Analgesic medication for UTI?
Teaching about this med?
turns pee orange
Prophylactic use of ABX for UTI?
may be used daily if have recurring UTI or may be used as single dose before event likely to provoke a UTI: sex
Subjective data needed for assessment of pt with UTI?
- 1. health Hx: UTIs, calculi, stasis, reflux, retention, neurogenic bladder, pregnancy, BPH, STI, bladder cancer
- 2. meds: ABX, anticholinergics, antispasmotics
- 3. surgery/Tx: recent urologic instrumentation: cath, cystoscopy, surgery
- 4. health mgmt: hygiene, energy level
- 5. nutrition/met: NV, anorexia, chills
- 6. elimination patterns & changes
- 7. cognitive/perceptual: suprapubic or low back pain, CVA tenderness, bladder spasms, dysuria, burning on urination
- 8. sexuality-repro: multiple sex partners, use of spermicidal agents or diaphragm
Objective data that may be found during assessment of pt with a UTI?
- 1. fever, chills
- 2. dysuria
- 3. urine changes: hematuria, foul-smelling,
- 4. tender, enlarged kidney
UTI s/s in elderly?
- 1. afebrile
- 2. absence of dysuria
- 3. anorexia
- 4. altered mental status
Possible Dx findings of pt with UTI?
- 1. leukocytosis
- 2. UA: bacteria, pyuria, RBC, WBC,
- 3. positive urine culture
- 4. IVP, CT scan, VCUG, & cystoscopy show urinary tract abnormalities
6 nursing interventions to prevent HAIs?
- 1. recognize pt at risk for UTI
- 2. Teaching how to avoid UTI, to seek early Tx & complete all ABX as orderd
- 3. avoid unnecessary cath & remove cath as soon as possible
- 4. aseptic technique, hand washing, gloves
- 5. perineal hygiene
- 6. answer call lights quickly & offer bedpan often
What should nurse teach pt about how to avoid getting UTI?
- 1. empty bladder regularly & completely
- 2. poop regularly
- 3. wipe from front to back
- 4. adequate fluids
- 5. daily intake of cranberry juice or cranberry essence tabs
- 6. women should void before & after sex
Acute interventions for UTI?
- 1. adequate fluids: need to teach pt that this will not make s/s worse but will decrease bladder irritation by diluting the urine
- 2. no bladder irritants: caffeine, alcohol, citrus juices, chocolate, or spicy
- 3. apply heat to suprapubic area or lower back to relieve discomfort: may also take bath or shower (heating pad on lowest setting)
Teaching for pt with a UTI?
- 1. can use heating pad on lowest setting, bath or shower to apply heat to suprapubic area or lower back & relieve discofort
- 2. pyridium turns pee orange
- 3. take all of ABX & report to MD if s/s persist after finished
- 4. Report onset of flank pain or fever
- 5. adequate fluids
- 6. void regularly: q3-4h
- 7. d/c use of diaphragm if using
When do recurrent s/s of UTI usually occur?
1 to 2 weeks after completion of therapy
Causes of pyelonephritis?
bacterial infection usually - can be other microbes
Urosepsis can lead to ___ ____ & ___.
septic shock & death
How does pyelonephritis usually begin?
What preexisting factors might cause pyelonephritis to occur?
lower UTI that ascends
- 1. vesicoureteral reflux
- 2. BPH
- 3. stricture or stone
- 4. catheterization
- 5. pregnancy
What may be present that increases chances of chronic pyelonephritis developing?
recurring episodes of pyelonephritis that occur & lead to a scarred, poorly functioning kidney
S/S of pyelonephritis?
- 1. s/s of lower UTI
- 2. acute flank pain: constant & colicky
- 3. fever & chills
- 4. CVA tenderness on affected side
Dx of pyelonephritis?
- 1. UA: pyuria,bacteria, hematuria, may have WBC casts,
- 2. CBC: leukocytosis with left shift (increased bands)
- 3. usually get blood cultures
- 4. imaging: ultrasound initially; later may have: IVP, VCUG, radionuclide imaging, CT scan
Why are IVP & CT not used initially in Dx of pyelonephritis?
they require IV contrast media -> can cause spread of infection (makes no sense to me) p1128
Management of uncomplicated pyelonephritis/mild s/s?
- outpatient or short hospitalization:
- 1. start empirically selected (best judgment) broad spectrum ABX then change to sensitivity guided ABX after C&S results
- 2. adequate fluid intake
- 3. NSAIDs or antiypyretics
- 4. follow-up urine culture & imaging studies
For mgmt of uncomplicated pyelonephritis what ABX may be used for empirical therapy & sensitivity-guided therapy?
Other ABX that may be used?
empirical broad spectrum: ampicillin or vancomycin with a aminoglycoside: micin/mycins
sensitivity-guided therapy: sulf/trim(bactrim, septra)
fluoroquinolones may also be used
Mgmt of complicated pyelonephritis/severe s/s?
- 1. IV ABX: same ABX as with uncomplicated: empirical then sensitivity guided
- 2. oral ABX when pt can tolerate PO
- 3. adequate fluid intake: initially IV fluids then switch to oral fluids as NV & dehydration subside
- 4. NSAIDs or antipyretic drugs for fever & relieve discomfort
- 5. urinary analgesics
- 6. follow-up urine culture & imaging studies
If a pt is Tx for pyelonephritis outpt, how long will they be on ABX?
14 to 21 days
How is the effectiveness of pyelonephritis therapy evaluated?
presence or absence of bacterial growth on urine culture
In the mgmt of complicated pyelonephritis requiring hospitalization how long does ABX therapy last? How is it given?
When will s/s typically improve?
will give IV ABX until pt can take po meds: will take po meds for 14 - 21 days
48 to 72 hours
Nursing interventions for health promotion r/t pyelonephritis?
- 1. similar to cystitis/UTI
- 2. early Tx of cystitis to prevent ascending infection
- 3. encouraging check ups for high risk pt: pt with structural abnormalities
- 4. pt teaching: finish ABX, fluids, need follow-up urine culture, rest can increase comfort
- 5. ID risk for recurrence
Result of chronic pyelonephritis?
kidneys atrophy/shrink & lose function r/t scarring/fibrosis
radiologic imaging & histologic testing: small, contracted kidney with thinned parenchyma
What does chronic pyelonephritis often progress to when both kidneys are involved?
Causes of urethritis?
yeast infection in women
usually STI in men
Urethritis with purulent discharge in men indicates _____.
S/S of urethritis?
similar to lower UTI s/s
Dx of urethritis in women?
get a split urine collection (collect at beginning of stream & in middle) & get cultures & check for discharge (may not occur in women)
Tx of urethritis?
ID cause & Tx s/s
Meds for urethritis bacterial infection?
Meds for urethritis fungal infection?
ABX: sulfa/trim (bactrim, septra) & nitrofurantoin (macrodantin)
fungal/yeast infection: metronidazole (Flaygyl), clotrimazole (Mycelex) for trichomonas; nystatin & fluconazole for monilial infections
Meds for chlomydial infections?
Teaching for women with urethritis?
- 1. warm sitz bath
- 2. avoid use of vaginal deodorant sprays
- 3. properly cleanse the perineal area after BM & urination
- 4. avoid sex until s/s subside
- 5. STI urethritis need to refer partner for eval & Tx if have had sex in the last 60 days
diverticula caused by obstruction & subsequent rupture of the periurethral glands into the urethral lumen with regrowth of tissue over the opening of the resulting perurethral cavity
4 causes of urethral diverticula?
- 1. trauma from childbearing
- 2. urethral instrumentation
- 3. dialtion
- 4. infection with gonococcal organisms
S/S of urethral diverticula?
- similar to UTI with:
- 1. postvoid dribbling
- 2. dyspareunia - pain during sex
- 3. feelings of incomplete bladder emptying
- 4. urinary incontinence
- 5. may have gross hematuria or sediment
- 6. anterior vaginal wall mass that is tender on palpation & may have purulent discharge
- some women have no s/s
Dx of urethral diverticula?
- 1. H&P
- 2. confirmed with imaging: VCUG, ultrasound, MRI (determine size of diverticula compared to urethra)
Tx of urethral diverticula?
- 1. transurethral incicsion of the diverticular neck
- 2. spence procedure - marsupialization (creation of a permanent opening) of the diverticular sac into the vagina
3. surgical excision of diverticula
Complications of urethral diverticula surgery?
1. excision: large urethral defect that requires reconstruction r/t diverticular sac may be adeherent to urethral lumen and it can be damaged during surgery
Others: stress urinary incontinence may occur with any urethral diverticula surgery
chronic, painful inflammatory disease of the bladder char. by s/s of urgency/frequency & pain in the bladder and/or pelvis
Painful bladder syndrome?
suprapubic pain r/t bladder filling
Average age of onset of interstitial cystitis/painful bladder syndrome?
Contributing factor to the development of interstitial cystitis/painful bladder syndrome?
chronic indflammation with mast cell invasion of the bladder wall - may be provoked by infection/autoimmune disorder
Risk factors for interstitial cystitis/painful bladder syndrome?
- 1. defects of glycosaminoglycan layer that protects bladder mucosa
- 2. abnormal urine contents
- 3. dysfunction of SNS function to lower urinary system
- 4. reflex sympathetic dystrophy
2 primary s/s of interstitial cystitis/painful bladder syndrome?
- 1. pain usually located in suprapubic area - may also occur in any area of perineum
- 2. frequency/urgency
What factors may cause exacerbation of interstitial cystitis/painful bladder syndrome?
- 1. bladder filling
- 2. postponing urination
- 3. physical exertion
- 4. pressure against the suprpubic area
- 5. eating certain foods
- 6. emotional distress
What may relieve pain of interstitial cystitis/painful bladder syndrome?
transiently relieved by urination
Characteristics of pain in interstitial cystitis/painful bladder syndrome?
- 1. remits & exacerbate over time
- 2. women: may occur premenstrually & aggravated by sexual intercourse &/or emotional stress
Dx of interstitial cystitis/painful bladder syndrome?
Dx of IC?
diagnosis of exclusion: need at least 1 negative urine culture during period of active s/s
in IC- cystoscopic exam may reveal small bladder capacity & superficial ulceratoins (glomerulations) with bladder filling
Tx of interstitial cystitis/painful bladder syndrome?
- no single Tx b/c no definite etiology: Tx s/s
- 1. dietary & lifestyle alterations to relieve pain & diminish voiding frequency (no bladder irritants)
- 2. may use OTC dietary supplement calcium phosphorus(prelief) that alkalinizes the urine & may provide relief from irritation
- 3. relaxation to decrease stress
- 4. lubrication or altering positions during sex
- 5. tricyclic antidepressants: reduce burning pain & urinary frequency
- 6. pentosan (Elmiron) is only oral agent approved for Tx of s/s of IC- enhances protection of bladder mucosa --> relieves pain
- 7. may get opiods for short-term relief
- 8. agents instilled directly into the bladder
- 9. distention of the bladder during endoscopic exam temprarly relieves pain r/t disruption of sensory nerves
- 10. surgical procedures
4 agents that may be instilled directly into the bladder/ urinary system?
- 1. dimethyl sulfoxide (DSMO) - desensitizes pain receptors in bladder wall
- 2. heparin & hyaluronic acid: relieve s/s by enhancin protective mucosa
- 3. lidocaine may be instilled with others: rapidly desensitizes bladder so instillation of others will be better tolerated
- 4. Bacille Calmete-Guerin (BCG): mycobacterium bovis admin intravesically -> alleviates possible autoimmune disorder
What surgery may be performed in Tx of interstitial cystitis/painful bladder syndrome?
may have urinary diversions
may have pain in urinary diversions if urine contents was the cause of the pain
Assessment of interstitial cystitis/painful bladder syndrome?
- 1. pain: char., relief/exacerbating factors
- 2. bladder log or voiding diary for at least 3 days to det. voiding frequency/nocturia
- 3. monitor pt for UTI- can cause exacerbations
Nursing interventions/education for pt with interstitial cystitis/painful bladder syndrome?
- 1. reassure pt that it is a real condition
- 2. teach pt about nutrition & what to avoid
- 3. educate pt not to take multivitamin with more than recommended dietary allowance - can irritate bladder
- 4. teach pt to avoid clothing that can create suprapubic pressure: tight waste bands
What should signal nurse that pt with interstitial cystitis/painful bladder syndrome may have developed a UTI?
pt develops further s/s of UTI not associated with IC/PBS: dysuria, fever, etc
Renal tuberculosis (TB) is usually secondary to what condition?
When does onset occur?
TB of the lung
5 t0 8 years after primary infection
S/S of initial infection of renal TB?
1. often asymptomatic but may complain of fatigue & have low-grade fever
What is usually the initial s/s that occurs with renal TB?
4 s/s that typically occur?
s/s of a UTI - lesions will ulcerate and infection descends to lower urinary tract
- 1. cystitis
- 2. frequent urination
- 3. burning on voiding
- 4. epidiymitis in men
What may happen to renal lesions as they heal?
What 3 s/s may occur r/t to this?
may calcify as they heal -> renal colic, lumbar & iliac pain, & hematuria may occur
Dx of renal TB?
localization of tubercle bacilli in the urine & IVP findings
Long-term complication of renal TB?
depends on duration of disease before Tx
scarring of renal parenchyma, ureteral strictures, & reduced bladder volume that may be irreversible
inflammation of the glomeruli r/t immunologic process that affects both kidneys equally
Glomerulonephritis is classified r/t what 3 factors?
- 1. extent of damage (diffuse or focal)
- 2. initial cause
- 3. extent of changes (minimal or widespread)
Etiology of glomerulonephritis?
caused by 2 types of antibody-induced injury r/t build-up of antigen-antibody complexes & complement deposited in glomeruli
2 types of antibody-induced injury that cause glomerulonephritis?
1. autoantibodies to own glomerular basement membrane occur -> immunoglobulins & complement are deposited along basement membrane (may be r/t virus or structural change in basement membrane)
2. antibodies react with a circulating antigen (bacteria/virus) & are randomly depositied as immune complexes along basement membrane -> accumulation of antigen/antibody & complement that releases chemotactoic factors -> inflammatory response-> glomerular injury
S/S of glomerulonephritis?
- 1. hematuria - microscopic to gross
- 2. urinary excretion of: RBC, WBC, casts, protein
- 3. elevated BUN & creatinine
Assessment for glomerulonephritis?
- 1. Hx - exposure to drugs, immunizations, infections (strep, hepatitis)
- 2. eval pt for immune disorders: systemic lupus erythematosus & systemic sclerosis
Acute poststreptococcal glomerulonephritis? (APSGN)?
glomerulonephritis that develops about 5 to 21 days after an infection of group A beta-hemolytic strep in throat/tonsils or skin(impetigo)
Patho of APSGN?
antibodies are produced to the strep antigen -> injury to glomeruli r/t antigen-antibody complexes deposited in glomeruli & complement activated -> inflammatory reaction
What is the result of inflammation in the glomeruli?
decrease in filtration of metabolic waste products from blood & increase in the permeability of the glomerulus to larger protein molecules
S/S of APSGN?
- 1. generalized body edema
- 2. HTN
- 3. oliguria
- 4. hematuria: smoky or rusty
- 5. proteinuria
- 6. flank or abd pain may occur
Why does edema occur in APSGN?
rluid retention r/t decreased GFR
Where does edema of APSGN first appear?
low-pressure tissues: around eyes
What is indicated by smoky urine?
bleeding in the upper urinary tract
Degree of proteinuria in APSGN indicates ____ of the problem
Why does HTN occur in APSGN?
increased extracellular fluid volume
What is critical to the Tx of APSGN?
accurate recognition & assessment
Labs needed for Dx of APSGN?
- 1. UA
- 2. CBC with WBC differential
- 3. serum BUN, creatinine, & albumin
- 4. complement levels & ASO (measures strep antibodies) titer
- 5. renal biopsy if indicated
What finding r/t complement components indicates APSGN?
decreased complement components indicates immune-mediated response that could be APSGN
What UA results may occur with APSGN?
- 1. lg # of RBC
- 2. RBC casts: highly suggestive
- 3. proteinuria: mild to severe
Tx of APSGN?
- focus on relief of s/s
- 1. rest until inflammation & HTN subside (eval by proteinuria & hematuria decrease)
- 2. edema Tx by restricting Na & fluid intake & admin diuretics
- 3. anti HTN drugs prn
- 4. Diet: low protein, low Na, fluid restricted
- 5. ABX if strep infection still present
Pt teaching to prevent APSGN?
- 1. early Dx & Tx of sore throats & skin lesions
- 2. hygiene to prevent skin strep spread
rare cytotoxic autoimmune disease char. by presence of circulating antibodies against glomerular & alveolar basement membrane
targets kidneys & lungs
Patho of kidney and lung damage in Goodpasture syndrome?
antibody-antigen binding causes inflammatory reaction mediated by complement fixation & activiation
Causative factors of Goodpasture syndrome?
- 1. type A influenza
- 2. hydrocarbons
- 3. penicillamine
- 4. unknown genetic factors
Ppl most at ris for Goodpasture syndrome?
young male smokers
S/S of Goodpasture syndrome?
- 1. flu-like s/s
- 2. pulmonary s/s: cough, mild dyspnea, hemoptysis, crackles, rhonchi, & pulmonary insuffciency
- 3. renal s/s: hematuria, weakness, pallor, anemia, & renal failure
- 4. pulmonary hemorrhage usually occurs - may precede glomerular probs by wks or months
Abnormal Dx findings in Goodpasture syndrome?
- 1. low H&H
- 2. elevated BUN & creatinine
- 3. hematuria
- 4. proteinuria
- 5. circulating serum anti-GBM antibodies
Tx of Goodpasture?
- 1. meds
- 2. plasmapheresis: removal of plasma containing components causing/thought to cause disease
- 3. dialysis
What meds are used for Goodpasture?
- 1. corticosteroids
- 2. immunosuppressive drugs: cytoxan, imuran
What is the purpose of plasmapheresis & immunosuppressive drugs in Goodpasture?
pasmapheresis removes circulating anti-GBM antibodies & immunosuppressive therapy inhibits further antibody production
What must be done prior to renal transplantation in Goodpasture?
decreased anti-GBM antibody titer (plasmapheresis)
What often causes death in Goodpasture?
hemorrhage in the lungs & respiratory failure
rapidly progressive glomerulonephritis - glomerular disease associated with ARF where there is rapid progressive loss of renal function
4 situations that may cause RPGN?
- 1. complication of inflammation or infection
- 2. complication of multisystemic diseases: lupus erythematosus, Goodpasture
- 3. idiopathic
- 4. use of certain drugs (penicillamine)
S/S of RPGN?
- 1. HTN
- 2. edema
- 3. proteinuria
- 4. hematuria
- 5. RBC casts
Tx of RPGN?
- 1. correction of fluid overload
- 2. HTN
- 3. uremia
- 4. inflammatory injury to the kidney
- 5. drugs
- 6. plasmapheresis
- 7. dialysis
- 8. transplantation
Tx of RPGN?
same as Goodpasture
end stage of glomerular inflammatory disease
Chronic GN is characterized by what 3 things?
- 1. proteinuria
- 2. hematuria
- 3. slow development of uremia
How long does it take chronic GN to progress to renal failure?
progressess insidiously toward renal failure over a few years up to 30 years
Dx of chronic GN?
usually found during UA or r/t HTN & confirmed by CT/ultrasound
Tx of chronic GN?
- supportive & symptomatic
- 1. Tx hypertension & UTIs
- 2. protein & phosphate restrictions slow progression
Nephrotic syndrome patho?
glomerulus is damaged -> excessively permeable to plasma proteins -> leads to low plasma albumin & edema
6 Characteristic S/S of nephrotic syndrome (NS)?
- 1. peripheral edema
- 2. massive proteinuria
- 3. hypertension
- 5. hyperlipidemia
- 6. hypoalbuminemia
What complications occur in NS?
- 1. decreased serum protein & its effects
- 2. altered immune response
- 3. calcium & skeletal abnormalities
- 4. hypercoagulability & thromboembolism/pulmonary embolism
3 CBC abnormalities found in NS?
- 1. decreased serum albumin
- 2. decreased serum total protein
- 3. increased serum cholesterol
What is the result of the decreased serum protein that occurs in NS?
- decreased serum protein -> decreased oncotic pressure causes 2 responses:
- 1. edema, ascites, & anasarka (massive edema)
- 2. increased lipoprotein production in the liver to replace proteins -> leads to hyperlipidemia
What Ca & skeletal abnormalities may occur in NS?
- vitamin D deficiency-> hypocalcemia & osteomalacia (soft bones) -> can lead to 3 things:
- 1. hyperparathyroidism - decreased Ca level stimulateds release of PTH
- 2. decreased calcemic response to PTH: too much PTH is released & desensitizes receptors
- 3. skeletal problems that occur r/t decreased calcium levels - fractures & bone breakdown
What is a primary cause of morbidity in NS?
Indication that hyperlipidemia r/t increased liver lipoprotein production is occurring with NS?
fat bodies appear in the urine
Common causes of nephrotic syndrome?
- 1. glomerular disease
- 2. conditions: SLE, DM, amyloidosis
- 3. infections
- 4. neoplasms: Hodgkins, lung, colon, stomach, breas, & leukemias
- 5. allergens: bees, pollen
- 6. drugs: penicillamine, NSAIDs, captopril, heroin
Goals of NS TX?
relieve edema & cure or control primary disease
Tx of NS?
- mgmt of s/s:
- 1. edema: ACE inhibitors, NSAIDs, low-Na/low to moderate protein diet, loop/thiazide diuretics
- 2. Tx of hyperlipidemia -
_____ restriction is a key to managing edema in NS.
How much Na is allowed on low-Na diet with NS?
2 - 3 g
Tx of hyperlipidemia in NS?
- usually not successful
- lipid lowering agents have some success
Tx of thrombosis in NS?
antigoagulant therapy may be needed for up to 6 months
Meds for NS?
- 1. diuretics
- 2. anticoagulants prn
- 3. corticosteroids & cyclophosphamide prn
Tx of NS r/t DM?
mgmt of DM & Tx of edema
The major nursing interventions of NS are r/t what complication?
What are the nursing interventions needed?
- 1. daily weights
- 2. I&O
- 3. measureing abd or limb girth
- 4. skin care to prevent B/D: hygiene, avoid trauma
- 5. monitor effectiveness of diuretic therapy
How is effectiveness of Tx for edema in NS evaluated?
compare daily assessment of fluid status findings qd
Nutrition consideration in NS?
pt may become malnourished r/t protein lost in urine & anorexia
small, frequent meals following diet for NS - finding right balance of protein is hard
Major considerations with a pt with NS?
- 1. dietary/nutrition - Na, protein intake
- 2. thrombus formation
- 3. infection risk
- 4. hypocalcemia - ECG, bone fractures
- 5. edema - monitor lungs, skin, & fluid status
- 6. altered body image r/t edema
Diet of a person with nephrotic syndrome?
- 1. Na restriction (2-3g per day)
- 2. low-moderate protein
- 3. may have increased protein if protein levels get very low (if urine protein exceeds 10g/day)
Where do damaging effects of urinary tract obstruction occur?
above the level of obstruction
What changes/complications occur when a urinary obstruction occurs at the level of the bladder neck (F) or prostate (M)?
bladder changes may occur
detrusor muscles of bladder need to contract harder to push out urine -> they hypertrophy -> will eventually lose ability to compensate for increased resistance & muscle bundles will separate & become less compliant (trabeculation) -> bladder mucosa may herniate b/t detrusor muscle bundles -> diverticula that drain poorly = high residual urine volume
Patho of urinary obstruction?
- obstruction increases resistance & bladder muscles have to work harder & hypertrophy to get out urine (diverticula may form):
- 1. reflux of urine (backflow)/hydronephrosis (backflow from lower to upper urinary tract)
- 2. dilation of ureters
- 3. hydronephrosis- dilation of renal pelvis & calyces
these changes result in chronic pyelonephritis & renal atrophy
What will occur in urinary obstruction if only one kidney is affected?
the other kidney will try to compensate & become hypertrophied
In partial urinary obstruction there is an increased risk of ______ r/t urinary stasis & reflux.
Progressive urinary obstruction can lead to ____ or ____.
oliguria or anuria
Tx of urinary obstruction?
- requires location & relief of the blockage
- 1. insertion of a tube
- 2. surgical correction
- 3. diversion of urinary stream above level of blockage
Risk factors for nephrolithiasis?
- 1. warm climates that cause increased fluid loss: live in Southeast, Southwest, or Midwest, summer months
- 2. dehydration
- 3. abnormalities that result in increased urine levels of Ca, oxaluric acid, uric acid, or citric acid
- 4. diet: high in proteins (increase uric acid), high in tea/fruit juices (increase oxalae), lg intake of Ca & oxalate, & low fluid intake/increased urine concentration
- 5. family Hx or cystinuria (genetic condition)
- 6. gout
- 7. renal acidosis
- 8. altered urine pH: increase or decrease
- 9. sedentary occupation or immobility
- 10. b/t 20 & 55 years old
- 11. more frequent in whites
- 12. had a stone before (50% recurrence)
- 13. urinary retention/stasis
- 14. UTI: some bacteria may cause urine to become more alkaline (struvite stones occur)
2 ways to reduce the risk of recurrent nephrolithiasis?
keep urine dilute & free flowing
Residual urine volume in a urinary obstruction indicates what?
bladder is no longer able to compensate for the resistance created by the obstruction
Complications that may occur in an infected urinary stone?
- 1. renal infection
- 2. hydronephrosis
- 3. loss of kidney function
4 risk factors for infection r/t urinary stones?
- 1. external urinary diversion
- 2. indwelling catheter
- 2. neurogenic bladder
- 4. urinary retention
genetic disorder characterized by marked increased excretion of cystine that may increase risk of kidney stones
5 major categories of kidney stones?
- 1. calcium phosphate
- 2. calcium oxalate
- 3. uric acid
- 4. cystine
- 5. struvite (Mg ammonium phosphate)
Predisposing factors for Ca oxalate kidney stones?
- 1. idiopathic hypercalciuria
- 2. hyperoxaluria
- 3. family Hx
Tx of Ca oxalate kidney stones?
- 1. increase hydration
- 2. reduce dietary oxalate
- 3. thiazide diuretics
- 4. cellulose phosphate to chelate Ca & prevent GI absorption
- 5. K+ citrate to maintain alkaline urine
- 6. cholestyramine to bind oxalate
- 7. Ca lactate to precipitate oxalate in GI tract
- 8. reduce daily Na intake
Predisposing factors for Ca phosphate stones?
- 1. alkaline urine
- 2. primary hyperparathyroidism
Tx of Ca phosphate stones?
Tx underlying causes & other stones
Predisposing factors for struvite (Mg ammonium phosphate) kidney stones?
urea-splitting bacteria cause urine to become alkaline
Does pH affect the formation of Ca oxalate stones?
Some bacteria that cause increased alkalinity of the blood & struvite kidney stones?
- 1. proteus
- 2. klebsiella
- 3. pseudomonas
- 4. some staphylococci
Tx of struvite kidney stones?
- 1. admin ABX
- 2. acetohydroxamic acid
- 3. surgical intervention to remove stone
- 4. measures to acidify the urine
Predisposing factors for uric acid kidney stones?
- 1. gout
- 2. acid urine
- 3. inherited condition
Tx of uric acid kidney stones?
- 1.reduce urinary concentration of uric acid
- 2. alkalinize urine with K+ citrate
- 3. admin allopurinol
- 4. reduce dietary purines
Foods high in purine?
meats: especially fish, seafood, bird meat, and organ meats,
Predisposing factor for cystine kidney stones?
Tx of cystine kidney stones?
- 1. increase hydration
- 2. give a-penicillamine & tiopronin to prevent cystine crystallization
- 3. give K+ citrate to maintain alkaline urine
When do urinary stones cause s/s?
when they obstruct urinary flow
S/S of urinary/kidney stone?
- 1. abd or flank pain (usually severe)
- 2. hematuria
- 3. renal colic
- 4. NV
- 5. mild shock: cool, moist skin
- 6. pain in groin, labia, or testicles
- 7. may have s/s of UTI: fever, chills, etc
What is the cause of renal colic?
increase in ureteral peristalsis in response to the passage of small stones causes intense colicky pain
Dx of renal stones?
- 1. UA: hematuria
- 2. urine culture
- 3. CT scan
- 4. IVP
- 5. retrograde pyelogram
- 6. ultrasound
- 7. cytoscopy
- 8. labs
What test may be used to differentiate a nonopaque renal stone from a tumor?
What test may be used to localize degree & site of obstruction or to confirm the presence of a radiolucent stone (uric acid/cystine stones) or staghorn calculus?
IVP or retrograde pyelogram
IVP should not be performed in what pt?
pt with renal failure
What is important in the diagnosis of the underlying problem causing kidney stones?
retrieval & analysis of the stones
What labs are important with kidney stones?
- 1. CMP: Ca, phosphorus, Na, K+
- 2. bicarb
- 3. uric acid
- 4. BUN
- 5. creatinine
What should be included when getting a history in pt with kidney stones?
- 1. previous stones
- 2. meds Rx & OTC
- 3. dietary supplements
- 4. family Hx of stones
What test should be done on person with recurrent stones?
24h urinary measurement of Ca, phosphorus, Mg, Na, oxalate, citrate, sulfate, K+, uric acid, & total volume
Tx of kidney stones?
- 2 parts of Tx performed at same time:
- 1. mgmt of the acute attack
- 2. eval of the cause of the stone formation & prevention of further development of stones
Interventions in mgmt of acute attack of kidney stones?
- 1. pain mgmt: opiods given frequently
- 2. stones larger than 4mm may require insertion of ureteral stent to prevent obstruction r/t inability to pass through ureter
- 3. may require procedures to remove/break up the stone
Interventions to ID cause of kidney stones & prevent further kidney stones?
- 1. obtain subjective data from pt
- 2. teaching for ppl that have reoccurring stones
- 3. meds or other Tx based on cause of the stones
What subjective data is needed to help ID cause of kidney stones?
- 1. Hx & family Hx
- 2. geographic residence
- 3. nutritional assessment including: vit A & D use
- 4. activity pattern
- 5. Hx of periods of prolonged illness with immobilization or dehydration
- 6. Hx of disease or surgery involving the GI or genitourinary tract
Tx of ppl who are active stone formers?
- teaching & therapy regimen
- 1. adequate hydration
- 2. dietary changes
- 3. meds: to alter urine pH, prevent excessive urinary excretion of a substance, or correct a primary disease
- 4. Tx of struvite stones involves controlling infection
Foods high in oxalate?
What type of stones may occur r/t increased oxalate consumption?
green leafty veggies, tomatoes, beets, nuts, celery, chocolate, instant coffee, tea, worcestershire sauce
Ca oxalate stones
6 indications for procedures to remove/break up kidney stones?
- 1. too lg to pass
- 2. occur r/t infection
- 3. cause impaired renal function
- 4. causing persistent pain, N, or ileus
- 5. inability of pt to be Tx medically
- 6. pt with 1 kidney
If a urinary stone is located in the bladder , a ____ is done to remove small stones.
For lg stones a ______ is done.,
lg stones are broken up with an instrument called a lithotrite (stone crusher) then the bladder is irrigated to wash out crushed stones
uses ultrasonic lithotrite to pulverize stones
Complications associated with cystoscopic precedures to remove stones from the bladder? (cystoscopy, cystolitholapaxy, & cystoscopic lithotripsy)
- 1. hemorrhage
- 2. retained stone fragments
- 3. infection
How may stones be removed from the renal pelvis & upper urinary tract?
flexible ureteroscopes inserted via a cystoscope & used to remove stones
may need to use ultrasonic laser or electrohydraulic lithotripsy to break up stones before removing with ureterscope
nephroscope inserted through skin into renal pelvis -> kidney stones fragmented -> stone fragments are removed -> renal pelvis is irrigated -> percutaneous nephrostomy tube is usually left in place to make sure ureter is not obstructed
Methods of breaking up kidney stone during percutaneous nephrolithotomy?
- 1. ultrasound
- 2. electrohydraulic
- 3. laser lithotripsy
Complications of percutaneous nephrolithotomy?
- 1. bleeding
- 2. injury to adjacent structures
- 3. infection
procedure used to eliminate calculi from the urinary tract
Contraindication for lithotripsy?
staghorn or partial staghorn cystine stones
4 types of lithotripsy procedures?
- 1. percutaneous ultrasonic
- 2. electrohydraulic
- 3. laser
- 4. extracorporeal shock-wave
Percutaneous ultrasonic lithotripsy?
small incision made in flank-> ultrasonic probe place in renal pelvis via a nephroscope -> probe placed against the stone -> produces ultrasonic waves that break stone in to sandlike particles
What type of anesthesia is used in percutaneous ultrasonic lithotripsy?
general or spinal anesthesia
When will percutaneous ultrasonic lithotripsy be used?
when stone is large & other lithotripsy procedrues have failed
same as percutaneous ultrasonic except stones are broken into small fragements & removed byu forceps or by suction & a continuous saline irrigation flushes out the stone particles
How are fragments collected during electrohydraulic lithotripsy?
drainage that occurs during irragation is strained to cathc particles to be analyzed
fragments may also be removed via basket extraction
Complications of electrohydraulic lithotripsy?
- complications are rare
- 1. hemorrhage
- 2. sepsis
- 3. abscess formation
Postop electrohydraulic lithotripsy considerations?
- 1. may have moderate to severe colicky pain
- 2. first few times pt urinates will be bright red
- then become darker/smoky
- 3. ABX usually admin X 2 weeks prophylactically
laser lithotripsy probes are used to fragment lower ureteral a& large bladder stones
Extracorporeal shock-wave lithotripsy (ESWL) procedure?
- noninvasive procedure
- pt placed in water bath (if electrohydraulic used) -> fluoroscopy or ultrasound used to focus a lithotripter on the affected kidney -> high-energy acoustic shock waves shatter stone without damaging surrounding tissues-> broken into fine sand & excreted within urine
other methods may be used that do not require submersion: electromagnetic & piezoelectric
What type of anesthesia is required for extracorporeal shock-wave lithotripsy?
general or spinal
needed to ensure pt position is maintained during procedure
Post-procedure considerations with extracorporeal shock-wave lithotripsy?
- 1. pain: some sedation/analgesia required
- 2. hematuria
- 3. self-retaining ureteral stent may be placed after procedure to facilitate passage of sand & prevent sand build-up in ureter - will be removed within 2 weeks
2 types of pt that may require open surgery for kidney stones?
- 1. obese pt
- 2. complex abnormalities in the calyces or at the UPJ
incision into the kidney to remove a stone
incision into the renal pelvis for stone removal
removal of stone in ureter
removal of stone in bladder
Where is incision made for open lithotomy procedures?
flank incision directly below diaphragm & across side
Interventions for prevention of urinary stones/recurrence of stones?
- 1. nutrition
- 2. self monitoring of urinary pH
- 3. measure UO
Complication of open lithotomy procedures?
Nutritional therapy r/t urinary stones?
- 1. adequate fluids: after stone episode need about 3L/day (excessive fluids may increase pain)
- 2. Limit colas, coffee, & tea -> increase formation of stones
- 3. increased Ca intake: decreases urinary excretion of oxalate
- 4. low Na diet: high Na increases Ca excretion
- 5. limit oxalate-rich foods: reduces oxalate excretion -> decreased Ca oxalate stones
- 6. limit purines: decrease uric acid stones
Fluids should be maintained to acquire UO of at least ____ per day in a pt who develops urinary stones.
What pt are more at risk for dehydration that may contribute to kidney stone formation?
pt who are very active, live in dry climate,
Interventions to prevent urinary stones in immobile pt?
- 1. same measures for others: fluids, diet, etc
- 2. turn pt q2h
- 3. help pt to sit up or stand for max urinary flow
Nursing interventions for urinary stone?
- 1. pain mgmt & pt comfort primary interventions for obstructing stone/renal colic
- 2. filter all UO to catch stone if passed
- 3. ambulate pt when possible to help stone pass from upper to lower urinary tract
Consideration when ambulating a pt that has a urinary stone?
if pt is experiencing renal colic or taking opioids -> risk for fall
***should not ambulate alone
Cause of ureteral strictures?
usually unintended complication of surgical intervention r/t adhesions or scar formation
s/s of ureteral strictures?
- 1. mild to moderate colic - may be worse if pt consumes lg volume of fluids
- 2. infection may occur
Tx for discomfort & obstruction of ureteral strictures?
may be temporarily bypassed by placing a stent under endoscopic control or by diverting urinary flow via a nephrostomy tube
Permanent correction of ureteral strictures?
What will be done if this fails or strictures reoccur?
dilation with a balloon or catheter
may be incised under endoscopic control - endoureterotomy
Open surgery for ureteral strictures?
excise stenotic area & reanastomose the ureter to the contralateral ureter (ureteroureterostomy) or to the renal pelvis
reimplantation of the ureter into the bladder wall
fibrosis or inflammation of the urethral lumen
4 causes of urethral strictures?
- 1. trauma
- 2. urethritis - esp caused by gonococcal infection
- 3. iatrogenic (following surgery or repeated catheterization
- 4. congenital defect
Patho of urethral strictures?
inflammation/fibrosis occurs -> lumen of urethra narrows -> compliance is compromised (ability to open/close) -> meatal stenosis may occur
When do s/s of urethral strictures occur?
s/s of urethral strictures?
occur when it creates voiding dysfunction of bladder outlet obstruction
- 1. diminished force of urinary stream
- 2. straining to void
- 3. sprayed stream
- 4. postvoid dribbling
- 5. split urine stream
- 6. feeling of incomplete bladder emptying
- 7. urinary frequency & nocturia
Urethral strictures may lead to acute ____ ____.
4 things pt may report in their Hx that may be r/t urethral strictures?
- 1. urethritis
- 2. difficulty with insertion of catheter
- 3. trauma involving penis or perineum
- 4. may also have Hx of UTI
What 2 tests are used to determine length, location, & caliber of urethral strictures?
- 1. retrograde urethrography (RUG)
- 2. voiding cystourethrography (VCUG)
Initial mgmt of a urethral stricture?
Problem with these procedures?
dilation with a urethral sound or filiforms & followers
urethral sound - metal instrument placed to dilate
filiforms & followers - series of progressivley enlarging stents placed in urethra to expand lumen
work initially but usually stenosis reoccurs
How are urethral stricture recurrances managed?
teaching pt to repeatedly dilate urethra by self-catheterization using a soft coude-tip catheter every few days
endoscopic or open surgical procedure (urethroplasty) may be performed to provide a more durable solution to an obstructive urethral stricture: may do reanastomosis or substitute segment with autotransplantation of skin flap
Clinical findings that support kidney trauma?
- 1. Hx of trauma to the area: abd, flank, back
- 2. gross or microscopic hematuria
- 1. UA
- 2. IVP with cystography
- 3. ultrasound, CT, or MRI
- 4. renal arteriography
- should eval injured and nonaffected kidney
Tx for kidney trauma?
range from bed rest, fluids, & analgesia to surgical exploration & repair/nephrectomy
Nursing interventions r/t kidney trauma?
- 1. assess CV status
- 2. monitor for shock (penetrating injury)
- 3. ensure increased fluid intake
- 4. monitor I&O
- 5. provide comfort measures
- 6. observe for hematuria
- 7. determine the presence of myoglobinuria
- 8. monitor potentially nephrotoxic ABX
3 vascular problems involving the kidneys?
- 1. nephrosclerosis
- 2. renal artery stenosis
- 3. renal vein thrombosis
sclerosis of the small arteries and arterioles of the kidney
Patho of nephrosclerosis?
sclerosis of arteries & arterioles -> decreased BF -> patchy necrosis of the renal parenchyma & necrosis & fibrosis of the glomeruli
Benign nephrosclerosis cause?
vascular changes resulting from HTN & atherosclerosis process
There is a direct relationship between the degreee of nephrosclerosis & the severity of ____.
Accelerated nephrosclerosis is associated with ____ _____.
Accelerated nephrosclerosis is AKA?
Who usually gets it?
complication of HTN characterized by a sharp increase in BP with a diastolic pressure >130
usually occurs in young adults - more in males
Progression of accelerated nephrosclerosis?
renal insufficiency progresses rapidly
The only detectable abnormality in benign nephrosclerosis may be ____.
_____ ____ _____ account for most of the loss of renal function associated with aging.
atherosclerotic vascular changes
Tx for benign nephrosclerosis?
- same as Tx for essential HTN:
- aggressive antihypertensive therapy
2 major complications of HTN?
renal dysfunction & renal failure
Renal artery stenosis?
partial occlusion of one or both renal arteries & their major branches r/t atherosclerotic narrowing or fibromuscular hyperplasia
When should renal artery stenosis be considered as a Dx?
when HTN develops abruptly especially if pt is under 30 or over 50 with no family Hx of HTN
Best Dx tool for IDing renal artery stenosis?
Goals of therapy for renal arterial stenosis?
control BP & restore perfusion to the kidney
First choice procedure for Tx of renal artery stenosis
When is surgery indicated?
percutaneous transluminal renal angioplasty
when BF decreased enough to cause renal ischemia & evidence indicates renovascular HTN & surgical intervention may result in the pt becoming normotensive
How is blood normally rerouted during percutaneous transluminal renal angioplasty?
What other surgery may be performed & when is it indicated?
normally involves anastomoses b/t kidney & another major artery - usually splenic artery or aorta
in some cases of unilateral renal invovement with high renein production may do unilateral nephrectomy
What 6 conditions are associated with renal vein thrombosis?
- 1. trauma
- 2. extrinsic compression (tumor, aortic aneurysms
- 3. renal cell carcinoma
- 4. pregnancy
- 5. contraceptive use
- 6. nephrotic syndrome
s/s of renal vein thrombosis?
- 1. flank pain
- 2. hematuria
- 3. fever
- 4. nephrotic syndrome & its s/s may be present
Tx of renal vein thrombosis?
- 1. anticoagulants -
- 2. corticosteroids (if has nephrotic syndrome)
- 3. surgical thrombectomy may be performed instead of or along with anticoagulation therapy
What are anticoagulants important in the Tx of renal vein thrombosis?
there is a high incidence of pulmonary embolism
Polycysti kidney disease (PKD)?
life-threatening autosomal dominant disease involving both kidneys where the cortex & medulla of the kidney are filled with lg, thin-walled cysts filled with fluid/blood/pus that enlarge & destroy surrounding tissue by compression
2 types of PKD?
one occurs in childhood & one in adulthood
adulthood occurs in 30's or 40's
When do s/s of PKD begin to appear?
First s/s of PKD?
What other s/s may occur?
when cysts begin to enlarge
- 1. HTN
- 2. hematuria (from cyst rupture)
- 3. feeling of heaviness in back, side, or abd
- other s/s
- 1. chronic pain that may be constant/severe
- 2. bilat enlarged kidneys palpated
- some ppl have no s/s
Dx of PKD?
- 1. H&P & s/s
- 2. family Hx
- 3. IVP
- 4. ultrasound
- 5. CT scan
Best screening measure for PKD?
Usual progression of PKD?
usually progresses to ESRD by age 60
What other body organs my be affected by PKD?
- 1. liver - liver cysts
- 2. heart - abnormal heart valves
- 3. blood vessels - aneurysms
- 4. intestines - diverticulosis
Most serious complication of PKD?
cerebral aneurysm - can rupture
Tx of PKD?
- no specific Tx
- 1. prevent UTI &/or Tx with ABX as infections occur
- 2. nephrectomy if pain, bleeding, or infection becomes a chronic serious problem
- 3. dialysis & kidney transplant may be needed to treat ESRD
Nursing interventions for PKD?
- those used for ESRD
- 1. diet modifications
- 2. fluid restriction
- 3. drugs: antiHTN
- 4. assisting pt to accept chronic disease process
- 5. assisting pt & family to deal with finances
- 6. counceling for pt who has children (usually Dx after have children) & genetic counceling for children b/c have 50% chance of having it
Medullary cystic disease?
Characteristics of meduallary cystic disease?
hereditary disorder that occurs in 2 forms
- 1. most cysts located in medulla
- 2. kidneys are asymmetric & significantly scarred
- 3. defects in conc. ability of the kidneys
s/s of medullary cystic disease?
- 1. polyuria
- 2. progressive renal failure
- 3. severe anemia
- 4. metabolic acidosis
- 5. poor Na conservation
What can occur with HTN in medullary cystic disease?
can result in death
Nursing interventions r/t medullary cystic disease?
- 1. get pt genetic counseling for family planning
- 2. Tx measures r/t ESRD
Alport Syndrome AKA?
AKA chronic hereditary nephritis
- 1. classic alport syndrome - sex-linked disorder
- 2. nonclassic alport syndrome - autosomal
s/s of classic alport syndrome?
- 1. hematuria
- 2. sensorineural deafness
- 3. deformities of the anterior surface of the lense
s/s of nonclassic alport syndrome?
1. hematuria occurs but with no deafness or lens deformities
When is alport syndrome usually diagnosed?
within first 10 years of life
Patho of alport syndrome?
defect in a mutation in a gene for collagen -> altered synthesis of GBM -> hematuria & progressive uremia
Tx of alport syndrome?
corticosteroids & cytotoxic drugs are not effective
does not recur if pt has kidney transplant
What is the clinical course of renal involvement in various metablic and connective tissue disease process?
chronic progressive nephopathy that can result in uremia & death
Tx of primary disorder along with symptomatic relief of renal involvement
What is the primary cause of ESRD?
Changes that occur in DM that cause renal dysfunction?
angiopathic changes in DM -> diffuse glomerulosclerosis -> thickening of GBM & nodular glomerulosclerosis
Nodular glomerulosclerosis is characterized by ____ ____.
How do we know if a diabetic pt is prone to glomerulonephropathy?
presence of trace proteinuria or retinopathy
need careful monitoring of glucose levels & insulin requirements
acute attacks of arthritis caused b y hyperuricemia
monosodium urate crystals deposited in joints cause syndrome - can cause renal disease r/t damage caused by deposition of uric acid crystaals in the renal tubules
group of disorders manifested by impaired organ function from the infiltration of tissues with a hyaline substance *amyloid
What do hyaline bodies that occur in amyloidosis consist of?
What is often first s/s of amyloidosis?
Systemic luipus erythematosus?
connective tissue disorder char by involvement of several tissues & organs: joints, skin, & kidneys especially
s/s of systemic lupus erythmatosus?
similar to those of other forms of glomerulonephritis
renal failure often occurs & has poor prognosis
systemic sclerosis (scleroderma)?
disease of unknown etiology char by widespread alterations of connective tissue & vascular lesions in many organs
How does sytemic sclerosis affect the kidneys?
What pt has a poor prognosis?
in the kidney vascular lesions are associated with fibrosis probably due to an immune complex mechanism
pt who develops severe renal lesions
Where do kidney cancers arise?
cortex or pelvis & calyces of kidney
may be benign or malignant (more common)
Most common type of kidney cancer?
renal cell carcinoma (adnocarcinoma)
When is adenocarcinoma usually discovered?
50 - 70 years old
Most significant risk factor for development of renal cell carcinoma?
Other risk factors?
- 1. first-degree relatives wit Hx
- 2. obesity
- 3. HTN
- 4. exposure to asbestos, cadmium, & gasoline
- 5. acquired cystic disease associated with ESRD
S/S of kidney cancer initially?
no s/s initially & may be undiagnosed until disease is progressed significantly
What causes s/s of kidney tumores?
cause s/s by compressing, stretching, or invading structures near or within the kidney
3 Most common s/s of kidney cancer?
Other s/s that may occur?
- 1 hematuria
- 2. flank pain
- 3. palpable mass in the3 flank or abd
- 1. weight loss
- 2. fever
- 3. HTN
- 4. anemia
Most common sites of metastases for kidney cancer are ___, ____, & ___ ____.
lungs, liver, & long bones
Dx of kidney cancer?
- 1. CT scan
- 2. ultrasound - differentiate b/t solid mass & cyst
- 3. angiography
- 4. percutaneous needle aspiration
- 5. MRI
- 6. IVP
What Dx test is used to detect metastases of kidney cancer?
radionuclide isotope scanning
System for staging renal carcinoma & basis for determining Tx?
- Stage I: limited to kidney, small tumor <7cm
- Stage II: spreading to perirenal fat but confined within fascia
- Stage III: tumor invades renal vein or vena cava, or regional lymph node involvement or both
- Stage IV: presence of metastases
Tx of choice for renal cancer for pt with stage I or II tumors & select stage III tumors?
How is the Tx performed?
open or laparoscopically
removal of the kidney, adrenal gland, surrounding fascia, part of the ureter, & the draining lymph nodes
Other Tx options for renal cancer besides radical nephrectomy?
- 1. may use radiation therapy palliatively or if have metastases to bone or lungs
- 2. cryoablation - freezing
- 3. radiofrequency ablation - destroying by using radiofrequency heat
- 4. chemo is used in metastatic disease
- 5. biologic therapy in metastatic disease
- 6. targeted therapy in metastatic disease
Cehmo drugs used in metastatic kidney cancer?
- 1. 5-flourouracil (5FU)
- 2. floxuridine
- 3. gemzar
usually not responsive to chemo
Bilogic therapy used in metastatic renal cancer?
- 1. alpha-interferon
- 2. interleukin - (IL - 2)
Targeted therapy used in metastatic renal cancer?
- 1. sunitinib/Sutent
- 2. sorafenib/Nexavar
- 3. temsirolimus/Torisel
- 4. everolimus/Afinitor
- 5. ofatumumab/Arzerra
- 6. bevacizumab/Avastin
- 7. pazopanib/Votrient
AE effects of alpha-interferon?
- 1. flu-like syndrome
- 2. cognitive changes
- 3. fatigue
- 4. NV
- 5. anorexia
- 6. weight loss
AE of interleukin?
- 1. same as alpha-interferon
- 2. capillary leak syndrome -> hypotension
- 3. bone marrow suppression
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