Chapter 27: Intrarenal Disorders

Question 1

Pain

Answer 1

• kidney and renal pain is referred to as nephralgia
• generally is felt at costovertebral angle; recorded as CVA TENDERNESS or FLANK PAIN
• due to distention/inflammation of the renal dermatomal capsule; has a dull, constant character
• Pain is transmitted to T10 and L1 by sympathetic afferent neurons; may be felt throughout dermatomes

Question 2

Abnormal Urinalysis Findings

Answer 2

• provides a foundation for the differential diagnosis of renal dysfunction
• Dipstick (macroscopic) and microscopic urinalysis results provide clues to intrarenal pathologies
• Color: dark, strong smelling urine indicates decreased renal function, while cloudy pungent urine indicates an infectious process

Question 3

Other DIagnostic Test Findings

Answer 3

• KUB identifies gross abnormalities related to size, position, and shape (may show renal calculi/kidney stones)
• Renogram/renal scan shows renal vasculate and tumors
• Ultrasonography differentiates tissue characteristics (MOST COMMON TEST USED)
• CT/MRI used to provide detailed info about vasculature and tissue

Question 4

Protective Mechanisms Against Kidney Infection

Answer 4

• acidic pH
• Presence of urea in the urine
• Men have bacteriostatic prostatic secretions
• women have glands in the distal urethra that secrete mucous which protects against UTI
• micturation: wash out pathogens
• unidirectional urine flow which prevents reflux

Question 5

Infection of the Kidney

Answer 5

• called pyelonephritis
• most common form is an ascending infection from the lower urinary tract
• the most effective preventive measure is the early removal of catheters, or just no use of catheters at all

Question 6

Acute Pyelonephritis

Answer 6

• infection of the renal pelvis/parenchyma usually from an ascending UTI
• a major risk factor in pregnancy
• clinical manifestations include CVA tenderness (classic sign) accompanied by fever, chills, N/V, anorexia, and an increase in fever induced dehydration
• urosepsis: organisms in the bloodstream originating from a uti
• diagnosis is made from a presence of WBC casts which is indicative of an upper UTI
• treatment includes immediate management with antimicrobials to avoid reduced renal function

Question 7

Chronic Pyelonephritis

Answer 7

• can result in chronic kidney disease
• usually associated with reflux or obstructive process leading to persistant urine stasis
• chronic inflammation causes scarring and loss of functional nephrons
• clinical manifestations include presenting with abdominal/flank pain, fever, malaise, and anorexia
• diagnosed through renal imaging
• treated by correcting the underlying processes and extending antimicrobial therapy

Question 8

Obstruction

Answer 8

• conditions that interfere with the flow of urine
• may be congenital or acquired
• changes result from location and degree of obstruction as well as the duration and timing of the obstruction

Question 9

Causes of Obstructive Processes and what they cause

Answer 9

• common causes include stones (most common), tumors, prostatic hypertrophy (enlarged prostate), and structures of the ureters or urethra
• Obstructive processes themselves cause urine stasis (this predisposes to infection and structural damage)
• Complete obstruction results in hydronephrosis, decreased GFR, Ischemic kidney damage because of increased intraluminal pressure. acute tubular necrosis (intrarenal acute renal failure), and chronic kidney disease

Question 10

Renal Calculi (Nephrolithiasis)

Answer 10

• Kidney Stones
• crystal aggregates composed of organic and inorganic salts within the urinary tract
• urinary supersaturation is essential requirement for stone formation
• stones tend to form in the urinary tract due to solute supersaturation, LOW URINE VOLUME, and abnormal urine pH
• Most stones are composed of calcium crystals (calcium oxylate). Others include uric acid, struvite, cystine, and stones associated with certain medications
• Stationary stones are usually asymptomatic; stone migration causes intense renal colic pain abrupt in onset and may radiate; N/V, diaphoresis is common; hematuria may be present
• most stones will pass spontaneously
• Diagnosed by a CT scan
• treatment includes fluids (IV) to pass stone, lithotripsy (shockwaves that break stone) or endoscopic approaches, ureteral stenting, and ureteroscopy
• stones tend to recur; prevetion enhanced by high fluid intake to dilute the urine and dietary changes based on the type of stone

Question 11

Nephrotic Syndrome (edema)

Answer 11

• occurs due to increased glomerular permeability to proteins
• urinary loss of 3 to 3.5g of protein per day (should have 0g loss)
• proteinuria leads to hypoalbuminemia and generalized edema; decreased blood colloid osmotic pressure
• increase in liver activity can cause hyperlipidemia and hypercoagulability
• most common finding is edema
• Treatment includes conservative symptom management (diuretics, lipid lowering agents, antihypertensives, and immunosuppression/immunomodulation)
• management of underlying process when identified
• may resolve spontaneously, others progress to end-stage renal disease