AKI and Male Reproductive Disorders

Question 1

Chronic Kidney Disease (CKD)

Answer 1

○ Progressive, irreversible loss of kidney function
○ Hypertension - chronically uncontrolled

Question 2

Acute Kidney Injury (AKI):

Answer 2

A potentially reversible, abrupt decline in kidney function leading to increased creatinine, decreased urine output, or both.
Usually associated with other life-threatening conditions
***Follows severe, prolonged hypotension, hypovolemia, or exposure to a nephrotoxic agent (gentamycin, CT contrast - flush with fluids)
Develops over hours - days
High mortality rate

Question 3

Most common people with AKI

Answer 3

■ Sepsis patients
■ Hypovolemic shock
■ Burn patients
■ Fractures - blood loss
■ Athletes - diaphoresis, not replacing fluids

Question 4

Manifestations of AKI

Answer 4

Mildly elevated serum creatinine –> anuric renal failure
Prerenal and postrenal AKI correctible – ADDRESS THE CAUSE
Untreated prerenal and postrenal causes +/ or intrarenal causes ATN

Question 5

Causes leading to AKI

Answer 5

Prerenal
- External to the kidneys (ie hypovolemia or meds)
- Usually, reversible
Infrarenal
- Conditions that cause direct damage to renal tissue (parenchyma) impaired nephron function (ie ATN due to ischemia, nephrotoxins, or sepsis)
- Due to prolonged ischemia OR the presence of nephrotoxins (ie gentamycin or CT contrast dye), Hgb from hemolyzed RBC’s (ie sickle cell disease) or myoglobin released from necrotic muscle cells
Postrenal
- Mechanical obstruction of urine outflow (ie BPH, Prostate Ca, renal calculi, tumors).
- Usually reversible if identified before permanent kidney damage occurs

Question 6

What are the three phases of AKI

Answer 6

Initiation
Maintenance
Recovery

Question 7

what happens if people do not recover from AKI?

Answer 7

CKD develops

Question 8

Initiation phase of AKI

Answer 8

Characterized by:
serum creatinine + BUN
urine output

Question 9

Maintenance phase of AKI

Answer 9

Days to weeks
May be anuric, oliguric, or nonoliguric

Question 10

Nonoliguric

Answer 10

dilute urine but uremic toxins present (low specific gravity)

Question 11

Oliguric

Answer 11

lasts 10-14 days usually. The longer it is prolonged, the poorer the outcome
Oliguric means the patient produces LESS THAN 400mL/day or 20mL/ hr
Manifestations include:
- Changes in urinary output
- Fluid and electrolyte abnormalities
- Uremia

Question 12

Anuric

Answer 12

Anuric means the patient produces NO URINE

Question 13

Oliguric changes in maintenance phase

Answer 13

Urinary Changes: U/O decreased to <400mL/24h
Fluid volume excess: JVD, edema, hypertension - pulmonary edema, pericardial and/ or pleural effusions
Metabolic acidosis: Kussmaul’s resps (deep rapid) to increase blowing off CO2 - lethargy/ stupor (if prolonged)
Sodium Balance: Hyponatremia
Potassium Excess: Hyperkalemia - tall, peaked T waves (ECG)
Hematological Disorders: Anemia, increased bleeding,, decreased WBCs.
Calcium and Phosphate: Hypocalemia + hyperphosphatemia
Waste Product Accumulation: increased creatinine, increased BUN, decreased eGFR
Neurological Disorders: Fatigue/ difficulty concentrating - seizures, stupor, coma

Question 14

Metabolic acidosis

Answer 14

Kidneys can’t synthesize ammonia, which is needed for hydrogen ion excretion or to excrete acid products of metabolism. Serum bicarb level decreases b/c bicarb is used up buffering H+ ions.

Question 14

Sodium Balance

Answer 14

Damaged tubules cannot conserve sodium, therefore, the urinary excretion of sodium may increase resulting in hyponatremia.

Question 15

Hematological Conditions

Answer 15

Anemia r/t impaired erythropoietin production. Uremia reduces platelet adhesiveness, leading to bleeding. WBC’s are altered leading to immune deficiency. Infection in association with AKI is associated with double the mortality rate.

Question 16

Potassium Excess

Answer 16

Occurs b/c the normal ability of the kidneys to regulate an dexcrete potassium is impaired. May be precipitated by a number of causes: massive tissue trauma; bleeding and blood transfusions may cause cellular destruction; acidosis worsens hyperkalemia a hydrogen ions enter the cells and potassium is driven out of the cells into the extracellular fluid. Prompt treatment is essential

Question 17

Calcium and PO4

Answer 17

Activated Vit D must be present for GI absorption of calcium. Only functioning kidneys can activate Vitamin D, therefore, in damaged kidneys, serum calcium decreases. In response, the parathyroid gland releases PTH, stimulating bone demineralization. Phosphate is released as well, leading to hyperphosphatemia, worsened by the reduced excretion of PO4 by the kidneys. Metabolic acidosis also causes more calcium to be in its ionized state (vs bound to protein). An ionized calcium level that decreases significantly can lead to tetany

Question 18

Waste Product Accumulation

Answer 18

Kidneys are the primary excretors for urea, the end product of protein metabolism and creatinine, and end product of endogenous muscle metabolism. BUN results have to be interpreted with caution b/c dehydration, corticosteroid use, catabolism d/t infection, severe injury, and GI bleeding can also increase BUN.  creatinine and BUN. BUN non-specific. Clinically, the recommended method to evaluate kidney function is with an eGFR.

Question 19

Neurological Disorders

Answer 19

related to accumulation of nitrogenous waste products in the brain and nervous tissue.

Question 20

Recovery phase

Answer 20

Marked by return of BUN, Creatinine and GFR towards normal states
Diuresis –> fluid & electrolyte abnormalities
- Begins 1-3 L/ 24h –> 3-5 L/ 24h
- Pts must be monitored for hyponatremia, hypokalemia and dehydration
- May last 1-3 weeks
Patient’s acid-base, electrolyte and waste product values begin to normalize
Renal function may take up to 12 mos to stabilize.

Question 21

Diuresis

Answer 21

The high urine output occurs d/t osmotic diuresis from the high urea concentration in the glomerular filtrate and the inability of the tubules to concentrate the urine. In this phase, the kidneys have recovered their ability to excrete wastes but not to concentrate the urine.

Question 22

AKI dx studies

Answer 22

Urinalysis
- Sediment WITH casts, cells or proteins - intrarenal disorders
Urine specific gravity, sodium content, osmolality - helps differentiate different types of AKI
Renal ultrasound: anatomy and function
Renal CT: can identify causes of obstruction, but exposure to radiation and nephrotoxic contrast is greater risk
MRI and MRA are NOT recommended

Question 23

Care of AKI

Answer 23

GOALS of CARE:
Eliminate the cause(s)
Manage signs and symptoms
Prevent complications

Question 24

Care of AKI

Answer 24

Is there sufficient Intravascular volume and cardiac output to perfuse the kidneys? Diuretic Therapy - Loop diuretics (ie Lasix) - Osmotic diuretic (ie mannitol) Fluid Restriction: 600mL (insensible losses) + previous 24h losses Treatment of Electrolyte imbalances Renal Replacement Therapy (RRT) – Usually, hemodialysis (HD) If AKI is already established, fluids and diuretics will not be effective and may be harmful. Generally, begin early RRT to minimize symptoms and prevent complications.

Question 25

Nutrition therapy of AKI

Answer 25

Main challenge - Balancing adequate calories to prevent catabolism despite restrictions required to prevent electrolyte and fluid disorders Energy from fat and carb sources prioritized to prevent ketosis 25-35kCal/kg Electrolyte replacement in accordance with serum levels - Sodium is restricted - Hyperphosphatemia, hypermagnesemia and hypocalcemia Enteral or parenteral feeding may be required (though parenteral would be done ++ cautiously if pt on RRT)

Question 26

Health promotion of AKI

Answer 26

ID high-risk populations for AKI Control nephrotoxic drugs (ie IV contrast) Prevent prolonged episodes of hypovolemia or hypotension

Question 27

AKI prevention

Answer 27

essential d/t high mortality rates associated with AKI For patients with ANY level of renal insufficiency (esp those with diabetes or older adults), special attention must be given to prevent nephrotoxic events secondary to contrast dye. ADEQUATE HYDRATION before and after the test is critical. Preventing prolonged episodes of hypovolemia INCLUDES monitoring output (esp when pts receiving ++ diuretic therapy, or in with excessive diarrhea/ NG/ vomiting.

Question 28

Acute intervention of AKI

Answer 28

Managing fluid and electrolyte balance Monitoring AND recording accurate intake and output Daily weights (at the same time, same scale) - 1 kg = 1L of fluid Reducing risk of infection - Blunted febrile response Correct dosing of antibiotics for renal impairment Skin care and mouth care

Question 29

Rhabdomyolysis

Answer 29

“..characterized by skeletal muscle injury and release of intracellular contents into the systemic circulation – namely, potassium, phosphate, myoglobin, creatinine kinase (CK) and lactate dehydrogenase (LDH).” Can cause intrarenal AKI secondary to myoglobin obstruction of the renal tubules due to muscle breakdown

Question 30

Rhabdomyolysis dx based on...

Answer 30

History – crush injury, fall followed by prolonged immobility, concomitant drug use, status epilepticus Physical exam Elevated serum Creatine Kinase (CK) >1000 Urinalysis +’ve for blood (but microscopy NOT), suggesting myoglobin as cause for urinalysis result.

Question 31

Rhabdomyolysis Manifestations

Answer 31

Aching muscles Tea-coloured urine Reduced urine output Tachycardia secondary to pain, dehydration, or fluid shifts ? Muscle swelling (usu post- fluid resuscitation) ?Bruising/ pressure sores - compression injury

Question 32

Rhabdomyolysis – Care

Answer 32

Aggressive IV Isotonic Fluid Resuscitation w/ crystalloid (non-anuric patient) Accurate recording of intake + output Monitoring pt for signs of fluid overload RRT as needed to treat AKI Trending CK and renal function tests (BUN, Creatinine, eGFR), along with electrolyte panel

Question 33

Benign Prostatic Hyperplasia

Answer 33

Non-inflammatory enlargement of prostate gland resulting from increase in # of epithelial cells and amount of stromal tissue Most common urological problem in male adults Research is unclear whether BPH predisposes men to the development of prostate cancer

Question 34

Prostate

Answer 34

Prostate = gland that surrounds neck of bladder & urethra in males; secretes fluid that forms part of seminal fluid

Question 35

Benign prostatic enlargement

Answer 35

= prostate growth sufficient to obstruct (block) urethral outlet resulting in lower urinary tract symptoms or UTI

Question 36

Patho of BPH

Answer 36

Hormonal changes with aging Develops in inner part of prostate Cancer more likely to develop in outer part Enlargement compresses urethra - eventual partial or complete obstruction Leads to development of clinical symptoms

Question 37

Risk factors of BPH

Answer 37

Aging Physical inactivity Diabetes Obesity (large waist circumference) Familial history in first-degree relative

Question 38

Protective factors of BPH

Answer 38

Diet of fruit & veggies; lycopene Physical activity

Question 39

BPH clinical manifestations

Answer 39

Bothersome “LUTS” – lower urinary tract symptoms Gradual onset Obstructive symptoms Decrease in calibre & force of urinary stream, hesitancy, intermittency, dribbling Irritative symptoms (associated with inflammation or infection) Urinary frequency, urgency, dysuria, bladder pain, nocturia, incontinence Complications Urinary retention, UTI & possible sepsis, calculi, renal failure (hydronephrosis)

Question 40

Dx of BPH

Answer 40

History and physical DRE – digital rectal exam PSA levels (trend) -Prostate specific antigen - a glycoprotein - elevated levels indicate a pathological condition of the prostate, though not necessarily prostate cancer. PSA levels can be slightly elevated in BPH, but more in prostatitis. Urinalysis with culture Postvoid residual Ultrasound Cysto -Urethroscopy

Question 41

BPH care

Answer 41

Goals: Restore bladder drainage, relieve symptoms and prevent/ treat complications. Treatment is generally based on the degree to which the symptoms bother the patient or the degree to which complications are present vs the size of the prostate.

Question 42

BPH care - active surveillance

Answer 42

"Watchful waiting” (mild luts) - dietary changes (decreasing caffeine & artificial sweeteners, limiting spicy or acidic foods) - avoiding decongestants & anticholinergic medications (prevent bladder contraction) - restricting evening fluid intake - timed voiding schedule

Question 43

BPH care - drug therapy

Answer 43

5α-Reductase inhibitors (reduce the growth of prostate tissue, takes time) – 6 mos to see change α-Adrenergic receptor blockers (smooth muscle relaxants, lowers BP) – 2-3 wks to see change – risk for ortho hypotension

Question 44

BPH care - invasive therapy

Answer 44

Transurethral resection of the prostate (TURP): GOLD STANDARD Transurethral incision of the prostate (TUIP): local anesthetic; as effective as TURP Prostatectomy: surgery of choice for larger prostates

Question 45

BPH care - minimally invasive therapy

Answer 45

TUMT, TUNA, Laser prostatectomy

Question 46

TURP

Answer 46

GOLD STANDARD Done under spinal or general anesthetic Associated with good outcomes in 90% of patients HOLD ASA or anticoagulants preop Pain and UTI most common preop problems necessitating TURP

Question 47

TURP preop care

Answer 47

Urinary drainage must be restored before surgery Use of lidocaine jelly ++ helpful May require coude (curved tip) catheter Antibiotics usually given before invasive procedures Patient education on common alterations in sexual function is important – retrograde ejaculation not harmful but orgasms might be less pleasurable

Question 48

TURP postop care

Answer 48

Main complications: - Hemorrhage (CBC) - Bladder spasms (smooth muscle relaxants) - Urinary incontinence - Infection Manage CBI – rate determined by colour of drainage. Goal is light pink with no clots. Small clots are expected for 24-36h, but bright red blood can indicate hemorrhage. Avoid activities that increase abdominal pressure (ie straining) Remove CBI 2-4 days postop; trial of void 6h after cath removal Urinary dribbling/ incontinence common initially; can usu improve with Kegel exercises over first 2 months postop Dietary interventions / bowel protocol to avoid straining; adequate fluid intake

Question 49

Prostate cancer

Answer 49

Malignant tumour of prostate gland Androgen-dependent adenocarcinoma (overgrowth of cells in a gland) - So after the age of 50 most men have a decrease in testosterone, but have an increase in dihydrotestosterone (a potent form of testosterone) Majority of tumours in outer aspect of prostate Usually slow growing but progressive if left untreated Can metastasize through direct extension, lymph system, or bloodstream

Question 50

Direct extension

Answer 50

seminal vesicles, urethral mucosa, bladder wall, & external sphincter

Question 51

Lymphatic system

Answer 51

regional lymph nodes

Question 52

Bloodstream

Answer 52

pelvic bones, head of femur, lower lumbar spine, liver, lungs

Question 53

Causes of prostate cancer

Answer 53

Age - Incidence rises markedly after 50 yrs of age (when screening starts); median age is 67 yrs of diagnosis Ethnicity Family history Diet: tomatoes and tomato-based products are protective. Diet high in fat, dairy products, red meat and processed meat and being obese are risk factors.

Question 54

Prostate cancer risk factors

Answer 54

> 50 years of age Ethnicity: Black > White > Asian Family history High levels of testosterone Diet high in fats & low in vegetables & fruits Occupational exposure to cadmium Genetic link -mutations in luminal and basal cells of the prostate. Also links to BRCA1 and BRCA2 (genetic mutations causing breast cancer)

Question 55

Prostate cancer prevention

Answer 55

1) Eat a wide variety of fruits & vegetables each day Consumption of tomatoes, tomato-based products, & garlic may protect against prostate cancer 2) Be physically active 3) Maintain a healthy weight

Question 56

Clinical manifestations of prostate cancer

Answer 56

Generally asymptomatic during early stages Urinary symptoms may occur (similar to BPH): - Difficulty starting or stopping urination - Slow stream - Painful urination or ejaculation - Dribbling - Frequent urination - Loss of urinary control - Blood in urine or ejaculate - Night-time voiding Advanced prostate cancer: - Weight loss - Fatigue - Backache or sciatica-like pain, or swelling of legs that doesn’t go away

Question 57

Dx of prostate cancer

Answer 57

DRE:GOLD STANDARD PSA screening: NOT RECOMMENDED - Not specific to prostate cancer! - Prostate biopsy required for diagnosis Transluminal ultrasound if suspected Biopsy to confirm (based on cell type) Prostate Cancer Associated 3 (PCA3) – gene in urine specific to prostate ca. AFTER DIAGNOSIS: - Bone scan - CT - MRI

Question 58

PSA

Answer 58

prostate-specific antigen; glycoprotein produced by prostate gland; elevated in prostate cancer, BPH or prostatitis; not specific to cancer but when cancer exists, is useful marker of tumour volume (i.e. higher the PSA, greater the tumour mass) Once a diagnosis is made, bone scan, CT and/ or MRI will determine extent of spread. No provincial screening program in BC - If screening is going to be done, men between the ages of 55 and 69 most benefit from it. Routine screening not recommended over the age of 70. (CDC) PSA (prostate specific antigen) used for: - Monitoring established prostate cancer & metastatic disease or detection of early recurrence, where prostate cancer is already known - Diagnostic adjunct in combination with other tests in symptomatic men - Screening tool

Question 59

Prostate cancer staging and grading

Answer 59

Whitmore-Jewett TNM Classification System Tumor Characteristics of the primary tumor (grading) Nodes Involvement of lymph nodes Metastasis Evidence of spread Gleason scale (2-10) Grading of tumour based on histology Provides an indication of the risk for spread

Question 60

Care of prostate cancer

Answer 60

Watchful waiting Chemotherapy Hormone therapy Radical prostatectomy Cryotherapy

Question 61

Radical prostatectomy for prostate cancer

Answer 61

removal of entire prostate, seminal vesicles, part of bladder - entire prostate removed b/c cancer tends to be in many different locations within the gland - catheter in place for 1-2 weeks postop - risk for erectile dysfunction & incontinence - may be possible to do nerve-sparing procedure to spare nerves responsible for erection

Question 62

Cryotherapy for prostate cancer

Answer 62

destroys cancer cells by freezing tissue

Question 63

Chemo for prostate cancer

Answer 63

limited to treatment for those with hormone-resistant cancer in late-stage disease

Question 64

Hormone therapy for prostate cancer

Answer 64

block androgen (testosterone) production to reduce tumour growth; may be used as adjunct therapy before surgery or radiation

Question 65

Treatment of prostate cancer

Answer 65

Most treatments have very undesirable side effects including: Hormonal side effects - Hot flashes, muscle atrophy, loss of libido Specific surgical side effects - Risk for incontinence or “dribbling” - Risk for impotence Chemotherapy and radiation therapy side effect - Depends on type of therapy. - Common side-effects may include: Nausea, vomiting, fatigue, hair loss …

Question 66

Testicular cancer

Answer 66

Most common type of cancer in males ages 15-29 years More common: - In right testicle - In males with hx of undescended testes - In males with a family hx of testicular anomalies or cancer Predisposing factors: HIV, orchitis, maternal exposure to diethylstilbestrol, testicular ca in contralateral testis

Question 67

Testicular cancer manifestations

Answer 67

Slow or rapid onset depending on type of tumor Painless lump, scrotal swelling, and/ or feeling of heaviness Scrotal mass usually nontender and very firm Sometimes concurrent lower abd/ scrotal/ perianal dull ache or heavy sensation

Question 68

Testicular cancer dx

Answer 68

Palpation of firm mas Ultrasound Serum alpha-fetoprotein, LDH, and hCG; CBC/ LFT’s CXR and/ or CT abdo/pelvis to detect metastases

Question 69

Care of testicular cancer

Answer 69

Early recognition: TSE (see Table 57-9) from the age of 15 yrs Fertility and sperm banking should be discussed preop. Tx can affect both erections and fertility Surgery Orchiectomy or radical orchiectomy (removal of affected testis, spermatic cord, and regional lymph nodes) Postop Care: - Surveillance - Chemotherapy/ radiation Treatment-related toxicity significant

Question 70

Vasectomy

Answer 70

Def’n: Bilateral surgical ligation of the vas deferens for the purpose of sterilization 15-30 minutes in duration Outpatient procedure under local anaesthesia Usually irreversible Does NOT affect production of hormones nor ejaculation Not “reliable” until 6 month postop; alternate forms of contraception should be used until verification occurs