Class 22 - Alterations in Urinary/Renals

Question 1

Urinary Tract Obstruction

Answer 1

Types

• Mechanical (renal calculi)
• Functional (neurogenic bladder)
• Renal Pelvis
• Ureters
• Bladder
• Urethra

Consequences
- Distention above the level of obstruction (increased urine in the ureter and or kidney)
- Obstructive uropathy
1. Hydroureter
(accumulation of urine in the ureter)
2. Hydronephrosis (accumulation of urine in the kidney)
3. Ureterohydronephrosis (accumulation of urine in the kidney and ureter)
- Urinary stasis: risk for infection and calculi (stone) cormation
- Ultimately can lead to renal destruction

Severity

• Location or obstruction - both sides or one, higher or lower in the tract
• Completeness of blockage - is there any urine that gets by
• Duration of obstruction

Question 2

Renal Calculi

Answer 2

Kidney Stones
Masses of crystals, proteins or others
- Calcium-oxalate or calcium phosphate (80%)
- Struvite - Mg ammonium-phosphate (10-20%)
- Uric acid

Risk factor

• Before the age of 50, not in children
• Hydration - fluid intake
• Geographic location/season

Manifestations

• Renal colic (flank, radiation to the groin, lower abdomen, pain)
• Hematuria (presence of blood in the urine)
• Pain comes in waves

Diagnosis

• History, physical exam
• Urinalysis
• Ct scan

Management
- Pain management, filter urine to find stone

Question 3

Neurogenic Bladder

Answer 3

Functional obstruction due to neurologic disorders secondary to stroke, brain are spinal cord injuries, MS etc. WE need to have the bladder contract and the sphincter to open togehter.

1. Disorders above the Micturition Centre in the pons - automatic emptying
   - Spastic bladder
   - Caused by tumour, stroke, traumatic brain injury, dementia
2. Lesions below the Micturition Centre in the pons, but above the sacral Micturition centre - dyssynergia
   - The bladder will contract, but the sphincter contracts as well
   - Spinal cord injury, vertebral disc disorders
3. Lesions at or below the Micturition Centre in the sacral area
   - Areflexia, urinary retention, atonic bladder (flaccid bladder)
   - Bladder will continue to fill until there is overflow incontinence

Question 4

Urinary Tract Infection

Answer 4

Second most common type of infection after respiratory tract infections
- E. Coli is the number 1 cause for UTI’s

Location

• Bladder (cystitis)
• Kidneys (pyelonephritis)

Risk factors

• Females
• Stasis of urine predisposes people to UTI’s
• Diabetes
• Poor hygienic practices
• Surgery in the urinary tract and indwelling catheters
• Premature infants

Question 5

Cystitis - Acute

Answer 5

Most common site of UTI (bladder)
- E coli most common pathogen

Manifestations

• Can be asymptomatic (confusion and delirium in elderly patients
• Urgency and frequency
• Dysuria (painful urination)
• Suprapubic or low back pain
• Hematuria (blood in the urine) cloudy urine

Diagnosis
- Urine culture and analysis

Treatment
- Remove causative agents, antibiotics, repeat cultures

Question 6

Pyelonephritis - Acute

Answer 6

Infection of the kidney

• Ascending pathogens from bladder
• Pathogens from the bloodstream
• Infiltration of renal prelvis, calyces and medulla
• Inflammation, edema and pus

Manifestations

• Fever, chills, flank pain, costovertebral tenderness
• Child and older adult manifestations more vague

Diagnosis

• Urine culture, blood culture
• Differentiate from cystitis
  1. Intravenous pyelogram (IVP)
• Put in dye and it goes to the kidney to show inflammation
  2. WBC casts are present in urine
• Little clumps of WBC that are in the shape of the nephrons
• Only show up in kidney infections

Management

• Correct the cause
• Antibiotics

Question 7

Pyelonephritis - Chronic

Answer 7

• Persistent or recurrent infection

- Chronic inflammation - scarring of renal calyces and pelvis, atrophy and loss of function

Question 8

Acute Glomerulonephritis

Answer 8

Common disease of children

• Triggered by Group A beta hemolytic streptococci (also staph and viral infections)
• Antibody-antigen complexes circulate and become trapped in the glomeruli (inflammation of glomerulus)
• Sudden onset of symptoms 7-10 days after streptococcal infection (process of forming antibodies causes the 7-10 day wait for symptoms)

Manifestations

• Hematuria (blood in urine)
• Proteinuria (proteins in urine)
• Hypertension and edema due to kidney dysfunction
• Azotemia (increase in nitrogenous waste, aka urea and creatinin)

Usually resolves without severe loss of function

Question 9

Acute Kidney Injury

Answer 9

Used to be called Acute Renal Failure
- Rapid reduction of renal function, reversible if treated early

Categories

1. Prerenal
   - Caused by anything that decreases renal blood flow into the kidney
   - shocks, burns, heart failure
2. Intrarenal (acute tubular necrosis)
   - Within the kidney
   - Kidney infections, different drugs, toxins, tumors
3. Postrenal
   - Something that impedes the flow of urine out of the kidney
   - Kidney stone, enlarged prostate gland

Phases

1. Initiation phase
   - Time from precipitating event until injury starts
   - Hours to days
2. Maintenance phase
   - Oliguria (decreased urine output) <30 ml/hour over 2 hours
   - Retention of wastes
   - Fluid retention
3. Recovery phase
   - Diuresis: starts to filter urine, but is unable to concentrate the urine
   - Trouble with electrolyte balances, dehydration and excreting wastes
   - 3 mo - 1 yr
   - Some people never regain full recovery

Question 10

Chronic Kidney Injury

Answer 10

• Progressive decrease in function over months or years until end-stage failure is reached. Refers to declining GFR

Causes

• Diabetes mellitus
• Chronic hypertension
• Intrinsic kidney diseases

Symptoms start occurring when renal function decreases to 25%

• End stage renal fialure occurs when 10% or less function remains in the kidney, resulting in uremia
• Problems with potassium and fluid overload