Alterations of Renal and Urinary Tract Function Chapter 36 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc

Alterations of Renal and Urinary Alterations of Renal and Urinary Tract FunctionTract Function

Chapter 36Chapter 36

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

22Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Urinary Tract ObstructionUrinary Tract Obstruction Blockage of urine flow within the urinary tractBlockage of urine flow within the urinary tract

Obstruction can be caused by an anatomic or Obstruction can be caused by an anatomic or functional defectfunctional defect• Obstructive uropathyObstructive uropathy

Severity based on:Severity based on:• LocationLocation

• CompletenessCompleteness

• Involvement of one or both upper urinary tractsInvolvement of one or both upper urinary tracts

• DurationDuration

• CauseCause


Urinary Tract ObstructionUrinary Tract Obstruction HydroureterHydroureter Hydronephrosis Hydronephrosis Tubulointerstitial fibrosisTubulointerstitial fibrosis ApoptosisApoptosis


Urinary Tract ObstructionUrinary Tract Obstruction


Urinary Tract ObstructionUrinary Tract Obstruction Compensatory hypertrophyCompensatory hypertrophy

Obligatory growthObligatory growth Compensatory growth Compensatory growth

Postobstructive diuresisPostobstructive diuresis Low bladder wall complianceLow bladder wall compliance


Kidney StonesKidney Stones Other factors affecting stone formationOther factors affecting stone formation

Crystal growth–inhibiting substancesCrystal growth–inhibiting substances Particle retentionParticle retention MatrixMatrix

StonesStones Calcium oxalate or calcium phosphateCalcium oxalate or calcium phosphate Struvite stonesStruvite stones Cystinuric stonesCystinuric stones Uric acid stonesUric acid stones IndinavirIndinavir


Kidney StonesKidney Stones ManifestationManifestation

Renal colicRenal colic EvaluationEvaluation

Stone analysisStone analysis Kidney-ureter-bladder (KUB)Kidney-ureter-bladder (KUB) Intravenous pyelogramIntravenous pyelogram Spiral abdominal computed tomography (CT)Spiral abdominal computed tomography (CT)

TreatmentTreatment Stone removalStone removal


Kidney Stone FormationKidney Stone Formation Supersaturation of one or more saltsSupersaturation of one or more salts

Presence of a salt in a higher concentration than Presence of a salt in a higher concentration than the volume able to dissolve the saltthe volume able to dissolve the salt

Precipitation of a salt from liquid to solid statePrecipitation of a salt from liquid to solid state Temperature and pHTemperature and pH

Growth into a stone via crystallization or Growth into a stone via crystallization or aggregationaggregation


Kidney Stones: CalculiKidney Stones: Calculi Masses of crystals, protein, or other Masses of crystals, protein, or other

substances that form within and may obstruct substances that form within and may obstruct urinary tracturinary tract

Risk factorsRisk factors MaleMale Age 20-40 yearsAge 20-40 years Inadequate fluid intake (biggest contributor)Inadequate fluid intake (biggest contributor) Living in desert or tropical regionLiving in desert or tropical region

• Temperature, humidity, fluid, and dietary patternsTemperature, humidity, fluid, and dietary patterns


Kidney Stones: CalculiKidney Stones: Calculi Composition of mineral saltsComposition of mineral salts

Calcium oxalate/phosphate (70%-80%)Calcium oxalate/phosphate (70%-80%) Struvite (magnesium, ammonium, phosphate, Struvite (magnesium, ammonium, phosphate,

15%)15%) Uric acid (7%)Uric acid (7%)


Lower Urinary Tract ObstructionLower Urinary Tract Obstruction Bladder neck dyssynergiaBladder neck dyssynergia Prostate enlargementProstate enlargement Urethral strictureUrethral stricture Severe pelvic organ prolapseSevere pelvic organ prolapse


Lower Urinary Tract ObstructionLower Urinary Tract Obstruction Neurogenic bladderNeurogenic bladder

Neurogenic detrusor overactivityNeurogenic detrusor overactivity• Detrusor sphincter dyssynergiaDetrusor sphincter dyssynergia

• Overactive bladder syndromeOveractive bladder syndrome

ObstructionObstruction Low bladder wall complianceLow bladder wall compliance


Neurogenic BladderNeurogenic Bladder


TumorsTumors Renal tumorsRenal tumors

Renal adenomasRenal adenomas Renal cell carcinomaRenal cell carcinoma

Bladder tumorsBladder tumors Papillary tumorsPapillary tumors Nonpapillary tumorsNonpapillary tumors Metastasis to lymph nodes, liver, bone, lungs Metastasis to lymph nodes, liver, bone, lungs


Urinary Tract Infection (UTI)Urinary Tract Infection (UTI) Inflammation of the urinary epithelium Inflammation of the urinary epithelium

following invasion and colonization by some following invasion and colonization by some pathogen within the urinary tractpathogen within the urinary tract

Complicated UTIComplicated UTI Uncomplicated UTIUncomplicated UTI Persistent UTIPersistent UTI Interstitial cystitisInterstitial cystitis


Urinary Tract Infection (UTI)Urinary Tract Infection (UTI) Most common pathogensMost common pathogens

Escherichia coliEscherichia coli Staphylococcus saprophyticusStaphylococcus saprophyticus EnterobacterEnterobacter spp spp

Virulence of uropathogensVirulence of uropathogens Host defense mechanismsHost defense mechanisms


Urinary Tract Infection (UTI)Urinary Tract Infection (UTI) CystitisCystitis

An inflammation of the bladderAn inflammation of the bladder ManifestationsManifestations

• Frequency, dysuria, urgency, and lower abdominal Frequency, dysuria, urgency, and lower abdominal and/or suprapubic painand/or suprapubic pain

TreatmentTreatment• Antimicrobial therapy, increased fluid intake, avoidance Antimicrobial therapy, increased fluid intake, avoidance

of bladder irritants, urinary analgesicsof bladder irritants, urinary analgesics


PyelonephritisPyelonephritis Acute pyelonephritisAcute pyelonephritis

Acute infection of the ureter, renal pelvis, and/or renal Acute infection of the ureter, renal pelvis, and/or renal parenchymaparenchyma

Contributing factorsContributing factors• CystitisCystitis

• Urinary tract obstruction with reflux infectionUrinary tract obstruction with reflux infection

• Women are 5 times more likely to develop pyelonephritisWomen are 5 times more likely to develop pyelonephritis


PyelonephritisPyelonephritis Clinical manifestationsClinical manifestations

Flank painFlank pain FeverFever ChillsChills Costovertebral tendernessCostovertebral tenderness Purulent urinePurulent urine

TreatmentTreatment Chronic pyelonephritisChronic pyelonephritis


Glomerular DisordersGlomerular Disorders Glomerulopathies are disorders that directly Glomerulopathies are disorders that directly

affect the glomerulusaffect the glomerulus Urinary sediment changesUrinary sediment changes

Nephrotic sedimentNephrotic sediment Nephritic sedimentNephritic sediment Sediment of chronic glomerular diseaseSediment of chronic glomerular disease


Glomerular DisordersGlomerular Disorders Glomerular disease has sudden or insidious Glomerular disease has sudden or insidious

onset of hypertension, edema, and an onset of hypertension, edema, and an elevated blood urea nitrogen (BUN)elevated blood urea nitrogen (BUN)

Decreased glomerular filtration rateDecreased glomerular filtration rate Elevated plasma creatinine, urea, and reduced Elevated plasma creatinine, urea, and reduced

creatinine clearancecreatinine clearance Glomerular damage causes decreased Glomerular damage causes decreased

glomerular membrane surface area, glomerular membrane surface area, glomerular capillary blood flow, blood glomerular capillary blood flow, blood hydrostatic pressure hydrostatic pressure


Glomerular DisordersGlomerular Disorders

Increased glomerular capillary permeability and Increased glomerular capillary permeability and loss of negative ionic charge barrier result in loss of negative ionic charge barrier result in passage of plasma proteins into the urinepassage of plasma proteins into the urine

Resulting hypoalbuminemia encourages plasma Resulting hypoalbuminemia encourages plasma fluid to move into the interstitial spacesfluid to move into the interstitial spaces EdemaEdema


Glomerular DisordersGlomerular Disorders GlomerulonephritisGlomerulonephritis

Inflammation of the glomerulusInflammation of the glomerulus• Immunologic abnormalities (most common)Immunologic abnormalities (most common)

• Drugs or toxinsDrugs or toxins

• Vascular disordersVascular disorders

• Systemic diseasesSystemic diseases

• Viral causesViral causes


Acute GlomerulonephritisAcute Glomerulonephritis PathophysiologyPathophysiology

Formation of immune complexes Formation of immune complexes (antigen/antibody) in the circulation with (antigen/antibody) in the circulation with subsequent deposition in glomerulussubsequent deposition in glomerulus

Antibodies produced against the strep organism Antibodies produced against the strep organism cross-react with the glomerular endothelial cells cross-react with the glomerular endothelial cells (may be related to inadequately treated strep)(may be related to inadequately treated strep)

Activation of complementActivation of complement Recruitment/activation of immune cells and Recruitment/activation of immune cells and

mediatorsmediators


Glomerulonephritis Glomerulonephritis


Glomerulonephritis Glomerulonephritis Acute poststreptococcal glomerulonephritisAcute poststreptococcal glomerulonephritis IgA nephropathy (Berger disease)IgA nephropathy (Berger disease) Crescentic glomerulonephritisCrescentic glomerulonephritis Membraneous nephropathyMembraneous nephropathy Membranoproliferative glomerulonephritisMembranoproliferative glomerulonephritis Antiglomerular basement membrane disease Antiglomerular basement membrane disease

(Goodpasture syndrome)(Goodpasture syndrome) Chronic glomerulonephritisChronic glomerulonephritis


Glomerulonephritis Glomerulonephritis


Acute GlomerulonephritisAcute Glomerulonephritis Decreased GFRDecreased GFR

Decreased glomerular perfusion (glomerular blood Decreased glomerular perfusion (glomerular blood flow) due to inflammationflow) due to inflammation

Glomerular sclerosis (scarring)Glomerular sclerosis (scarring) Thickening of the glomerular basement membrane Thickening of the glomerular basement membrane

(but increased permeability to proteins)(but increased permeability to proteins)


Clinical Manifestations of Clinical Manifestations of Acute GlomerulonephritisAcute Glomerulonephritis

Hematuria Hematuria Smoky, brown-tinged urineSmoky, brown-tinged urine Red blood cell castsRed blood cell casts

ProteinuriaProteinuria Low serum albuminLow serum albumin EdemaEdema

Eventual oliguriaEventual oliguria Oliguria: urine output <30 ml/hour or <400 ml/dayOliguria: urine output <30 ml/hour or <400 ml/day


Nephrotic Syndrome Nephrotic Syndrome

Excretion of 3.5 g or more of protein in the urine Excretion of 3.5 g or more of protein in the urine per dayper day

Protein excretion is due to glomerular injuryProtein excretion is due to glomerular injury FindingsFindings

Hypoalbuminemia, edema, hyperlipidemia, and Hypoalbuminemia, edema, hyperlipidemia, and lipidurialipiduria


Causes of Nephrotic SyndromeCauses of Nephrotic Syndrome GlomerulonephritisGlomerulonephritis Genetic defects that alter the glomerular Genetic defects that alter the glomerular

membranemembrane Systemic diseases (diabetes, SLE)Systemic diseases (diabetes, SLE) Drug/toxin injuryDrug/toxin injury Infections (especially chronic and/or Infections (especially chronic and/or

recurrent)recurrent)


Nephrotic Syndrome Nephrotic Syndrome


Renal Dysfunction Renal Dysfunction Renal insufficiencyRenal insufficiency Renal failureRenal failure End-stage renal failureEnd-stage renal failure UremiaUremia AzotemiaAzotemia


Renal Failure Renal Failure AcuteAcute

Sudden and rapidly progressive within hours (often Sudden and rapidly progressive within hours (often reversible); abrupt reduction in renal functionreversible); abrupt reduction in renal function

ChronicChronic Chronic, slowly progressing to end-stage renal failure Chronic, slowly progressing to end-stage renal failure

over months or yearsover months or years


Renal FailureRenal Failure Azotemia: increased urea and frequently Azotemia: increased urea and frequently

creatinine levelscreatinine levels Uremia: elevated urea and creatinine levels Uremia: elevated urea and creatinine levels

with fatigue, anorexia, nausea, vomiting, with fatigue, anorexia, nausea, vomiting, diarrhea, weight loss, pruritus, edema, diarrhea, weight loss, pruritus, edema, neurologic changes (all related to retention of neurologic changes (all related to retention of toxic wastes, deficiency states, and toxic wastes, deficiency states, and electrolyte disorders)electrolyte disorders)


Prerenal ARFPrerenal ARF

Most common cause of ARFMost common cause of ARF Caused by impaired renal blood flow (sudden Caused by impaired renal blood flow (sudden

reduction of perfusion to the kidneys)reduction of perfusion to the kidneys) GFR declines due to the decrease in filtration GFR declines due to the decrease in filtration

pressure (results in oliguria)pressure (results in oliguria) Ischemia leads to hypoxic injury and acute Ischemia leads to hypoxic injury and acute

tubular necrosis (ATN)tubular necrosis (ATN)


Intrarenal ARFIntrarenal ARF Damage to the renal parenchymaDamage to the renal parenchyma

ATN (most common cause)ATN (most common cause)• PostischemicPostischemic

• Nephrotoxic injuryNephrotoxic injury

Corticol necrosisCorticol necrosis Acute glomerulonephritisAcute glomerulonephritis Vascular disease (i.e., malignant hypertension)Vascular disease (i.e., malignant hypertension) Toxic injury (drugs, such as antibiotics; Toxic injury (drugs, such as antibiotics;

nephrotoxins)nephrotoxins)


Postrenal ARFPostrenal ARF Occurs with urinary tract obstructions that Occurs with urinary tract obstructions that

affect the kidneys bilaterally and increase the affect the kidneys bilaterally and increase the intraluminal pressure upstream (thus a fall in intraluminal pressure upstream (thus a fall in GFR)GFR) Prostatic hypertrophyProstatic hypertrophy Bladder outlet obstructionBladder outlet obstruction Bilateral ureteral obstructionBilateral ureteral obstruction


Clinical Manifestations of ARFClinical Manifestations of ARF Oliguria/anuriaOliguria/anuria Elevated BUN and creatinineElevated BUN and creatinine HyperkalemiaHyperkalemia Metabolic acidosisMetabolic acidosis Hypertension (volume overload)Hypertension (volume overload)


Acute Renal Failure (ARF)Acute Renal Failure (ARF) Initiation phaseInitiation phase Maintenance phaseMaintenance phase Recovery phaseRecovery phase


Chronic Renal Failure Chronic Renal Failure The irreversible loss of renal function that The irreversible loss of renal function that

affects nearly all organ systemsaffects nearly all organ systems ProgressionProgression

Reduced renal reserveReduced renal reserve Renal insufficiencyRenal insufficiency Renal failureRenal failure End-stage renal diseaseEnd-stage renal disease


Chronic Renal Failure Chronic Renal Failure Creatinine and urea clearanceCreatinine and urea clearance Sodium and water balanceSodium and water balance Phosphate and calcium balancePhosphate and calcium balance Potassium balancePotassium balance Acid-base balanceAcid-base balance


Chronic Renal Failure Chronic Renal Failure Skeletal and bone alterationsSkeletal and bone alterations Cardiopulmonary systemCardiopulmonary system Neural function Neural function Endocrine and reproductionEndocrine and reproduction Hematologic alterationsHematologic alterations


Chronic Renal Failure Chronic Renal Failure Immunologic Immunologic Gastrointestinal Gastrointestinal IntegumentIntegument Alterations in proteins, carbohydrates, and Alterations in proteins, carbohydrates, and

lipidslipids


Progression of Progression of Chronic Renal FailureChronic Renal Failure

Decreasing renal functionDecreasing renal function Reduced renal reserve (GFR reduced to 50%)Reduced renal reserve (GFR reduced to 50%) Renal insufficiency (GFR declines to 25%)Renal insufficiency (GFR declines to 25%) Renal failure: significant loss of function (GFR Renal failure: significant loss of function (GFR

<20% of normal)<20% of normal) End-stage renal failure (near absence of GFR)End-stage renal failure (near absence of GFR)


Reduced Renal ReserveReduced Renal Reserve GFR reduced to 50%GFR reduced to 50%

No clinical symptomsNo clinical symptoms BUN BUN may may be elevatedbe elevated


Renal InsufficiencyRenal Insufficiency GFR reduced to 25%GFR reduced to 25%

Compensation of remaining nephronsCompensation of remaining nephrons Mild clinical symptoms (mild uremia)Mild clinical symptoms (mild uremia) Increased BUN/creatinineIncreased BUN/creatinine Mild anemiaMild anemia Impaired renal function during stressImpaired renal function during stress


Renal FailureRenal Failure GFR <20%GFR <20% Increased BUN/creatinineIncreased BUN/creatinine OliguriaOliguria Metabolic acidosisMetabolic acidosis Electrolyte imbalancesElectrolyte imbalances

Hyperkalemia, hypernatremiaHyperkalemia, hypernatremia Severe anemiaSevere anemia Increasing uremia and affects nonrenal Increasing uremia and affects nonrenal

organsorgans


End-Stage Renal Disease End-Stage Renal Disease (ESRD)(ESRD)

GFR = 0%GFR = 0% Severe uremiaSevere uremia Severe water, electrolyte, acid-base Severe water, electrolyte, acid-base

imbalancesimbalances Multiorgan/multisystem failuresMultiorgan/multisystem failures


Multiorgan/Multisystem FailuresMultiorgan/Multisystem Failures

CardiovascularCardiovascular Hypertension, congestive heart failureHypertension, congestive heart failure

• Volume overload, hyperactivity of renin systemVolume overload, hyperactivity of renin system Atherosclerosis, stroke, coronary artery diseaseAtherosclerosis, stroke, coronary artery disease

• DyslipidemiaDyslipidemia

HematologicHematologic Anemia (lack of erythropoietin)Anemia (lack of erythropoietin) Platelet defects—bleeding disordersPlatelet defects—bleeding disorders


Multiorgan/Multisystem FailuresMultiorgan/Multisystem Failures NeurologicNeurologic

NeuropathiesNeuropathies EncephalopathyEncephalopathy

GastrointestinalGastrointestinal Nausea, vomiting, anorexiaNausea, vomiting, anorexia Uremic fetorUremic fetor


Multiorgan/Multisystem FailuresMultiorgan/Multisystem Failures EndocrineEndocrine

Insulin resistanceInsulin resistance Decreased sex hormonesDecreased sex hormones

MetabolicMetabolic Altered protein, lipid, carbohydrate metabolismAltered protein, lipid, carbohydrate metabolism


Multiorgan/Multisystem FailuresMultiorgan/Multisystem Failures Integumentary, bone, mineralIntegumentary, bone, mineral

HyperphosphatemiaHyperphosphatemia Hypocalcemia Hypocalcemia Hyperparathyroidism; brittle bonesHyperparathyroidism; brittle bones Skin changes (bruises, itching, uremic frost, Skin changes (bruises, itching, uremic frost,

yellowing)yellowing) Immune dysfunctionImmune dysfunction

ImmunosuppressionImmunosuppression


Dialysis or Transplant?Dialysis or Transplant? Immediately life threatening: hyperkalemiaImmediately life threatening: hyperkalemia Severe uremia and multi-organ effectsSevere uremia and multi-organ effects Metabolic acidemiaMetabolic acidemia

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Alterations of Renal and Urinary Tract Function Chapter 36 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc