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Seminar on nephritis, nephrotic

syndrome,bladder cancer

Presented by:Ligi Xavier1 yr MSc nursing

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Nephritis

Nephritis is inflammation of the nephrons in the kidneysSubtypes

•By main location of inflammation•By cause

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Interstitial nephritis

• Interstitial nephritis is a kidney disorder in which the spaces between the kidney tubules become swollen (inflamed). The inflammation can affect the kidneys' function, including their ability to filter waste.

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Causes

• Allergic reaction to a drug (acute interstitial allergic nephritis)

• Analgesic nephropathy• Long-term use of medications such as

acetaminophen (Tylenol), aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDS). This is called analgesic nephropathy

• Side effect of certain antibiotics (penicillin, ampicillin, methicillin, sulfonamide medications, and others)

• Side effect of medications such as furosemide, and thiazide diuretics

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Symptoms

:• Blood in the urine• Fever• Increased or decreased urine output • Mental status changes (drowsiness, confusion,

coma)• Nausea, vomiting • Rash• Swelling of the body, any area• Weight gain (from retaining fluid)

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Investigations

• Arterial blood gases• Blood chemistry• BUN and blood creatinine levels• Complete blood count• Kidney biopsy• Urinalysis• Urine osmolality

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Treatment

• Treatment focuses on the cause of the problem. Avoiding medications that lead to this condition may relieve the symptoms quickly.

• Limiting salt and fluid in the diet can improve swelling and high blood pressure. Limiting protein in the diet can help control the buildup of waste products in the blood (azotemia) that can lead to symptoms of acute kidney failure.

• If dialysis is necessary, it usually is required for only a short time.

• Corticosteroids or anti-inflammatory medications can help in some cases

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Glomerulonephritis

• Glomerulonephritis is inflammation of the glomeruli. Also called glomerular disease, glomerulonephritis can be acute , a sudden attack of inflammation or chronic ,coming on gradually.

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Types

• Thin Basement Membrane Disease• Acute Nephritic Syndromes• Non Proliferative

– Minimal change GN also known as Minimal Change Disease

– Focal Segmental Glomerulosclerosis (FSGS)

– Membranous glomerulonephritis

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Membraneous glomerulonephritis

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Proliferative

• IgA nephropathy (Berger's disease)• Post-infectious• Membranoproliferative/

mesangiocapillary GN• Rapidly progressive glomerulonephritis• Acute glomerulonephritis• Chronic

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RPGN

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Causes

• Infections – Post-streptococcal glomerulonephritis– Bacterial endocarditis. – Viral infections.

Immune diseases

Vasculitis

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Pathophysiology

Antigen

Antigen – antibody product

Leukocyte infitration of glomerulus

Thikening glomerular filtration membrane

Scarring and loss of glomerular filtration membrane

Decreased GFR

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Signs and symptoms

• primary presenting features are hematuria,edema,azotemia(concentration of nitrogenous wasteproducts in the blood),proteinuria

• Pink or cola-colored urine from red blood cells in your urine (hematuria)

• Foamy urine due to excess protein (proteinuria,<3g/day)

• High blood pressure (hypertension)

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Cntd………….

• Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen

• Fatigue from anemia or kidney failure• Hypoalbunemia,hyperlipidemia,fatty casts in urine• Blood urea nitrogen, creatine level may increase

as urine output decreases.• In severe conditions• -headache, malaise, flank pain,dyspnea,

cardiomegaly,pulmonary edema, neurological manifestations also occur.

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Diagnostic studies

• History and physical examination • Laboratory studies• Urinalysis;reveal the presence of erythrocytes.• CBC with WBC differencial• BUN, creatine,albumin• Complement levels and ASO titre:the finding of

decreased complement components (c3 and CH50) indicates immune mediated response.

• Renal biopsy

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Medical Management

• Antibiotic Penicillin is the choice. Corticosteroids and immunosuppressive agents

• Dietary protein ,sodiums restricted.• Loop diuretics and antihypertensives to

control hypertension• Bedrest

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Chronic glomerulonephritis

• Chronic glomerulonephritis sometimes develops after a bout of acute glomerulonephritis. It reflects the end stage of glomerular inflammatory disease. One of the inherited cause Alport syndrome, may also involve hearing or vision impairment

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Pathophysiology

• Chronic glomerulonephritis may occur due to repeated episodes of acute glomerulonephritis, hypertensive nephrosclerosis,hyperlipidemia,glomerular sclerosis, chronic tubulointerstitial disease and amyloidosis.secondary diseases lupus nephritis,Good pastures syndrome. Kidneys are reduced to as little as one fifthof normal size (consisting largely of fibrous tissue).the cortex layer shrinks to 1-2mmin thickness or less.bands of scar tissue makes the surface of kidney irregular.glomeruli and tubules become scarred, and artery become thickened. The result is severe glomerular damage can result in ESRD.

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Clinical manifestations

• BUN and creatinine values are increased• Sudden severe nosebleed, stroke, • Peripheral and periorbital edema• loss of weight• ocular findings:retinal hemorrhage, papilledema• cardiomegaly,signs of heart failure• peripheral neuropathy• in later stages,pericarditis, pericardial friction rub

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Assessment and diagnostic findings

• Urine test• Blood tests• Imaging tests• Kidney biopsy.

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Complications

• Acute kidney failure. • Chronic kidney failure• High blood pressure• Nephrotic syndrome• Hypertensive encephalopathy• Heart failure• Pulmonary edema

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Treatment for an underlying cause

• Strep or other bacterial infection. • Lupus or vasculitis• IgA nephropathy• Goodpasture's syndrome.

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Nephrotic syndrome(nephrosis)

• Results when the glomerulus is excessively permeable to plasma protein,causing proteinuria that leads to low plasma albumin and tissue edema

• Nephrotic syndrome can affect all age groups. In children, it is most common between ages 2 and 6. This disorder occurs slightly more often in males than females.

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Causes

• Primary glomerular disease– Membraneousproliferative glomerulonephritis– Primary nephritic syndrome– Focal glomerulonephritis– Inherited nephritic diseases

• External causes– SLE– Diabetes mellitus– Amyloidosis

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• Neoplasms– Hodgkin’s lymphoma– Solid tumoprs of lung,colon, stomach, breast,– Leukemias

• Infections– Bacterial:streptococcal, syphilis– Viral:hepatitis,HIV– Protozoal: malaria

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• Allergens• Drugs

– Penicillamine– NSAIDS– Captopril

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Pathophysiology

Damaged glomerular capillary membrane

Loss of plasma protein

Hypoalbuminemia

Decreased oncotic ressure

Generalised edema

Activation of RAAS

Sodium retension

edema

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Clinical manifestations

• It comprises of cluster of clinical findings• Marked increase in protein• Hypoalbuminemia• Edema• Hyper lipidemia• Other symptoms include:• Foamy appearance of the urine• Poor appetite• Weight gain (unintentional) from fluid retention

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Diagnostic measures

• Proteinuria: exceeding 3.5g/day is the hall mark of the diagnosis of nephritic syndrome.

• Albumin blood test• Blood chemistry tests such as

basic metabolic panel or comprehensive metabolic panel

• Blood urea nitrogen (BUN)• Creatinine - blood test• Creatinine clearance - urine test• Urinalysis

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Contd……..

• Creatinine clearance - urine test• Urinalysis

• Fats are often also present in the urine. Blood cholesterol and triglyceride levels may be high.

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Treatment

• Keep blood pressure at or below 130/80 mmHg to delay kidney damage. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the medicines most often used. ACE inhibitors may also help decrease the amount of protein lost in the urine.

• corticosteroids • Antineoplastic agents (cyclophosphamide),

immunosuppressants (azathioprine,chlorambucil, cyclosporine)

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• Treat high cholesterol to reduce the risk of heart and blood vessel problems. A low-fat, low-cholesterol diet is usually not very helpful for people with nephrotic syndrome. Medications to reduce cholesterol and triglycerides (usually statins) may be needed.

• Low-protein diets may be helpful. Your health care provider may suggest eating a moderate-protein diet (0.5-0.6 gram of protein per kilogram of body weight per day).

• vitamin D supplements if nephrotic syndrome is long-term and not responding to treatment.

• Blood thinners may be needed to treat or prevent blood clots.• Diuretics for severe edema

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Complications

• Acute kidney failure• Atherosclerosis and related heart diseases• Chronic kidney disease• Fluid overload, congestive heart failure,

pulmonary edema• Infections, including pneumococcal pneumonia• Malnutrition• Renal vein thrombosis• Pulmonary emboli

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Bladder cancer

• It is more common in people between the ages of 50 and 70yrs. it affects more men than women(4:1)

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Types

• Transitional cell bladder cancer• Non muscle invasive (superficial)

bladder cancer• Invasive bladder cancer

–  Squamous cell bladder cancer– Adenocarcinoma of the bladder– cell cancer of the bladder

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Causes of Cancer of the Bladder

• smoking - is 2-6 times greater in smokers than in nonsmokers.

• Chemical exposure • textile workers, Dry cleaners• Dental workers• Physicians• Barbers,dye, leather, and rubber workers,

plumbing, autowork, painters

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• Race - Caucasians have twice as high a risk of developing this cancer as people of African descent; Asians have the lowest risk

• Gender - men have a 2 to 3 times higher risk than women of developing bladder cancer

• haematobium infection causes most cases of bladder SCC

• Age - most cases of bladder cancer are diagnosed in people over the age of 40 years

• previous use of certain chemotherapy medications, such as cyclophosphamide(often used in breast cancer and lymphoma treatment), can significantly increase the risk of later developing bladder cancer

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• Cancers arising from prostate,colon,rectum• Radiation treatment of the pelvis• Spinal cord injuries requiring long-term

indwelling catheters - A 16- to 20-fold increase in the risk of developing SCC of the bladder

• Previous radiation to the pelvic area• Family or personal history of bladder cancer• Schistosomiasis :In many developing countries

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Clinical features

• blood in the urine (most common)• pain or burning sensation while urinating• a feeling of urgency or needing to urinate

immediately• the feeling of not having emptied the

bladder completely after urinating• pain in the lower back

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Irritative bladder symptoms

• such as dysuria, urgency, or frequency of urination occur in 20-30% of patients with bladder cancer. Although irritative symptoms may be related to more advanced muscle-invasive disease, carcinoma in situ (CIS) is the more likely cause. Patients with advanced disease can present with pelvic or bony pain, lower-extremity edema from iliac vessel compression, or flank pain from ureteral obstruction.

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Diagnostic measures

• Urine studies include the following:• Urinalysis with microscopy• Urine culture to rule out infection, if

suspected• Voided urinary cytology• Urinary tumor marker testing

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Cystoscopy

• Cystoscopy in patients with CIS may reveal a characteristic red, velvety appearance that resembles an area of inflammation. In some cases, however, CIS is not visible on gross inspection

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Imaging studies

• Computed Tomography Scanning• Intravenous Pyelography• Renal Ultrasonography• Bone scans determine if the cancer has

spread to the bones.• Chest X-rays show if the cancer has

spread to the lungs.

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• Other tests• Complete Blood Count and Chemistry

Panel

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Staging

• The following is the TNM staging system for bladder cancer:• CIS - Carcinoma in situ, high-grade dysplasia, confined to

the epithelium• Ta - Papillary tumor confined to the epithelium• T1 - Tumor invasion into the lamina propria• T2 - Tumor invasion into the muscularis propria• T3 - Tumor involvement of the perivesical fat• T4 - Tumor involvement of adjacent organs such as the

prostate, rectum, or pelvic sidewall• N+ - Lymph node metastasis• M+ - Metastasis

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Management

• Surgical therapy– Trans urethral resection with fulgration– Laser photo coagulation– Open loop resection with fulgration– Cystectomy– Urinary diversion

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Trans urethral resection with fulgration

• Used for the diagnosis and treatment of superficial lesions with low recurrence rate. Also used to control the bleeding.

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Laser photo coagulation

• Used to teat superficial bladder cancer

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Open loop resection with fulgration

• it is used for the control of bleeding, for large superficial tumors and for multiple lesions.

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cystectomy

• Cystectomy is surgery to remove the bladder.– Partial cystectomy removes only part of the

bladder. It is used to treat cancer that has invaded the bladder wall in just one area.

– Simple cystectomy removes all of the bladder.– Radical cystectomy removes all of the bladder

as well as nearby lymph nodes, part of the urethra, and nearby organs that may contain cancer.

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Urinary diversion

• Urinary diversion is surgery that makes a new way for your body to store urine. This can be done with a pouch created inside your body from part of your intestines, called a continent reservoir.

• After cystectomy is performed, a urinary diversion must be created from an intestinal segment. Diversions can be incontinent(cutaneous) and continent.

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Cutaneous urinary diversions

• A. Conventional ileal conduit• B.Cutaneous ureterostomy• C.Vesicostomy• D.Nephrostomy

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Ileal conduit

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Cutaneous ureterostomy

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Nephrostomy

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Continent urinary diversions

• A.Indiana pouch • B.Continent ileal urinary

diversions(Kock pouch• C.Charleston pouch• D.Ureterosigmoidostomy

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Indiana pouch

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Kock pouch

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Ureterosigmoidostomy

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Other urinary diversion procedures

• Camey procedure, uses a portion of the ileumas a bladder substitute. In this procedure, the isolated ileum serves as the reservoir for urine. It is anastomosed directly to theporion of the remaining urethra after cystectomy.this procedure permits emptying of the the bladder through the urethra. However , the camay procedure applies only to men because the entireurethra is removed when a cystectomy is performed for women

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Orthotopic neobladder

• : is the constructions of a new bladder in the new anatomic positions of the bladder; with discharge of urine through the urethra. The reconstruction or neobladder can be derived from various segments of the intestine to create a low – pressure reservoir. An isolated segment of the distal ileum is often preferred

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Cystectomy - complications

• Ileus• Wound infection• Sepsis• Pelvic abscess• Hemorrhage• Wound dehiscence• Bowel obstruction• Enterocutaneous fistula• Rectal injury

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Urinary diversion-complications

• Complications of urinary diversion include the following:• Hyperchloremic metabolic acidosis - If the ileum or

colon is used• Urinary tract infections (UTIs)• Stomal-peristomal inflammation, hernia, or stenosis• Urinary calculi• Vitamin B-12 deficiency - For diversions affecting the

terminal ileum• Ureterointestinal stenosis leading to hydronephrosis

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Radiation therapy

• Radiation treatment for bladder cancer uses high-energy X-rays to kill cancer cells and shrink tumors. It may be given after surgery. It may be used along with chemotherapy. Sometimes it is used instead of surgery or chemotherapy.

• External beam radiation comes from a machine outside the body. The machine aims radiation at the area where the cancer cells are found.

• Internal radiation uses needles, seeds, wires, or catheters that contain radioactive materials placed close to or directly into the bladder.

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Intravesical therapy

• It is the instillation of immune stimulating agent into the bladder by urethral catheter. Usually BCG is used. It stimulates the immune system rather than directly act on the cancer cells in the bladder. If BCG fais, alpha interferon , valrubicin etc are used.

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Chemtherapy

• Antineoplastics, Antimetabolite• These agents inhibit cell growth and proliferation. They interfere

with DNA synthesis by blocking the methylation of deoxyuridylic acid.

• Fluorouracil (Adrucil)•  • Methotrexate (Trexall, Rheumatrex)•  • Gemcitabine (Gemzar)•  • Pemetrexed (Alimta)•  

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Antineoplastics, Vinca Alkaloid

• Vinca alkaloids act on the G and S phases of mitosis, inhibiting microtubule formation and inhibiting DNA/RNA synthesis.

• Vinblastine (Velban)

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Antineoplastics, Anthracycline

• Anthracycline antineoplastics inhibit DNA and RNA synthesis by steric obstruction. They intercalate between DNA base pairs and trigger DNA cleavage by topoisomerase II.

• Doxorubicin (Adriamycin, Caelyx, Rubex)

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• Valrubicin (Valstar) :It is indicated for intravesicular treatment of bladder carcinoma in situ (CIS) that is refractory to treatment with bacillus Calmette-Guérin (BCG).

• Antineoplastics, Alkylating• Cisplatin•  Carboplatin (Paraplatin)•  • Ifosfamide (Ifex)•  • Thiotepa (Thioplex, TSPA)

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• Antineoplastics, Antimicrotubular• These agents prevent cell growth and

proliferation. They work by enhancing tubulin dimers, as well as by stabilizing existing microtubules and inhibiting their disassembly.

• Docetaxel (Taxotere, Docefrez)

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• Chemotherapy – First Line • - Gemcitabine – Cisplatin • - Intensified MVAC Dose-intense MVAC +

GCSF • - Carboplatin – Gemcitabine • Chemotherapy – Second Line • - Paclitaxel – Carboplatin • - Docetaxel • - Ifosphamide

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• Neoadjuvant chemotherapy • Indications for Neoadjuvant Chemotherapy • 1. Clinical stage T2 – T4a • 2. No nodal or metastatic disease • 3. Urothelial histology only • 4. Candidate for radical cystectomy • Regimens: • To receive 3-4 cycles • Possible (not evaluated in RCT): • 1. Gemcitabine + cisplatin/carboplatin • 2. Dose-intense MVAC

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Chemotherapeutic Regimens for Metastatic Bladder Cancer

• First-line, platinum-based combinations are active in locally advanced and metastatic urothelial carcinoma.

• Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) is a standard combination regimen for treatment of metastatic bladder cancer

• Gemcitabine and cisplatin (GC) is a newer regimen that has been shown to be as effective as MVAC but with less toxicity. GC is now considered a first-line treatment for bladder cancer

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Nursing management

• preoperative period Assessment• Nutritional assessment • Advise tobacco cessation • Assessment of activities of daily living functional status • Determination of eligibility for financial support • Inclusion of partner/family members to establish support mechanism • Psychological assessment • Provision of audio and visual information • Provision of opportunity to meet similar patients • Addressing religious and cultural issues • Implementation of care plans• Cardiopulmonary assessment • Learning needs

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• Nursing diagnoses• Anxiety related to surgical procedure• Deficient knowledge about the surgical

procedure and postoperative care

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Post operative

• Nursing diagnoses• Risk for impaired skin integrity related to problems

in managing the urin collection appliance• Acute pain related to surgical incision• Disturbed body image related to urinary diversion• Potential sexual dysfunction related to structural

and physiologic alterations• Deficient knowledge about the management of

urinary function.

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Interventions in post op period

• In the post operative period , urine volumes are monitored hourly. Through out the patient’s hospitalization, the nurse monitors closely for complications.

• A urine output below 3oml/h may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureterileal anastomosis. Hematuria may be noted in the first 48 hrs after the surgery.if the ureteral stents are not draining , the nurse may be instructed to carefully irrigate with 5-10 ml sterile normal saline solution.

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• Providing stoma and skin care • Encouraging fluids and relieving

anxiety• Promoting home care

– Teaching patient self care– Changing the appliance – Controlling odor– Managing ostomy appliance– Contining care

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Thank

you