NUR 180 Pathophysiology: URINARY SYSTEM

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NUR 180 Pathophysiology: URINARY SYSTEM Essentials of Pathophysiology: Concepts of Altered Health States, 2nd Edition Carol Mattson Porth 1. Basic Urinary System Info 2. Kidney 3. Nephron 4. Parts of Nephron 5. Urine Formation 6. Urination 7. Functions of the Kidney 8. Normal Characteristics of Urine 9. Blood and Urine Dx Studies 10. Radiological Studies 11. URINARY TRACT INFECTION (UTI) 12. CYSTITIS 13. PYELONEPHRITIS 14. GLOMERULONEPHRITIS 15. GOOD PASTURE SYNDROME 16. NEPHROTIC SYNDROME 17. U…

KIDNEYS

1. ...maintains the volume and composition of body fluid by filtration of blood and selective reabsorption or secretion of filtered solutes
2. Removes waste
3. Filters fluid

NEPHRON

1. Functional units of the kidney

GLOMERULUS

1. Filters fluid
2. Uncontrolled filtration

PROXIMAL CONVOLUTED TUBULE

1. Controlled absorption of glucose, sodium, and other solutes goes on in this region

LOOP OF HENLE

1. This region is responsible for concentration and dilution of urine by utilizing a counter-current multiplying mechanism

2. Water-impermeable but can pump sodium out, which in turn affects the osmolarity of the surrounding tissues and will affect the subsequent movement of water in or out of the water-permeable collecting duct.

DISTAL CONVOLUTED TUBULE

1. Absorbs water back into the body with water-permeable collecting duct

URINE FORMATION

Blood entering the glomerulus is filtered through the capillary cell membranes, a thin basal lamina and the thin membrane of the visceral layer of BOWMAN'S CAPSULE.
Blood pressure drives filtration with some local control given by constriction of the afferent or efferent arterioles.
Water, small molecules (glucose, amino acids, urea), electrolytes (sodium, chloride, potassium) some small proteins are freely filtered at the glomerulus while blood cells and large plasma proteins (larger than ~70,000 MW) are retained in the blood stream. The resultant ultrafiltrate in the nephron is altered by the processes of secretion and reabsorption before exiting the kidney.

URINATION

Urine collects in the renal pelvis and then flows with the assistance of PERISTALSIC CONTRACTION of the ureter to the bladder.
When there is 150-300 ml of urine in the bladder, stretch receptors become active and a SPINAL REFLEX to void the bladder is initiated.
Increased filling causes increased pressure and a further increase in the frequency of the reflex. Higher brain centers can override the urgency to urinate for a time or actually facilitate it
MICTURATION REFLEX is initiated and the internal bladder sphincter relaxes and the detrusor muscle of the bladder contracts to expel the urine via the urethra. The female urethra is about 9.5 cm long and the male urethra is some 20 cm long

FUNCTIONS OF THE KIDNEY

1. Erythropoietin
2. RENIN
3. Activation of Vit. D

Erythropoietin

1. Hormone released in response to hypoxia, anemia
2. Stimulates RBC production

RENIN

1. Released by nephron with decrease in arterial pressure or increase in urine Na+ conc. Acts as catalyst in converting Angiotensin I to II.which stimulates adesterone to be released and also vasoconstrtiction

RENIN>ANGIOTENSIN I>ANGIOTENSIN II>ALDOSTERONE

AMBER OR STRAW

NORMAL COLOR OF URINE

4.6 to 8 (although it is normally acidic)

NORMAL pH

less than 0.1 gm

PROTEIN

less than 0.3 gm

GLUCOSE

600 to 2500 ml may be voided

24 HOURS URINATION PG. 1167

BLOOD AND URINE DX STUDIES

1. Urinalysis
2. Urine Culture
3. Creatinine Clearance
4. Urea Clearance
5. Serum Osmolality
6. Uric Acid Level
7. Serum protein
8. BUN
9. Electrolyte

RADIOLOGICAL STUDIES

1. Intravenous pyelogram (IVP)
2. Isotope renography (radio-isotope scan of the kidneys)
3. Ultrasound of the kidneys or abdomen
4. CT scan of the kidneys or abdomen
5. Abdominal MRI

UTI

an infection that can happen anywhere along the urinary tract -- the kidneys, the ureters, the bladder, or the urethra

UTI

CAUSES:
1. usually caused by a bacteria from the anus entering the urethra and then the bladder. This leads to inflammation and infection in the lower urinary tract.
2. Women, Elderly people, People with diabetes

UTI

RISK FACTORS:
Pregnancy and menopause
Kidney Stones
Sexual intercourse
Prostate inflammation or enlargement
Narrowed urethra
Immobility
Not drinking enough fluids
Bowel incontinence
Catheterization

UTI

SYMPTOMS:
Pressure in the lower pelvis
Pain or burning with urination
Frequent or urgent need to urinate
Need to urinate at night
Cloudy urine
Blood in the urine
Foul or strong urine odor

UTI

DX STUDIES:
urinalysis
urine culture (clean catch)

UTI

PATHOGENESIS:
1. Escherichia coli (about 80% of uncomplicated and 20% of complicated cases) Most common cause of UTI
2. Klebsiella, Proteus
3. Pseudomonas, Staphylococcus saprophyticus
4. Candida (most common fungal)
5. Schistosoma (most common parasitic)

UTI

TREATMENT:
1. Nitrofurantoin
2. Cephalosporins
3. Sulfa drugs (sulfonamides)
4. Amoxicillin
5. Trimethoprim-sulfamethoxazole
6. Doxycycline (should not be used under age 8)
7. Quinolones (should not be used in children)

CYSTITIS

1. Chronic bladder problem
2. Women
3. Inflamed and irritated bladder wall

CYSTITIS

CAUSES:
1. IDIOPATHIC
2. Theories autoimmune, hereditary, infectious or allergic condition.

CYSTITIS

SYMPTOMS:
1. A persistent, urgent need to urinate.
2. Frequent urination that occurs during the day and night
3. Only passing small volumes of urine each time, 16x/day
4. Pain in your lower abdomen (suprapubic) or between the vagina and anus in women or the scrotum and anus in men (perineal).
5. Pain during sexual intercourse
6. Chronic pelvic pain
7. Urine cultures are usually free of bacteria

CYSTITIS

DX STUDIES:
1. URINE CULTURE
2. CYSTOSCOPY

PYELONEPHRITIS

An infection of the kidney and the ducts that carry urine away from the kidney (ureters).

PYELONEPHRITIS

CAUSES:
1. Bacterial infection
2. Viral or fungal infection

PYELONEPHRITIS

CLASSIFICATION:
1. ACUTE UNCOMPLICATED PYELONEPHRITIS
2. CHRONIC PYELONEPHRITIS
3. REFLUX NEPHROPATHY

ACUTE UNCOMPLICATED PYELONEPHRITIS

sudden development of kidney inflammation

CHRONIC PYELONEPHRITIS

a long-standing infection that does not clear

REFLUX NEPHROPATHY

an infection that occurs in the presence of an obstruction

PYELONEPHRITIS

SYMPTOMS:
Flank pain or back pain
Severe abdominal pain (occurs occasionally)
Fever
Chills with shaking
Warm skin
Flushed or reddened skin
Moist skin (diaphoresis)
Vomiting, nausea
Fatigue
General ill feeling
Urination, painful
Increased urinary frequency or urgency
Need to urinate at night (nocturia)
Cloudy or abnormal urine color
Blood in the urine
Foul or strong urine odor
Mental changes or confusion

PYELONEPHRITIS

DX STUDIES:
urinalysis commonly reveals white blood cells (WBCs) or red blood cells (RBCs).
A urine culture (clean catch) or urine culture (catheterized specimen) may reveal bacteria in the urine.
A blood culture may show an infection.
An intravenous pyelogram (IVP) or CT scan of the abdomen may show enlarged kidneys with poor flow of dye through the kidneys. (IVP and CT scan of the abdomen can also indicate underlying disorders.)
Voiding cystourethrogram
Renal ultrasound
Renal scan
Renal biopsy

GLOMERULONEPHRITIS

1. Inflammation of the kidney resulting in hampering the kidneys' ability to remove waste and excess fluids.
2. Can be acute, referring to a sudden attack of inflammation, or chronic, which comes on gradually.
3. Can be part of a systemic disease, such as lupus or diabetes, or it can be a disease by itself — primary _____________

GLOMERULONEPHRITIS

CAUSES:
1. Infections or Immune diseases causing antigen antibody complexes to damage the kidney is thought to be the most common cause
Inflammation of the blood vessels (vasculitis)
Conditions that scar the glomeruli.
2. IDIOPATHIC

GLOMERULONEPHRITIS

SYMPTOMS:
1. Tea-colored urine from red blood cells in urine (hematuria)
2. Foam in the toilet water from protein in urine (proteinuria)
3. High blood pressure (hypertension)
4. Fluid retention (edema) with swelling evident in face, hands, feet and abdomen
5. Fatigue from anemia or kidney failure
6. Less frequent urination than usual

GLOMERULONEPHRITIS

DX STUDIES:
Urinalysis
CBC and CMP
Complement levels
CT scan kidneys
Renal bx

GOODPASTURE SYNDROME

An autoimmune disease characterized by glomerulonephritis (inflammation of the capillary loops in the glomeruli of the kidney), pulmonary hemorrhage (bleeding in the lungs), and autoantibodies to the glomerular and alveolar basement membranes (anti-GBM) antibodies.

GOODPASTURE SYNDROME

CAUSE:
1. IDIOPATHIC
2. FATAL IF LEFT UNTREATED

GOODPASTURE SYNDROME

SYMPTOMS:
Hemoptysis
Crackles and rhonchi
Pulmonary hemorrhage
Renal involvement
Hematuria
Acute renal failure
Weakness
Pallor

GOODPASTURE SYNDROME

DX STUDIES:
chest x rays
urinalysis
renal (kidney) biopsy
lung biopsy
Serology for circulating anti-GBM antibodies

GOODPASTURE SYNDROME

TREATMENT:
Steroids
Immunosuppressive drugs: Cytoxan, Imuran
Plasmapheresis

NEPHROTIC SYNDROME

1. Another form of glomerular dysfunction.
2. Primarily massive proteinuria, specifically defined as 3.5 grams or more in 24 hours. In some cases, patients may excrete as much as 10 grams in 24 hours

NEPHROTIC SYNDROME

1. Clinical condition of edema and proteinuria in which the renal histology (light microscopy) demonstrates fatty degeneration of the tubules associated with normal appearing glomeruli..
2. Characterized by massive loss of urinary protein (primarily albuminuria) leading to hypoproteinemia (hypoalbuminemia) and its result, edema

NEPHROTIC SYNDROME

CAUSE:
1. IDIOPATHIC
2. PNS is believed to have an immune pathogenesis, but the precise nature of the process has yet to be defined.

NEPHROTIC SYNDROME

SYMPTOMS:
Proteinuria
Hypoalbuminemia
Edema
Hyperlipidemia
Lipiduria
Decreased vitamin D

NEPHROTIC SYNDROME

DX:
Urinalysis may show protein, renal tubular cells, blood, white blood cells, and casts.
Protein in the urine test may be positive.
Urine for albumin
Lipid profile
Elevated BUN and creatinine
The creatinine clearance may be decreased.
Potassium may be elevated.
Kidney biopsy reveals glomerulosclerosis which may indicate the cause.

NEPHROTIC SYNDROME

TREATMENTS:
Steroids
Diuretics to relieve edema
Low Na+ and protein diet
Treatment for hyperlipidemia
Immunosupressive agents: Cytoxan

RENAL CALCULI

1. Prevalence of urolithiasis is approximately 2 to 3 percent in the general population, and the estimated lifetime risk of developing a kidney stone is about 12 percent for white males.
2. COMMON IN MALES
3. ADULT>ELDERLY>CHILDREN
4. WHITES>ASIANS>BLACKS
5. Occurs more frequently in hot, arid areas than in temperate regions.

RENAL CALCULI

CAUSES:
1. Decreased fluid intake and consequent urine concentration are among the most important factors influencing stone formation.
2. Certain medications, such as triamterene (Dyrenium), indinavir (Crixivan) and acetazolamide (Diamox), are also associated with urolithiasis.
3. Dietary oxalate is another possible cause, but the role of dietary calcium is less clear, and calcium restriction is no longer universally recommended

RENAL CALCULI

SYMPTOMS:
Classic presentation of renal colic is excruciating unilateral flank or lower abdominal pain of sudden onset that is not related to any precipitating event and is not relieved by postural changes or nonnarcotic medications

RENAL CALCULI

DX STUDIES:
Intravenous pyelogram (IVP)
Isotope renography (radio-isotope scan of the kidneys)
Ultrasound of the kidneys or abdomen
CT scan of the kidneys or abdomen
Abdominal MRI

RENAL CALCULI

COMPLICATIONS:
Renal failure Ureteral stricture Infection, sepsis Urine extravasation Perinephric abscess Pyelonephritis

BLADDER CANCER

1. Cancer of the sac that collects and holds urine until it exits your body.
2. MOSTLY ADULTS

BLADDER CANCER

CAUSES:
Smoking.
Exposure to certain toxic chemicals and drugs also makes it more likely to develop the disease
Treatment with the anti-cancer drugs cyclophosphamide (Cytoxan) and ifosfamide
Infection with parasites. In Egypt, a chronic parasitic infection (schistosomiasis) can lead to squamous cell carcinoma
Use of the herb Aristolochia fangchi. This Chinese herb, which is included in some weight loss supplements
Use of chlorine in water and artificial sweetners such as Saccharin and Cyclamate

BLADDER CANCER

SYMPTOMS:
Hematuria
Pelvic pain
Pain during urination
Frequent urination or feeling you need to urinate without being able to do so
Slowing of your urinary stream

BLADDER CANCER

DX STUDIES:
Urine for cytology
IVP
Cystoscopy
MRI
CT Scan
Bone Scan

NEUROGENIC BLADDER

Dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of micturition

NEUROGENIC BLADDER

CAUSES:
Spinal cord diseases,
Neural tube defects including spina bifida.
Brain tumors
Common complication of major surgery in the pelvis, such as for removal of tumors.

NEUROGENIC BLADDER

SYMPTOMS:
Urinary retention
urinary frequency and urgency,
painful urination (dysuria)
urinary tract infection (UTI) caused by urine being held too long in the bladder.
(Pyelonephritis)
Stones may also form in the urinary tract of individuals with a neurogenic bladder

ACUTE RENAL FAILURE

Sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes.

PRE-RENAL AZOTEMIA

ARF
a problem in a part of the body before the kidneys that is causing a ↓ in renal blood flow

Intra-renal azotemia (intrinsic)

ARF
A PROBLEM WITHIN A KIDNEY

Post-renal azotemia

ARF
OBSTRUCTION AFTER THE KIDNEY

Azotemia

ARF
elevation of the nitrogenous waste products (creatinine and urea nitrogen)

UREMIA

ARF
clinical syndrome resulting from azotemia and is characterized by anorexia, N/V, and mental status changes

PRE-RENAL

CAUSES: ARF
Hypotension from any cause
-CHF or severe pulmonary dz
-Volume depletion: vomiting, diarrhea, burns, dehydration, hemorrhage
-Hypercalcemia (which may result in afferent arteriolar vasconstriction)
-Medications: cyclosporine, ACE-I, NSAIDs, osmotic diuretics

INTRA-RENAL

CAUSES: ARF
Ischemia: thromboembolism, hypoperfusion from systemic hypotension, vasoconstriction
Toxins
endogenous: myoglobin, Hgb, uric acid, Ca-Phos compounds
exogenous: AG, PCN, cepholasporins, acyclovir, ampho B, cisplatin, methotrexate, ciprofloxacin, IV dyes
-Inflammation: acute glomerular nephritis (GN), acute tubular nephritis (ATN), pyelonephritis, infection
-Tumor: tumor infiltration, myeloma kidney

POST RENAL

CAUSES: ARF
-prostatic hypertrophy
-malignancy - cervical cancer
-urethral stricture
-ureter obstruction: stone or crystals (uric acid, Ca oxalate), papillae, fibrosis, tumor
*may require renal imaging to determine obstruction

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