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Y2 PX4 Renal regulation
Terms in this set (72)
Types of GFR regulation
Auto regulation of GFR
Drop in systemic BP causes dilation of afferent arteriole and constriction of efferent arteriole.
Hormonal regulation of GFR
Renin released from the juxtaglomerular apparatus when BP drops stimulating release of aldosterone and a rise in BP.
Autonomic regulation of GFR
Sympathetic innervation constricts afferent arterioles to decrease the GFR. As the crisis passes sympathetic tone decreases & GFR returns to normal levels.
GFR depends on:
Permeability of capillary walls.
Reduced renal reserve
GFR = 40 to 70ml/min.
GFR = 20 to 40ml/min.
GFR = 10 to 20ml/min.
End stage (EDSR)
GFR = < 10ml/min.
Most accurate measure of renal function.
Calculated using age, serum creatinine levels, ethnicity, gender, height and weight (ideally included but not on the form).
Blood test to measure renal function includes
Electrolytes - sodium, potassium, chloride and bicarbonate usually measured.
Waste from the breakdown of proteins.
Waste product from muscles.
A more accurate marker of kidney function than urea.
Common UTI bacteria
Chlamydia and Mycoplasma can cause similar symptoms but do not infect the bladder.
Risk factors for UTI
Spinal cord injuries (usually requires a suprapubic catheter).
Other nerve damage.
Abnormality of the urinary tract that obstructs the flow of urine (eg. enlarged prostate).
Sexual activity and barrier contraceptives.
Catheter Acquired Urinary Tract Infection.
Catheter also provides surface for biofilm to grow.
Culture and susceptibility.
Men, Pregnancy, children.
Recurrent UTI (within two weeks).
Failed antibiotic treatment or persistent symptoms.
Recent urinary tract instrumentation.
More than three UTIs in a 12 month period.
Inflammation of the renal pelvis.
Pyelonephritis signs and symptoms
Systemically unwell with:
High fever (fever > 38oC).
Nausea & vomiting.
Blood cells & pus in urine.
Community treatment if mild (low fever, no N&V) with:
In hospital treat with:
Types of urinary incontinence
Overactive bladder syndrome.
Associated with physical activity or increased intra-abdominal pressure eg. sneezing.
Caused by atrophy or damage to the pelvic floor muscles, ligaments.
Associated with childbirth and menopause.
Occurs due to detrusor muscle over-activity.
Neurogenic causes (eg. CVA, MS).
Secondary to underlying pathology (eg. UTI, STI, surgery).
Overactive bladder syndrome
Frequency of voiding - more than eight x/day.
Urgency & frequency can occur without any resulting incontinence.
Managed the same as urgency incontinence.
Defined as a combination of stress and urgency incontinence.
Occurs in one-third of females with incontinence.
Becomes more common with age.
Occurs when there is obstruction at the bladder neck, prolapse, neurological damage or an impairment of detrusor contractility.
Leakage occurs from an over-filled bladder.
More common in males.
Occurs when cognitive or physical impairments prevent the patient from voiding independently and appropriately.
Leakage occurring after voiding due to urine remaining in the urethra.
A passage opens between the bladder/urethra and the vagina, bypassing the urethral sphincter.
Usually due to complications from gynaecological surgery, e.g. hysterectomy.
Bladder diary (3 days).
Post void bladder volume scan.
? smoking status (toxins are bladder irritants).
Records flow rate, residual urine, capacity and can identify involuntary spasm prior, during or after voiding that leads to leakage.
Pelvic floor muscle exercises.
Botulinum toxin Injections (reduces spasms but needs to be repeated every 6 months).
Incontinence pads and devices.
Benign Prostatic Hyperplasia (Hypertrophy).
Aka. Enlarged prostate.
International Prostate Symptom Score (IPSS)
Questionnaire score 1-5 = severity of symptoms over past month
Over the past month:
How often have you had the sensation of not completely emptying your bladder after urinating?
How often have you had to urinate again less than two hours after finishing urinating?
How often have you found that you stopped and started again when urinating?
How often have you found it difficult to postpone urination?
How often have you had a weak stream of urine?
How often have you had to push or strain to begin urinating during the course of one night?
How often have you had to get up during the night to urinate?
International prostate symptom score.
Urinalysis - leukocytes and nitrites.
Digital rectal examination (physical).
Prostate-specific antigen (PSA) test.
Trans rectal ultrasound (TRUS).
Intravenous urography (IVU).
Indicates enlargement of the prostate.
A significantly raised level may indicate prostate cancer but cannot give a definitive diagnosis.
Limited value as a screening test but can contribute to overall picture.
Measures size prostate.
Can confirm or rule out a diagnosis of prostate cancer.
Measures bladder pressure and function during voiding.
Catheter inserted under local anaesthetic.
Water injected through the catheter into bladder.
Computer measures the pressure & assesses bladder function.
Not used much as expensive, invasive, and same information can be gathered from TRUS test.
Bladder training programme.
BPH lifestyle recomendations
Avoid liquids 2 hours before bed.
Avoid smoking, alcohol, and caffeine.
Finasteride or dutasteride.
Blocks prostate from growing larger but won't necessarily cause it to shrink.
Useful for mild to moderate cases.
Teratogenic, impotence, low sperm count.
Trans-urethral resection of the prostate (TURP) - uses wire loop to remove excess tissue.
Laser enucleation of the prostate.
Catheterised after. Push fluids till no more debris and blood.
Acute kidney injury.
ARF (acute renal failure) old term.
Acute kidney injury (AKI)
An abrupt or rapid decline in renal filtration function.
A medical emergency and can be life threatening.
Pre-renal, intrinsic, and post-renal.
Often associated with acute illness, e.g. respiratory tract infection, UTI, sepsis or GI illness.
Interference with renal perfusion.
Fluid volume shifts e.g. burns.
Medication - NSAIDs, ACE inhibitors, ARBs.
Characterised by direct damage to the nephrons. May be secondary to another illness.
Acute tubular necrosis as a result of pre-renal injury or direct toxicity.
Acute glomerulonephritis, particularly as a result of small vessel vasculitis.
Severe transfusion reactions.
Caused by blockage to the flow of urine resulting in backflow into the kidney causing damage to nephrons.
Bilateral obstruction in the urinary tract.
Renal calculi, strictures, prostatic enlargement, pelvic malignancy.
Phases of AKI
Onset, Oliguric, Diuretic, Recovery.
Restore renal blood flow (fluid replacement).
Treat urinary obstructions.
Chronic kidney disease.
Chronic kidney disease (CKD)
Chronic renal failure.
Caused by long term disease or damage to kidneys.
AKI may develop -called acute-on-chronic renal failure.
eGFR; Creatinine (abnormal rise only after 50% functionality lost), BUN and markers of kidney damage, urinalysis, imaging or biopsy.
End-stage renal disease (ESRD)
Renal functions almost totally absent.
GFR less than 5% of normal.
Dialysis or transplantation required to maintain life.
CKD risk factors
Other renal disease or abnormality.
Family history (not hugely significant).
Long-term use of nephrotoxic medicines, e.g. NSAIDs, ACE inhibitors, diuretics, lithium.
Markers of renal damage
Persistent proteinuria/albuminuria (? smoker?).
Persistent haematuria/WBC in urine.
Red blood cell casts/dysmorphic cells on urine microscopy.
Ultrasound/other radiological abnormalities.
2=eGFR 60-89. Mildly reduced function.
3=eGFR 30-59. Moderately reduced function.
4=eGFR 15-29. Severely reduced function.
5=eGFR <15, ESRD or needing dialysis.
Monitoring CVD risk.
Maintaining BP below target levels (less than 130/80, or 125/75 in people with diabetes).
Dietary reduction of sodium intake to <80 mmol/day (1 tsp).
First-line- ACE inhibitors or ARBs and diuretics.
Stop unsafe medications.
Avoid nephrotoxic medications.
NSAID, ACE inhibitor, and diuretic POTENTIALLY FATAL COMBINATION.
Osteoporosis/osteopaenia (Vit D synthesised in the kidneys).
Anorexia - poor food intake.
Restless legs syndrome.
Usually three sessions lasting four hours each per week.
Can be done at home with significant education.
Strict fluid restriction (approx. 1-1.5L/day).
Low Na, K, and phosphorus diet.
Surgical insertion of catheter usually just below naval (permanently attached).
Dialysate fluid passes through the catheter into the peritoneal cavity.
Risk of peritonitis.
Types of peritoneal dialysis
Continuous ambulatory peritoneal dialysis (CAPD).
Automated peritoneal dialysis (APD).
Continuous ambulatory peritoneal dialysis
Involves exchanging old dialysate fluid that contains waste products and excess fluids with new dialysate fluid.
Drain the old fluid then new dialysate is drained into your peritoneal cavity through catheter.
Takes about 30-40 minutes to complete.
The dialysate is left in the peritoneal cavity for a number of hours.
As blood passes through the peritoneum the dialysate fluid draw out waste products and excess fluid from the blood into the fluid using osmosis.
Most people require four exchanges a day.
Automated peritoneal dialysis (APD)
Similar to CAPD but a machine is used to control the drainage of fluid.
The machine automatically performs a number of exchanges overnight.
Takes 8-10 hours- final exchange-the dialysate is in situ all day.
24-hour hotline in case of technical problems.
Indications for catheterisation
Pre-surgery (to ensure complete bladder emptying).
Relieve chronic and acute urinary retention.
Post-op drainage when intermittent inappropriate (eg. gyne).
To accurately measure urine output in acute pts.
Following epidural or spinal anaesthesia and childbirth complications.
Management for intractable urinary incontinence.
Infection and trauma: UTI, uretheral injury - new and scar tissue, injury to bladder or rectum.
Leakage around the catheter.
Blood or debris in the catheter tubing.
Prevention of CAUTI
Minimise catheter use and remove them when no longer required.
Infection control programmes.
Closed catheter drainage system (with anti-reflux valve or chamber).
Anchoring catheters - butterfly fold tape, leave some give.
Position of bags and tubing below the bladder - prevents backflow.
Emptied every 3-6 hours when 1/2 or 2/3 full.
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