What is a Renal system?

• Renal function can be impaired by disorder w/in kidney or systemic diseases
• Kidney filter blood & regulate fluid, electrolytes, acid-base balance, RBC volume
• Renal failure (from whatever! cause) --> life threatening condition affecting all other organ system

• It is an interference with the flow of urine at any site along the urinary tract
• May be anatomical or functional obstraction
• Impedes flow proximal to blockage
• Dilates of the urinary system
• Increase risk of infection
• Compromise renal function

It's a ANATOMIC change in the urinary system caused by obstruction.The severity determined by:

1. Location
2. Completeness (severity) of the blockage
3. Involvement of one or both upper urinary tract
4. Duration
5. Cause

What is a "Hyroureter"?

• It's a dilation of ureter; accumulation of urine in the ureter.
• The obstruction of upper urinary tract can cause the dilation

Answer Hydronephrosis ---> enlargement of renal pelvis and calyce.

[image]

• Dilation fo the upper urinary tract is a early response to obstruction and reflects smooth muscle hypertrophy & accumulation above the level of blockage (urinary stasis/retention)
• The increased pressure is transmitted to the glomerulus, which decreases filtration.
• Unless the obstruction is relieved, this dilation leads to enlargement of tubulointerstitial fibrosis (deposition of excessive amount of extracellular matrix ex. collgen, protien) and apoptosis affecting the distal nephron and renal function

Hypertension

• Acute unilateral renal obstruction  cascade which increases BP activates RAA
• Chronic, bilateral renal obstruction causes retention of water, Na, urea

The most common types of kidney stone (Calculi)

Composition of mineral salt:

1. Calcium oxalate or calcium phosphate ***most common type of kidney stone (70-80%)
2. Struvite stone--> magnesium, ammonium, and phosphate (15%)
3. Uric acid (7%)

Renal colic

The pain typically begins in the abdomen and often radiates to the

hypochondrium or the groin. The pain is often colicky (comes in waves) due to ureteric peristalsis, but may be constant. It may come in two varieties: dull and acute; the acute variation is particularly unpleasant and is often described as one of the strongest pain sensations felt by humans (being worse than childbirth, broken bones, gunshot wounds, burns, or surgery).^[1]

Depending on the type and size/s of the kidney stones moving through the urinal tract the pain may be stronger in the renal or bladder area or equally strong in both. In lower obstructions, males may experience pain in the genitals.

How can you evaluate kidney stones?

1. Stone analysis

2. Kidney-ureter-bladder (KUB)

• X-ray film of kidney, ureter, bladder; to evaulate radiopaque stones (comprising more than 90% of all stones)
• Lower abodominal X-ray

3. Intravenous pyelogram

• Dye study!

4. Spiral abdominal computed tomography (CT)

• Determines the location of calculi, the severity of obstruction, and associated obstructive uropathy. CT urography is used to pre- and postoperative evaluation and fluoroscopy guides intraoperative imaging
• Safer than intervenous pyelogram

If you'd like to find the location of the calculi and its severity, which evaluation method would be most appropriate?

a. KUB

b. Intervenous pyelogram

c. Spiral abdominal computed tomography (CT)

• Supersaturation of one or more salts 
• Presence of a salt in a higher concentration than the volume able to dissolve the salt
• Precipitation of a salt from liquid ---> solid state
• Temperature and pH
• Growth into a stone via crystallization or aggregation

Characteristics of Calculi (or known as kidney stone)

• Masses of crystals, protein, or the substances that form w/in and may obstruct urinary tract.

What are the risk factors of Calculi?

a. Female

b. Male

c. Age 20-40

d. Well hydrated

e. (b), (c) are correct

Answer E

Risk factors:

1. Male

2. Age 20-40

3. Inadequate fluid intake (biggest contributor!)

4. Living in desert or tropical region

• Temperature, humidity, fluid, humidity, dietary patterns

Answer Drink lots water!

Remember, Calculi formation is when the concentration of salts is higher that volume level (supersaturation), which unable to dissolve all the salt to maintain equilibrium

**A problem in which person lacks of bladder control due to brain or nerve condition

Several muscles and nerves must work together for your bladder to hold urine until you're ready to empty it. Nerve messages go back and forth between the brain and the muscles that control bladder emptying. If these nerves are damaged by illness or injury, the muscles may not be able to tighten or relax at the right time.

Disorders of the central nervous system commonly cause neurogenic bladder. This can include:

• Alzheimer's disease

• Birth defects of the spinal cord (meningomyelocele)

• Brain or spinal cord tumors

• Multiple sclerosis

• Parkinson disease

• Spinal cord injury

• Stroke recovery

   

Neurogenic bladder

Described as:

• Neurogenic sphincter dyssynergia
• Detrusor sphincter dyssynergia --> Loss of coordinated neuromuscular contraction ( could be overactivity or under activity due to site of lesion)
• The lesion that develop in upper motor neuron  of the brain and spinal cord result in dyssynergia and overactive or hyperreflxive bladder function
• Overactive bladder syndrome ---> is a syndrome of detrusor overactivity; urgency with involuntery detrusor contraction during bladder filling phase that may be spontaneous or provoked
• Obstruction
• Low bladder wall compliance

Which site of lesion in following causes underactive, hypotonic, atonic (flaccid) bladder function, often with loss of bladder sensation?

a. Brain, spinal cord

b. Sacral area of spinal cord or peripheral nerve

• Inflammation of urinary rpithelium following invasion and colonization by some pathogen w/in the urinary tract

1. Escherichia coli
2. Staphylococcus
3. Enterobacter spp.

Which type is not a type of urinary tract infection?

a. Pyelonphritis

b. Cystitis

c. Calculi

Answer C.

Pyelonphritis = kidney inflammation (infection)

Cystitis = Bladder inflammation (infection)

Calculi = Kidney stones

How can acute unilateral renal obstruction cause hypertension?

a. Activates RAA cascade

b. Cause the retention of water, Na, urea

Answer A 

• Acute unilateral renal obstruction = Activates RAA
• Chronic, bilateral renal obstruction = retention of water, Na, urea

• Cystitis is a type of UTI
• Caused by bacteria infection

Which one is not manifestation of Pyelonephritis?

a. Fever

b. Costovertebral tenderness

c. Purulent uria

d. Flank pain

e. Suprapubic pain

Answer E

• Suprapubic pain = Cystitis
• Remember! Pyelonephritis is a infection in the kidney area, so the pain will be found where the kidney located. That's why we need to hit lightly on the back of pt. to see if he has any pains (Flank pain)

• Acute infection of the ureter, renal pelvis, and/or parenchyma
• Contributing factor:
• Cystitis (from bladder up to kidney)
• Urinary tract obstruction with reflux infection
• WOMEN are 5 times more likely to develop pyelonephritis (because of anatomy of the urinary tract; women can also develop this infection during pregnancy)
  
  Read more: http://www.livestrong.com/article/192339-causes-of-an-enlarged-kidney-on-an-ultrasound/#ixzz1nVZFI900

• A persistent or recurrent infection of the kidney leading to scarring to kidney
• Primary cause is UNKNOWN

Answer Acute pyeonephritis

Contributing factor:

1. More likely occurs in WOMEN
2. Urinary tract obstrction with reflux infection
3. Cystitis = the inflammation of bladder

Disorders that directly affect the glomerulus

..... Recall anatomy of Glomerular

Nephrotic V.S. Nephritic sediment

They are type of glomerular disorder!

• Nephrotic sediment = contain massive amounts of protein and lipid ; either microscopic of blood or no blood
• Nephritic sediment = Presence of blood in the urine w/ red cell cast, white cells cast, vary degree of protein, usually not severe

Characteristic of Glomerular Disorder

• Has sudden or insidious (slow) onset of hypertension & edema (excessive salt and water retention), and an elevated blood urea introgen (BUN)
• Decreased glomerular filtration rate (causing renal failure)
• Elevated plasma creatinine, urea, and reduced creatinine clearance
• Glomerular damage cause decreased: (1.) glomerular membrane surface area (2.) glomerular blood flow, and (3.) blood hydrostatic pressure (which is the pressure that the volume of blood within our circulatory system exerts on the walls of the blood vessels that contain it-- BP)
• Increased glomerular capillary permeability and loss of negative ionic charge barrier--> cause plasma protein moves out of capillary to urine
• Resulting Hypoalbuminemia encourages plasma fluid to move in to the interstitial spaces ---> causing EDEMA (remember-- water also follows the oncotic (protein) pressure (movement)

1. The retention of salt and water leads to hypertension and edema
2. Hypoalbuminemia (low albumin protein in the blood) due to the change of hydrostatic and oncotic pressure

What are the causes of Glumerulonephiritis?

• Most COMMON--> Immunologic abnormality (immune injury)
• Drugs or toxics
• Vascular disorder
• Systemic disease
• Viral causese

Which bacteria provoke the immune response and cause glomerulonephritis?

a. Staph.

B. Strep.

c. E.coli

Answer B

Antibodies produce against Strep.

Pathophysiology of Acute Glomerulonepritis

• Formation of immune complexes (antigen-antibody, type III hypersensitivity); circulation w/subsequent deposition in glomerular
• Antibody produces aganist Strep (may be related to inadequately treated strep).
• Activation of complement
• Recruitment /activation of immune cells and mediator (ex. neutrophils, macrophage, which releases oxident that damage the glomerular epthelial cell.

Characteristic of acute poststreptococcal glomerulonephritis

• Involves an immunologic mechanism that activates inflam. with damage to glomerular basement membrane, capillary endothelium
• Associated with "Streptococcal infection"
• Usually occurs 7 to 10 dats after a strep. infection of skin (impetigo) or of the throat (pharyngitis)
• Glomerula injury is immune mediated with streptococcal antigen-antibody complexes either depositing in GBM or forming in situ against planted antigen.
• Activiate complement and all the inflamatory response

What are the symptoms of Acute poststreptococcal glomerulonephritis?

Symptom can be insidious or sudden

• Hematuria
• Red blood cell casts
• Proteinuria
• Decrease GFR
• Oliguria (reduction of protien production)
• Hypertension
• Edema around eyes, or feet and ankles
• Blood urine nitrogen is elevated (BUN)

• Oliguria (reduction of urine production)
• Edema around the eyes, ankles, or feet
• Red blood cell casts
• Hematuria
• Proteinuria
• Decreased GFR

Characteristics of IgA Nephropathy

• Also known as "BURGER" disease
• It's a most common form of acute glomerulonephritis in developed countries
• More common in age 20-30

• IgA-1  (galactose-deficiency) produced by bone marrow and complement molecule
• IgA-1 binds to glomerular mesangial cells, stimulating them to proliferate and release oxident and proteases
• Leads to diffuse mesangioproliferative glomerular injury and glomerulosclerosis

• Manifests w/ Gross or microscopic hematuria for 24-48 hrs after an upper respiratory or gastrointestinal viral infection 
• Proteinuria and hematuria are less common

Answer  IgG

• IgG formation against glomerular basement membrane and turn on the neutrophils and complement that damage the basement membrane
• Most often in MEN age 20-30
• Accompanied by pulmonary hemorrage and renal failure

1. Decreased glomerular perfusion (glomerular blood flow)---> due to inflammation
2. Glomerular scarring---> can be caused by activated complement & oxidents that damage the basement membrane causing scarring
3. Thickening of the glomerular basement membrane (but increased permeability to protien)

• Hematuria
• Smoky, brown-tinged urine
• Proteinuria
• Low serum protein in the blood, but high serum protein in the urine due to the blood vascle permeability
• Oliguria
• It's the reduction of urine produce
• Oliguria urine output <30 ml/hr or  < 400 per day

• Excretion of 3.5 g or more of protein in the urine per day!
• Protein excretion is due to glomerilar injury
• Findings
• Hypoalbuminemia-->low serum protein in the blood but high in urine
• Edema--> due to the change of oncotic pressure. When the vessel became permeability from the injury or inflammation, the oncotic shift from the intravascular to the tissue area and cause EDEMA
• Hyperlipidemia
• Lipiduria

• Glomerulonephritis (the inflammation of glomerular)
• Genetic defects that alter the glomerular membrane
• Systemic disease (diabetes, SLE or systemic lupus empthamatosis)
• Drug/ toxic injury
• Infection (esp. chronic or recurrent)

Acute Renal failure

• Sudden & rapidly progressive w/in hours
• Often  reversible!
• Abrupt reduction in renal function

Which type of renal failure is REVERSIBLE?

a. Acute

B. Chronic

Answer A

Sudden & rapid but reversible!

Chronic Renal failure

• Chronic
• Slowly progressing to end-stage renal failure over months or years

What  causes Azotemia?

• Renal insufficiency,  or renal failure

It's a increased of serum urine level and frequently increased creatinine level 

• Creatinine is a waste produce of the muscle; the high or increased level of it may indicate kidney problem

What is Uremia?

• It's a syndrome of renal failure 
• Includes elevated blood urea & creatinine levels accompanied by fatigue, anorexia, nausea, vomitting, neurologic change
• Uremia represents the numerous consequences related to renal failure, including retention of toxic waste, deficiency states, and electrolyte disorder

Which one in the following in te most common cause of Acute renal failure?

a. Intrarenal ARF

b. Prerenal ARF

c. Postrenal ARF

• Most common cause of ARF
• Caused by impaired renal blood flow (sudden reduction of perfusion to the kidneys)
• GRF declines due to the decrease in filtration presure--> result in Oliguria
• Ischenia-->hypoxia injury--> acute tubular necrosis (ATN)
• ATN = Lacks of oxygen to kidney tissue

It is the functional tissue of kidney that consists of nephrons

[image]

• It's a damage to the renal parenchyma (a normal functional tissue of kidney)
• ATN is the most common cause of Intrarenal ARF
• Postischemia
• Nephrotoxic injury

• Rare!
• usually ocurrs with urinary tract obstruction that affects the kidney bilaterally
• Prostatic hypertrophy (unlarged of prostate)
• Bladder outlet obstruction
• Bilateral ureteral obstruction
• The obstrction causes an increase in intralunimal pressure upstream from site of obstruction with gradual fall in GFR 

Clinical Manifestations of ARF

Think "HHome"

H = Hyperkalemia

H = Hypertension (volume overload)

O = Oliguria (<30ml/day),anuria 

       (< 50 ml/day)

M= Metabolic acidosis

E = Elevated BUN/creatinine (waste 

      produce)

Acute = Reverible

Chronic = Irreversible, affects nearly all organ system

Progression of decreasing renal function in Chronic renal failure

·       Progression of Decreasing Renal Function: (see page 1392 for simple algorithm)

o   Reduced renal reserve (GFR reduced to 50%).

o   Renal insufficiency (GFR declines to 25%).

o   Renal failure: significant loss of function (GFR <20% of normal)

o   End-stage renal failure (near absence of GFR,~ 0%).

*** Many drugs administered need to be excreted by kidneys, need to access a decrease in renal function to avoid toxicity.

Factors Representing Progression of Chronic Kidney Disease (Table 1392)

" Creatinine and urea clearance"

Factors Representing Progression of Chronic Kidney Disease (Table 1392)

"Sodium & water balance"

Factors Representing Progression of Chronic Kidney Disease (Table 1392)

Factors Representing Progression of Chronic Kidney Disease (Table 1392)

Factors Representing Progression of Chronic Kidney Disease (Table 1392)

Tubular secretion of Potassium balance Increase until oliguria develops -> oliguria -> unable to excrete potassium -> Increase potassium