finalll

• • Kidneys receive 20-25% of total cardiac output
• • Urine is formed in the NEPHRONS (functional unit of the kidney, >1 million per kidney)
  • Urine passes through the collecting ducts that form renal pelvis
  • Urine then travels to ureter which connects kidney and bladder
  • Then exits bladder through urethra for voiding
  • Adults: 1-2 Liters of urine a day (30-50mL/hr)
• • Glomerular Filtration Rate (GFR): preferred method of monitoring kidney function
  • Volume of fluid filtered from glomerular capillaries to Bowman’s capsule per unit of time
  • Expressed as mL/minute
  • Normal GFR: 125mL/minute by 1.73m^2 (body surface area)
  • Typically lose 1mL a year after 40
  • As long as it’s >60mL, kidneys are functioning WELL
• • Bladder holds 500mL of urine
  • Desire to pee occurs when bladder has 150-200mL
  • 8x a day
  • Bladder capacity at birth: 20-50mLs
  • To measure bladder capacity
  • AGE + 2 = capacity in OUNCES
  • Residual urine
  • 0-50mLs in middle aged patients
  • 50-100mLs in >60 years old
• • VP (intravenous pyelogram)
  • X-ray exam of the urinary tract (KUB)
  • Contrast injected and outlines those structures
  • Avoid with significant kidney damage
  • Contraindicated with shellfish allergy, stop Metformin before and two days after
  • Check BUN and Creatinine prior to IVP
• • KUB (kidney, ureter, bladder x-ray)
  • No dye used
• • Ultrasonography
  • To detect abnormalities
  • Requires full bladder
• • Cystoscopy 
  • Empty bladder prior to procedure
• • Cystography
  • To evaluate Vesicoureteral Reflux (backflow of urine from bladder to ureters)
• • Kidney Biopsy
  • Nursing Responsibilities
  • Contraindicated in patients with ONE kidney
  • Patients NPO 6-8 hours prior
  • Informed consent
  • Urine specimens before and after procedure
  • Complications
  • Bleeding, pain and pressure
  • NSAIDS stopped 24 hours before, anti-platelets stopped 7 days before biopsy, Warfarin stopped 7 days prior (converted to Heparin), Heparin stopped 24 hours before (prophylactic and LMW), anticoagulants restarted 1 week post-op IDEALLY
• • Absolute Contraindications for Kidney Biopsy
  • Bleeding disorders
  • One kidney
  • Uncontrolled HTN
• • Relative Contraindications of Kidney Biopsy
  • Suspected kidney infection
  • Possible vascular lesion
• • Post-Biopsy Nursing Responsibilities
  • Patient lines supine 12-24 hours, may be allowed to turn to unaffected side
  • Provide pressure to biopsy site for 30 minutes
  • Force fluids ~3000mL a day
• • Kidney Biopsy Patient Teaching
  • Patients may notice blood in urine for 24-48 hours post-op
  • Call HCP for:
  • Inability to urinate
  • Blood in urine past 48 hours
  • Fever, chills
  • Increasing pain at biopsy site
  • Faintness or dizziness
  • No heavy lifting for 2 weeks
• • Oliguria (<400-500mL/day or <0.5mL/kg/hr x 6 hours)
  • Anuria (<50mL/day)
  • Residual (<50mL in middle aged adult, <50-100mL in older adult)
• • Stage 5 is *End Stage Renal Disease*
  • Only options are dialysis and eventual transplant
  • Caused by: Uncontrolled DM and/or HTN
• • Most accurate indicator of fluid change in an acutely ill patient: WEIGHT
  • Common s/s
  • Weight gain (1kg = 1L fluid, 1.5-2lbs/day)
  • Edema
  • Electrolyte imbalances
• Nephrosclerosis

  • Hardening of renal arteries due to prolonged, uncontrolled DM, HTN, diabetic nephropathy, aging
  • Major cause of CKD which can lead to Stage 5, End Stage Kidney Disease
• • Signs and Symptoms of Nephrosclerosis
  • HTN
  • Headache
  • Fatigue
  • Nausea and/or vomiting
  • Due to waste products not being EXCRETED
  • Proteinuria
  • Protein is supposed to be in the blood, not the urine
  • Must rule out infection first - GET A CULTURE
  • Protein makes the urine FROTHY
  • Hypoalbuminemia (means less albumin *PROTEIN* in blood)
  • Hematuria
  • Edema/swelling
  • Less protein in the blood means more in the fluid (EDEMA)
  • Decrease in GFR = Increase in creatinine
• Renal Protective drugs: ACE Inhibitors (-prils)
• • Acute Nephritic Syndrome
  • An inflammation/swelling or scarring of the glomerular capillaries or nephron often involving a type of Acute Glomerulonephritis (AGN)
• • Chronic Glomerulonephritis (CGN)
  • Damage to glomerulus due to repeated episodes of AGN or underlying disease
• • Nephrotic Syndrome
  • Systemic or intrinsic kidney disease damages glomerulus and causes massive PROTEINURIA and EDEMA
• Acute Nephritic Syndrome/Acute Glomerulonephritis

  • Diseases commonly associated:
  • Post-streptococcal GN (80-90% of cases)
  • Infective endocarditis
• • Signs and Symptoms of Acute Nephritic Syndrome / AGN
  • History of pharyngitis (2-3 weeks earlier)
  • Hematuria
  • Dark, cola colored urine
  • Oliguria
  • Urine output is <400mL a day
  • Proteinuria
  • Azotemia
  • Increased BUN and Creatinine
  • Serum protein is decreased due to proteinuria
  • Edema
  • Starts in the eyelids and face (periorbital), then generalized
• • Generalized Symptoms of Acute Nephritic Syndrome
  • Hypertension
  • Mild to moderate
  • CVA tenderness
  • Headache/confusion
  • Lethargy/malaise
  • Pallor due to edema and/or anemia
  • Increased specific gravity (protein and blood in the urine make it heavy)
  • Decreased GFR
  • Anorexia
  • Nausea and vomiting (build up of waste products in system)
• • Complications of AGN
  • Hypertensive encephalopathy
  • HF
  • Acute pulmonary edema
  • Acute renal necrosis
• Glomerulonephritis Diagnostic Tests

  • ASO Titer 
  • ESR 
• • Dietary modifications for Acute Nephritic/ AGN
  • High calorie and high carb
  • Possible restricted protein (kidneys breakdown proteins, want to rest kidneys)
  • Fluids according to weight and losses
• • Signs and Symptoms of Chronic Glomerularnephritis
  • May be asymptomatic for years as damage increases
  • Edema
  • HTN
  • Nocturia
  • Headache and dizziness
  • Fixed specific gravity
  • 1.010
  • Proteinuria
  • With urinary casts
  • Electrolyte imbalances
  • GFR <50
• • As Chronic Glomerularnephritis progresses, resembles CRF
  • Hyperkalemia 
  • Cannot excrete K
  • Metabolic acidosis
  • Decreased acid secretion by the kidney
  • Anemia
  • Decrease in erythropoiesis
  • Hypoalbuminemia
  • Edema secondary to protein loss
  • Increase in serum phosphorus
  • Decrease in serum calcium
  • Mental status changes

  Electrolyte imbalances leading to impaired nerve conduction
• Nephrotic Syndrome

  • Causes:
  • Chronic Glomerulonephritis
  • Diabetes Mellitus
  • Lupus Erythematosus
• • Signs and Symptoms of Nephrotic Syndrome
  • Weight gain (can be insidious)
  • Edema (facial and periorbital)
  • Ascites
  • Respiratory difficulties
  • Irritability and fatigue
  • Low BP r/t hypovolemia
  • Dark, frothy, decreased urine (r/t hypovolemia)
• • Changes in kidney from Nephrotic Syndrome lead to:
  • Hypoalbuminemia
  • Edema
  • Proteinuria
  • Hypercholesterolemia
• Diet for Nephrotic Syndrome

  • Sodium restrictions with large amounts of EDEMA
  • Low to moderate protein with AZOTEMIA
• Polycystic Kidney Disease

  • Hereditary
  • Slowly progressive, symptoms develop in 30-40s
• • Signs and Symptoms of Polycystic Kidney Disease
  • Flank pain
  • Increased abdominal girth
  • Hematuria
  • Microscopic or gross
  • Proteinuria
  • Polyuria 
  • Initially, because kidneys are trying to rid of waste products
  • Nocturia
  • Symptoms of CRF by age 50-60
• • Medical Management for Polycystic Kidney Disease
  • Mainly supportive
  • Prevent further damage from UTI, nephrotoxic meds, obstructions, HTN
  • Fluid intake of 2-2.5L to prevent UTI and calculi
• • AKI/ARF
  • Sudden and reversible loss of kidney function from obstruction, reduced circulation or renal disease
  • Decreased GFR and oliguria
• • CKD/CRF
  • Progressive and irreversible deterioration of renal function
  • Results in AZOTEMIA