Post on 16-Apr-2017
transcript
CHAPTER 27
INTRARENAL DISORDERS
COMMON MANIFESTATIONS OF KIDNEY DISEASE
Pain• Renal pain generally felt at costovertebral
angle• Pain transmitted to the spinal cord between
T10 and L1 by sympathetic afferent neurons; may be felt throughout dermatomes of T10-L1• Due to distention and inflammation of the
renal capsule, has a dull, constant character
COMMON MANIFESTATIONS OF KIDNEY DISEASE (CONT.)
Abnormal Urinalysis Findings• Provides a foundation for the differential
diagnosis of renal dysfunction• Dipstick and microscopic urinalysis results
provide clues to intrarenal pathologies
COMMON MANIFESTATIONS OF KIDNEY DISEASE (CONT.)
COMMON MANIFESTATIONS OF KIDNEY DISEASE (CONT.)
Other Diagnostic Tests• KUB identifies gross abnormalities related to
size, position, and shape (may show renal calculi)• Renogram/renal scan shows renal vasculature• Ultrasonography differentiates tissue
characteristics• CT/MRI used to provide detailed information
about the vasculature and tissue
CONGENITAL ABNORMALITIESRenal Agenesis and Hypoplasia• Relatively rare; associated with other
congenital abnormalities• Bilateral renal agenesis not compatible with
life• Unilateral renal agenesis results in
compensatory hypertrophy of functional kidney• A single normal kidney is sufficient to
maintain normal renal function
CONGENITAL ABNORMALITIES (CONT.)
Cystic Kidney Diseases• Genetically transmitted renal disorder
resulting in cysts that can expand and disrupt urine formation and flow; may be localized to one area or affect both kidneys• Autosomal recessive forms are evident at
birth• Autosomal dominant types cause symptoms
later in life• Renal failure necessitates dialysis or
transplantation
NEOPLASMSBenign Renal Neoplasms• Symptoms depend on the size; may be
asymptomatic until large enough to form palpable abdominal mass, hematuria, and flank pain• Usually diagnosed with renal ultrasound
and/or CT scan• Nephrectomy remains treatment of choice
NEOPLASMS (CONT.)Renal Cell Carcinoma• May have familial pattern• Risk factors include smoking and obesity• Usually asymptomatic until advanced;
presenting S/S include CVA tenderness, hematuria, palpable mass• Nephrectomy is typical treatment;
metastases may be particularly resistant to radiation, immunotherapy and chemotherapy
NEOPLASMS (CONT.)
NEOPLASMS (CONT.)Nephroblastoma (Wilms Tumor)• Most common kidney cancer in children• Identified by palpable abdominal mass;
may also have pain, hypertension, and/or hematuria• Nephrectomy, radiation therapy, and
chemotherapy are used for treatment; excellent cure rate
INFECTIONAcute Pyelonephritis• Infection of renal pelvis and parenchyma
usually due to an ascending urinary tract infection• CVA tenderness a classic sign• Accompanied by fever, chills, N/V, anorexia• Presence of WBC casts is indicative of upper
UTI• Should be promptly managed with
antimicrobials to avoid decreased renal function
INFECTION (CONT.)
INFECTION (CONT.)Chronic Pyelonephritis• Can result in chronic kidney disease• Usually associated with vesicoureteral
reflux or obstructive process leading to persistent urine stasis• Ongoing inflammation causes fibrosis and
scarring and loss of functional nephrons• Diagnosed by renal imaging• Treatment includes correction of underlying
processes and extended antimicrobial therapy
OBSTRUCTIONRenal Calculi (Nephrolithiasis)• Obstructive processes result in urine stasis,
predisposing to infection and structural damage• Common causes include stones, tumors,
prostatic hypertrophy, and strictures of the ureters or urethra• Renal stones are most common
OBSTRUCTION (CONT.)
OBSTRUCTION (CONT.)Renal Calculi (Nephrolithiasis)• Complete obstruction leads to
hydronephrosis, decreased GFR, and ischemic damage due to increased intraluminal pressure• Prolonged postrenal ARF may result in ATN
and CKD• Stones tend to form in urinary tract due to
solute supersaturation, low urine volume, and abnormal urine pH
OBSTRUCTION (CONT.)Renal Calculi (Nephrolithiasis)• Most stones composed of calcium crystals;
others include uric acid, struvite, cystine, and stones associated with certain medications• Stationary stones usually asymptomatic;
stone migration causes intense renal colic pain abrupt in onset and may radiate; N/V, diaphoresis is common
OBSTRUCTION (CONT.)Renal Calculi (Nephrolithiasis)• Most stones pass spontaneously• Other interventions may be necessary
including lithotripsy or endoscopic approaches• Stones tend to recur; prevention enhanced
by high fluid intake to dilute the urine and dietary changes based on the type of stone
GLOMERULAR DISORDERS• Glomerulopathies alter glomerular capillary
structure and function• Damage mediated by immune processes• May result in some combination of
hematuria, proteinuria, abnormal casts, decreased GFR, edema, and hypertension
GLOMERULAR DISORDERS (CONT.)
Glomerulonephritis• Immune response to variety of potential
triggers; may have primary or secondary etiology• Attraction of immune cells to the area of
inflammation results in lysosomal degradation of the basement membrane• GFR may fall due to contraction of
mesangial cells resulting in decreased surface area for filtration
GLOMERULAR DISORDERS (CONT.)
Glomerulonephritis• Treatment may include steroids,
plasmapheresis, and supportive measures such as dietary and fluid management• Management of systemic and renal
hypertension• ESRD is a common outcome of chronic
glomerulonephritis; dialysis or kidney transplantation may be necessary
GLOMERULAR DISORDERS (CONT.)
GLOMERULAR DISORDERS (CONT.)
Nephrotic Syndrome• Occurs due to increased glomerular
permeability to proteins• Urinary loss of 3 to 3.5 g of protein per day• Proteinuria leads to hypoalbuminemia and
generalized edema; decreased blood colloid osmotic pressure; increase in liver activity can cause hyperlipidemia and hypercoagulability
GLOMERULAR DISORDERS (CONT.)
GLOMERULAR DISORDERS (CONT.)
Nephrotic Syndrome• Treatment is conservative; consists of
symptom management• Management of underlying process when
identified• Many cases resolve spontaneously but can
progress to ESRD