Chronic Renal Failure and Urinary Conditions Part 2

Prepared by Gabrielle Metelli

15/04/2009 UANE&S 2009 1

Objectives

¾ Define and describe the major features of Chronic Renal

Failure (CRF)
¾ Differentiate between Nephritic and Nephrotic syndromes
¾ Discuss the effects of CRF on body systems
¾ Discuss the aetiology, diagnosis, treatment of:
¾ CRF
¾ Glomerulonephritis

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 Definition: Chronic Renal Failure (CRF)

¾ A condition in which there is

“a progressive reduction of functioning renal tissue such that the remaining
kidney mass can no longer maintain the body’s internal environment”
(Black & Hawks, 2005, p. 949).

¾ It can take years to develop OR

¾ It can result from Acute Renal Failure (ARF) from which the person has
not recovered

(Black & Hawks, 2005).

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CHRONIC RENAL Glomerular Filtration Rate

FAILURE (GFR)
¾ Also known as Chronic Kidney ¾ GFR = Total amount of
Disease
filtrate formed/min
¾ Slow and insidious with
irreversible damage ¾ Factors affecting GFR:
¾ Surface area available for
¾ CRF when Glomerular Filtration filtration
Rate (GFR) 25-40 mL/min normal ¾ Permeability of filtration
is 100-125 mL/min). membrane
¾ Net filtration pressure
¾ Early symptoms:
¾ nocturia, ¾ Normal GFR 120-125
¾ nausea and vomiting, mL/min
¾ headaches,
(Marieb, 2005)
¾ breathlessness,
¾ weight loss.
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 CHRONIC RENAL MAJOR CAUSES OF CRF IN
FAILURE(cont’d.) AUSTRALIA
¾ As disease continues there is a
progressive loss of renal 2005
function
¾ Glomerulonephritis (GN) 27%
¾ GFR decreases
¾ Serum Urea Nitrogen & ¾ Diabetic Glomerulonephropathy
Creatinine levels increase 26%
¾ Hypertertension 15%
¾ End Stage Renal Failure ¾ Polycystic Renal Disease 5%
(ESRF): 90% damage to kidneys ¾ Reflux Nephropathy 4%
¾ Analgesic Nephropathy 4%
¾ Supportive measures: (Australian Institute of Health and Welfare, 2005)

¾ dialysis
¾ renal transplantation (when
GFR below 15mL/min).

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Glomerulonephritis (GN)
Bowman’s Capsule

27% of all cases of CKD

¾ An inflammatory reaction in the
glomerular basement membrane
(GBM)
¾ due to an antigen-antibody reaction.
¾ Many different types of GN:
¾ Nephritic or
¾ Nephrotic

http://www.siumed.edu/~dking2/crr/rnguide.htm

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 GN: Nephritic Syndrome
• Also known as nephritis
Signs & Symptoms:
Post-Streptococcal or Post-
Infectious GN ¾ haematuria
¾ headache
• Usually following a sore throat or ¾ facial oedema
dental treatment in children or young ¾ hypertension
adults. ¾ flank pain
¾ oliguria
• Causative organism usually β-
haemolytic Streptococcus
– stimulates the immune system, and
deposits in the glomerulus

Other types
– IgA Nephropathy
– Rapidly Progressive GN
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Nephritic Syndrome

Diagnosis Treatment
¾Most recover completely
¾ Urine microscopy
¾Control fluids & hypertension
¾ Elevated urea & K+
¾Treat electrolyte and acid/base
imbalances
¾ Antistreptolysin-O
¾Treat underlying infection
¾ Renal biopsy
¾Long term follow up

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 Nephrotic Syndrome
Characterised by:
¾ Abnormality of the GBM
¾ Can be seen acutely or (increased permeability to protein),
chronically in all ages. so results in

¾ Heavy proteinuria (> 3

¾ Reasonably common in gm/1.73m2/day)
children ¾ Hypoproteinaemia &
¾ also known as Minimal hypoalbuminaemia
Change GN ¾ Oedema (face, legs, scrotal,
labial)
¾ Hypovolaemia
¾ Decreased urine output

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Nephrotic Syndrome

¾ Low colloidal osmotic pressure of the plasma causes oedema

¾ Ascites & pleural effusion
¾ Weight gain
¾ Reduced ability to fight
infections

http://renux.dmed.ed.ac.uk/edren/EdRe
nINFObits/nephroticpic.100-
0034_IMG.JPG

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 Minimal Change Nephrotic Syndrome

¾ Most common cause of nephrotic

syndrome (85-90%)
in children
¾ 1 – 10 yrs of age (peak 3 yrs old)
¾ Morning facial oedema
¾ Acute febrile illness (occasionally)

http://www.itg.be/itg/DistanceLea
rning/LectureNotesVandenEnden
E/imagehtml/ppages/CD_1003_0
40c.htm

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Nephrotic syndrome (cont’d) Diabetic

Glomerulonephropathy
In Adults
¾ In the elderly ¾ Incidence increases with age and
¾ Nephrotic syndrome develops duration of diabetes
slowly due to sclerosis of the
glomerulus (Bevan, 2000) ¾ More common in poorly controlled
diabetics
¾ Nephrotic syndrome can
also develop due to ¾ Proteinuria (microalbuminuria)
and hypertension are hallmarks of
¾ diabetes mellitus, potential renal failure
¾ systemic lupus erthematosous
(SLE).

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 MAJOR CAUSES OF CRF IN AUSTRALIA (cont’d)

Hypertension Hydronephrosis
¾ Prolonged hypertension causes
nephrosclerosis

Polycystic Renal Disease

¾ Autosomal dominant inherited
disorder
¾ many, and often large cysts develop
within the kidney
¾ reducing the number of functioning
nephrons

Reflux Nephropathy
¾ Damage due to back flow of the
urine

Analgesic Nephropathy
¾ Many drugs are toxic to the
(http://renux.dmed.ed.ac.uk/edren/EdRe
kidneys nINFObits/Obstruction.html)
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Multi-system effects of CRF

¾Clinical manifestations become more apparent due to
¾the progressive deterioration in glomerular filtration rate.

¾Early symptoms of renal insufficiency (50% ↓in function) begin

during stage 3 of CRF
¾hypertension,
¾elevated urea and creatinine levels,
¾Anaemia

¾In later stages

¾oedema,
¾electrolyte imbalances,
¾metabolic acidosis,
¾multi-systemic effects of uraemia develop

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 MANAGEMENT OF CRF/ESRF
¾ Goal
¾ maintain renal function and
homeostasis for as long as
possible in order to prevent
the need for dialysis or a
kidney transplant
¾ Treatment is not a cure
¾ Initial management is
conservative
Fluid restrictions
¾ fluid allowance is 500 mL plus
the previous day’s urine output
¾ e.g. voided 500 mL, then allowed
to drink 1,000 mL next day
Medications
¾ antihypertensives and diuretics
¾ phosphate binders

¾ Dietary restrictions ¾ sodium bicarbonate

¾ protein restrictions
¾ low salt (Na and K) and ¾ +/- Resonium to manage hyperkalaemia
phosphate diets
¾ Synthetic Erythropoietin (EPO)
¾ Dietary supplements
¾ Ca++, Folic acid ¾ +/- Calcitriol (Vit D3)
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Diuretics

¾ Block reabsorption of Na+ & Cl- in

tubules
¾ Results in diuresis

Loop Diuretics
¾ eg. Frusemide (Lasix)
¾ most effective of all diuretics
¾ oral and IV formulations
¾ works within 60 min (oral), 5 mins
(Bolus IV)
¾ adverse effects eg. K+ loss, Na+ loss,
Cl- loss

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 Thiazide Diuretics
¾ Eg ydrochlorothiazide
(Dichlotride)
¾ Similar to loop diuretics except
diuresis is less
¾ Often in combination with
potassium-sparing diuretics (e.g.
Moduretic)
¾ Adverse effects similar to loop
diuretics
¾ Oral administration (rarely IV)
15/04/2009
Osmotic Diuretics
¾ Work by creating an osmotic force
in the tubules which results in
diuresis
¾ Eg Mannitol, used to
¾ avoid renal damage
¾ reduce intracranial pressure (e.g.
severe head injury/surgery)
¾ given IV
¾ S/E: headache, nausea/vomiting,
oedema
15/04/2009
Potassium-Sparing Diuretics
Aldosterone Antagonists
¾ Eg Spironolactone (Aldactone)
¾ Works on distal convoluted tubule
¾ Salt & water loss, potassium sparing
¾ Often in combination with a Thiazide
(e.g. Moduretic)
¾ S/E: Hyperkalaemia (so in CRF must
not be given with K or another K-
sparing diuretic)
Non- Aldosterone Antagonists
¾ Eg Amiloride
UANE&S 2009 17
Drug Cautions in Renal Failure
¾ Digoxin - reduce the dose
¾ Gentamicin, Vancomycin –
reduce frequency. Check trough
serum levels
¾ NSAIDs – (Neurofen) avoid if
possible
¾ Opiates – reduce dose &
frequency
¾ Never give Pethidine – causes
seizures
UANE&S 2009 18
 MANAGEMENT OF CRF/ESRF (cont’d)

As damage becomes worse and renal function deteriorates, dialysis or

kidney transplantation can take place to prevent death.

Main types of dialysis are:

¾ Haemodialysis
¾ Peritoneal dialysis

Dialysis is used to control:

¾ Fluid overload (→ pulmonary oedema)

¾Hyperkalaemia (→ cardiac arrest)
¾ Uraemia (→ coma)
¾ Hypertension
¾ Metabolic acidosis

15/04/2009 UANE&S 2009 19

¾ < 5 yrs – congenital

CRF in Children
problems
¾ 5 – 15 yrs – glomerular
disease
¾ Similar to adults
¾ uraemia
¾ hyperkalaemia
¾ hypertension
¾ anaemia
¾ renal osteodystrophy
¾ Differences
¾ failure to thrive
¾ nutrition
¾ growth hormone
¾ psychosocial issues

15/04/2009 UANE&S 2009 20

 Urinary Conditions (Part 2)

URINARY OBSTRUCTION
Definition

¾ complete or partial obstruction of

any part of the urinary tract

¾ most commonly caused by

urolithiasis, (the development of
stones [calculi] within the urinary
tract).

¾ formed due to the presence of

crystalline substances in the urine
(eg. calcium oxalate, calcium
phosphate, uric acid).

¾ common cause is Idiopathic Example of Renal Calculi

Source: http://www.phys.vitginia.edu/classes/304/stones.jpg

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SIGNS & SYMPTOMS DIAGNOSIS

¾ symptoms vary depending on size ¾ x-ray (kidney, ureter & bladder -

& location of the calculi KUB)
¾ back (loin) pain varies in intensity
¾ Intravenous Pyelogram (IVP)
¾ renal colic occurs due to the calculi
blocking the peristaltic action of
the ureters & causing ureteral ¾ Urinalysis
spasm
¾ may also include dysuria, ¾ Urine calcium/uric acid studies
haematuria, cystitis and
pyelonephritis ¾ Ultrasound, CT Scan, MRI

¾ Cystoscopy

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 SURGICAL MANAGEMENT POST-OPERATIVE
OPTIONS MANAGEMENT
¾ wounds and drains
Primarily removed via less ¾ catheters:
¾ nephrostomy tube
invasive options:
¾ ureteric ('stent')
¾ Cystoscopy & dormia basket
¾ urethral (IDC)
extraction
¾ suprapubic (SPC)
¾ Lithotripsy
¾ fluids & diet - high oral fluid intake
(once recovered from anaesthetic).
Or surgical intervention: ¾ diet restrictions
¾ Ureterolithotomy ¾ to prevent formation of future calculi.
¾ Pyelolithotomy ¾ pain
¾ always check that catheter(s) are not
¾ Nephrolithotomy obstructed which prevent urine
drainage thus causing pain.
¾ analgesia PRN
¾ education esp. about fluids & diet

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NEPHROSTOMY TUBE

¾ tube inserted into the renal pelvis for the purpose of urinary diversion
following:

¾ kidney surgery (eg. pyelolithotomy)

¾ conservative managment due to
¾ obstruction in the ureter (eg. cancer)

¾ frequently this tube is a foley's catheter

¾ the balloon of which is holding it in the renal pelvis and
¾ there is a stitch on the person's flank.

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 NEOPLASTIC DISORDERS
RENAL CARCINOMA

Some interesting Statistics: ¾ Most common type Renal Cell

¾ Renal Ca – ranks 10th for males & 13th carcinoma (85%)

for females in
¾ Usually asymptomatic –
¾ terms of incidence & 15th for males
presentation occurs when tumour
and 13th for females for mortality in
has grown extensively & patient is
NSW
experiencing some degree of
impairment
¾ Median age – males 68yrs; females
69yrs ¾ Or diagnosed while being
Source: Cancer in NSW – Incidence & Mortality 2005
investigated for another disease
entity

15/04/2009 UANE&S 2009 25

Source: http:www.vanderbilturology.com/van/specialities/kidney cancer

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 SOME INTERESTING FACTS
cont’d TREATMENT OPTIONS
¾ Initial symptom commonly
haematuria
¾ Surgical – removal of kidney
¾ Other symptoms include: (partial or complete )
¾ low back pain, Nephrectomy
¾ mass or lump in the abdomen, ¾ Nursing management as per care
¾ fatigue, of a person following
¾ unexplained weight loss, nephrectomy
¾ fever
¾ + or – Radiation
¾ Cause: unknown ¾ Nursing management as per NT 5
principle of radiation nursing
¾ Risk Factors
¾ Immunotherapy
¾ Diagnosis

15/04/2009 UANE&S 2009 27

NEOPLASTIC DISORDERS
BLADDER CARCINOMA

¾ Bladder Ca – ranks 8th for ¾ Incidence and mortality rates

males & 15th for females in
terms of incidence
¾ Mortality ranks for
males & 17th for females in
terms
¾ Median age – males 74yrs;
females 76yrs
Source: Cancer in NSW – Incidence & Mortality 2005
rapidly increase with age
¾ Commonly Transitional Cell
Carcinoma – either flat (30%)
12th or papillary lesions (70%)
¾ Bladder is most common site in
the urinary tract for tumour
development
¾ May be either superficial or
invasive

15/04/2009 UANE&S 2009 28

 Cystoscopy reveals a papillary lesion(arrows) typical TCC
Source: http://www.medscape.com/viewimage/11229
15/04/2009 UANE&S 2009 29

DIAGNOSIS & TREATMENT

Contributing Factors: OPTIONS
¾ presence of carcinogens in urine
¾ Diagnosis
¾ Urinalysis,
¾ chronic infection & inflammation of ¾ Urine Cytology,
the bladder ¾ Cystoscopy
¾ Treatment Options
¾ Risk Factors ¾ Instillation of
Chemotherapy agents
¾ Presentation is by painless ¾ Radiation
haematuria (75%)
¾ Surgery
¾ - Transurethral resection
¾ - Partial cystectomy
¾ - Radical cystectomy

15/04/2009 UANE&S 2009 30

 URINARY DIVERSIONS

¾ Definition:
¾ developed at the time of cystectomy surgery to provide for urine
collection & drainage

¾ Types:
¾ Ileal Conduit (most common)
¾ Continent Urinary Diversion

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ILEAL CONDUIT
¾ A segment of ileum is separated
from the small intestine & formed
into a tubular pouch.

¾ The open end is brought to the

surface to form a stoma.

¾ The ureters are connected to the

pouch.

¾ A bag can then be attached for

collection of the urine.

http://www.ohiohealth.com/healthreference/reference/50A4
B9CD-D592-4458-
BEE9EA61FA97FC3B.htm?category=5446

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 CONTINENT URINARY DIVERSION

¾ A segment of ileum is
separated from the small
intestine & formed into a
pouch.

¾ Nipple valves are formed at

each end of the pouch by
intussuscepting tissue
backward into the reservoir to
prevent leakage

http://www.cancerhelp.org.uk/help/default.as
p?page=3169#cont
15/04/2009 UANE&S 2009 33

Bibliography

Australian Institute of Health and Welfare (2005). Chronic kidney disease in Australia
2005. Canberra: Australian Government Printer.
Bevan, M. (2000). The older person with renal failure. Nursing Standard, 14(33), 48-54.
Black, J. M., & Hawks, J. (2004). Medical-surgical nursing. Clinical management for
positive outcomes (7th ed.). Philadelphia: W.B. Saunders.
Brown, D., & Edwards, H. (Eds.). (2005). Lewis’s medical-surgical nursing. Assessment
and management of clinical problems. Sydney: Elsevier.
Farrell, M. (Ed.). (2005). Smeltzer & Bare’s textbook of medical surgical nursing
(1st Australian & New Zealand ed.). Philadelphia: Lippincott.
Ileal Conduit Illustration (n.d.). Retrieved from
http://www.ohiohealth.com/healthreference/reference/50A4B9CD-D592- 4458-
BEE9EA61FA97FC3B.htm?category=5446
Invasive Kidney Cancer illustration (n.d.) Retrieved from
http://www.vanderbilturology.com/van/specialities/kidneycancer
Lehne, R. A., Moore, L., Crosby, L., & Hamilton, D. (2007). Pharmacology for nursing
care (6th ed.). Philadelphia: Saunders.

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 Bibliography
LeMone, K., & Burke, P. (2008). Medical/surgical nursing: Critical thinking in client
care (4th ed.). Upper Saddle River, New Jersey: Prentice Hall.
Marieb, E. N. (2007). Human anatomy and physiology (7th ed.). San Francisco, CA:
Pearson Benjamin Cummings.
Miller, D., & MacDonald, D. (2006). Management of paediatric patients with chronic
kidney disease. Pediatric Nursing, 32(2), 128-135.
Polaschek, N. (2003). Negotiated care: A model for nursing work in the renal setting.
Journal of Advanced Nursing, 42(4), 355–363.
Polycystic kidney disease. (June 20, 2006). Retrieved July 24, 2006, from
http://www.emedicine.com/med/topic1862.htm
Porth, C. M. (2005). Pathophysiology: Concepts of altered health states (7th ed.).
Philadelphia: Lippincott.
Snyder, S., & Pendergraph, B. (2005). Detection and evaluation of chronic kidney
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Urinary Diversion Illustration (n.d.). Retrieved from
http://www.cancerhelp.org.uk/help/default.asp?page=3169#cont

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