1. Alterations of Renal and Urinary Tract Function Concept Maps Gary L. Schofield, RN

2. Potential Causes & Process of Renal Failure Renal Failure Obstruction UTI Renal Cancer Pylenephritis Glomerulonephritis AcuteChronicEnd Stage Renal Disease -Reverses - Abrupt ↓ renal functions Impaired Renal Blood Flow Pre renal (Renal Ischemia) Shock ↓ CO Anaphylaxis Intra renal Acute tubular necrosis Acute glomerulonephritis Renal Vascular Obstruction Cortical Necrosis Allograft Rejection Post renal Kidney Stones Neoplastic Disease Progressive/ Irreversible GFR gradually ↓ Nephrons destroyed Remaining Nephrons ↑ Workload -Hypertrophy - ↓ability to concentrate urine Complete Renal Failure Transplant Dialysis

3. Obstruction Hydroureter Hydronephrosis ↑ Bladder = infection ↓Bladder = Acute or Chronic Renal Failure Kidney StonesNeurogenic Bladder Interruption of nerve supply Most common in pelvis of kidney Calcium or Phosphate 75- 80 % of the time Gender Race Geographic Location Seasonal Factors Fluid Intake Diet Occupation Upper Motor Neuron Lesion Lower Motor Neuron Lesion Loss of Voluntary control of voiding Loss of voluntary and involuntary control of voiding Lower Urinary Tract Obstructions Bladder Neck Dyssynergia Prostate Enlargement Urethral StrictureSevere Pelvic Organ Prolapse Tumors RenalBladder Wilms Tumor Embryonal Tumor Nephroblastoma Sporadic and inherited origins Associated with other anomalies

4. UTI Tumors Caused By Bacteria, Fungal and Parasite Cystitis Virulence of UropathogensHost Defense Mechanisms Pyleonephritis Most Common Site for UTI Chronic Acute Periurethral Mucus Secreting Gland Sphincter Mechanisms Bacterial Attaches to Uroepithelium Bacteria Form Biofilm Causes: E. Coli, Klebsiella, Pseudomonas, Staph Infection initiates inflammatory response Renal AdenomaRenal Cell Carcinoma Bladder Tumors Body Immune System (Bladder Wall) Common Causes: Kidney Stones Vesicoureteral Reflux Pregnancy Neurogenic Bladder Instrumentation Female Sexual Trauma Benign Tumors Located near cortex of kidney Most common renal neoplasm Proximal tubule epithelial cells Primary Associated with mutation of gene P53 Secondary Association: Tobacco Use, Obesity, Long-term Analgesic use Increase Risk Result of invasion of cancer from bordering organs Smokers (men) Workers exposed to chemicals, rubber, & in textile industry Vesicoureteral Reflux Congenitally abnormal ureter Reflux of urine from bladder to kidney Infection, renal scarring, pyelonephritis

5. Pyelonephritis Acute Chronic Infection of renal pelvis and interstutium Common Causes Kidney Stones Vesicoureteral Reflux Pregnancy Neurogenic Bladder Instrumentation Female Sexual Trauma Inflammatory Process damages tubular cells Usually localized abscesses Healing occurs Deposition of Scar tissue Atrophy of affected tubules Affects primarily the pelvis, calyces, and medulla Rarely causes renal failure Excretion of diluted urine Impairment of function Urine-concentration ability affected Destruction of tubules Areas of atrophy/dilation/ diffuse scaring Inflammation and scarring of kidney Pelvis, calyces – dilated & blunted Recurrent Autoimmune Infections Renal Failure Common Cause: E Coli

6. Glomerular Disorders Glomerulonephritis Nephrotic Syndrome Chronic Glomerulonephritis Crescentic Glomerulonephritis (Rapidly Progressive) IgA Nephropathy Berger Disease Acute Glomerulonephritis ProteinuriaLipiduria Hypocalcemia S/S Hematuria Red Blood Cell Casts Protenuria ↓ GFR Oliguria Edema HTN Abrupt onset 7-10 after infection Group A Strep S/S 10-21days after infections Most individuals Children recover with minimal loss of renal function Most Common Form Unknown cause 24-48 hrs after URI or GI infection Prognosis variable 20-50% progress to Renal Fail Idiopathic Proliferative glomerular diseases Example of Crescent Glomerulo- nephritis Antiglomerular Basement Membrane (Good-pasture Syndrome) Antibody Formation Affects: Pulmonary Capillary Glomerular Basement Membs Poor Prognosis Renal Failure Several Glomerular Diseases Focal or Diffuse Segmental fibrosis and deterioration Poor Prognosis Tubular dilation and atrophy Cause: Immune response Toxin/Drugs Vasc. Disorders Damage: Biochemical Mediators of Inflammation Complement activation Neutrophils/Monocytes Disturbance in Glomerular Basement Memb (metabolic, biochemical, physiochemical) leads to increase permeability to protein HypoalbuminemaHyperlipidemia Treatment: Normal, Low-fat Diet; Salt Restriction Diuretics; Antigoagulants; Removal of toxins; Steroids; Albumin Replacements

7. Structural Abnormality DefinitionFacts Hypospadias Congenital condition in which the urethral meatus is located on the ventral side of the penis Related to disruption in male hormones Accompanied by Chordee or penile torsion Corrective Surgery Epispadias Exstrophy of the bladder- Urethral opening on the dorsal surface of penis. Urethral opening small and situated behind the glans with fissure extending the length of penis Constant dribbling of urine Exstrophy of Bladder Extensive congenital anomaly in which the lower urinary tract is exposed directly to the surface of the body Caused by intrauterine failure of the abdominal wall and the mesoderm of the anterior bladder to fuse Reconstructive surgery girls – teens Boys – 2-3 yrs of age Ureteropelvic Junction Obstruction Blockage of the tapered point where the renal pelvis transitions into the ureter Intrinsic malformation of smooth muscle or urothelial development produces obstruction in 90% of cases. Causes kinking and scarring Bladder Outlet Obstruction A urethral valve is a thin membrane of tissue that occludes the urethral lumen and obstructs urinary outflow in males. Polyps rarely arise form the prostatic urethra – often cause sever obstruction and impair renal embrogenesis leading to UTI, Vesicoureteric reflux, and renal failure. Resection as soon as possible Hypoplastic(Dysplastic Kidneys Ureteric duct grows into the metanephric tissue, triggering the formation of the kidneys in utero. If this growth does not occur the kidney is absent or hypoplastic (small) Renal dysplasia results from abnormal differentiation of renal tissue Associated with a functional or organic obstruction of the collecting system Obstruction may begin prior to birth Renal Agenesis Absence of one or both kidneys Potter syndrome (bilateral renal agenesis) Clearly hereditary Bilateral agenesis is usually fatal Unilateral – males more affected Polycystic Kidneys Autosomal dominant inherited disorder PKD-1 and PKD-2 mutations account for the disease The gene products regulate epithelial growth and differentiation.

8. References Corwin, E. J. (2000). Handbook of Pathophysiology (2nd ed.). Philadelphia, PA: Lippincott. Gray, M., Huether, S., & Forshee, B. (2006). Alterations of renal and urinary tract function. In K. L. McCance & S. Huether (Eds.), Pathophysiology: The Biologic Basis for Disease in Adults & Children (pp.1301- 1336). St Louis, MO: ElSevier Mosby. Huether, S. (2006) Alteration of renal and urinary tract functions in children. In K. L. McCance & S. Huether (Eds.), Pathophysiology: The Biologic Basis for Disease in Adults & Children (pp.1337- 1351). St Louis, MO: ElSevier Mosby.