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Chapter 33: Disorders of Renal Function

Disorders of the Kidneys

Subject to many of the same types of disorders that affect other body structures

Developmental defects

Infections

Altered immune responses

Neoplasms

Fetal Anomalies

Most common: anomalies in shape and position

Less common are disorders involving

A decrease in renal mass (e.g., agenesis, hypogenesis)

A change in renal structure (e.g., renal cysts)

Organ Development

Dysgenesis

Failure of an organ to develop normally

Agenesis

The complete failure of an organ to develop

Hypoplasia

Failure of an organ to reach normal size

Potter Syndrome

Characteristic facial features of newborns with renal agenesis

The eyes are widely separated and have epicanthic folds.

The ears are low set.

The nose is broad and flat.

The chin is receding.

Limb defects often are present.

Causes of Neonatal Renal Failure with Potter Phenotype

Cystic renal dysplasia

Obstructive uropathy

Autosomal recessive polycystic disease

Unilateral agenesis (uncommon)

Cystic Disease of the Kidney

Definition

Fluid-filled sacs or segments of a dilated nephron

Causes

Tubular obstructions that increase intratubular pressure

Changes in the basement membrane of the renal tubules that predispose to cystic dilatation

Types of Cystic Disease of the Kidney

Simple and acquired renal cysts

Medullary cystic disease

Polycystic kidney disease

Autosomal recessive polycystic kidney disease

Autosomal dominant polycystic kidney disease

Causes of Urinary Tract Obstruction

Developmental defects

Calculi (stones)

Pregnancy

Benign prostatic hyperplasia

Scar tissue resulting from infection and inflammation

Tumors

Neurologic disorders such as spinal cord injury

Damaging Effects of Urinary Obstruction

Stasis of urine

Predisposes to infection and stone formation

Development of backpressure

Interferes with renal blood flow and destroys kidney tissue

Manifestations of Urinary Obstruction

Depend on

The site of obstruction

The cause

The rapidity with which the condition developed

Common Symptoms:

Pain

Signs and symptoms of UTI

Manifestations of renal dysfunction

Kidney Stones

Definition

Crystalline structures that form from components of the urine

Requirements for formation

A nidus to form

A urinary environment that supports continued crystallization of stone components

Factors Influencing the Formation of Kidney Stones

The concentration of stone components in the urine

The ability of stone components to complex and form stones

The presence of substances that inhibit stone formation

Question #1

Which of the following conditions does not lead to stone formation?

Acidic pH

Supersaturated urine

Urine stasis

High Na+ concentration

Answer to Question #1

D. High Na+ concentration

Rationale: High Na+ concentration has nothing to do with stone formation, rather the above facts will lead to kidney stone development.

Types of Kidney Stones

Calcium stones

Oxalate or phosphate

Magnesium ammonium phosphate stones

Uric acid stones

Cystine stones

Kidney Stone Treatment

Preventative

Dietary restriction

Calcium salt supplementation

Thiazide diuretics

Cellulose phosphate

Treatment for pain

Antibiotic for infection

Removing stones

Ureteroscopic removal

Percutaneous removal

Extracorporeal lithotripsy

Diagnosis

Urinalysis

Radiography

Intravenous pyelography

Ultrasonography

Types of Urinary Tract Infections

Asymptomatic bacteriuria

Symptomatic infections

Lower UTIs

Cystitis

Upper UTIs

Pyelonephritis

Causes of UTIs

Most uncomplicated UTIs caused by Escherichia coli

Other uropathic pathogens include

Staphylococcus saprophyticus in uncomplicated UTIs

Both non–E. coli gram-negative rods (Proteus mirabilis, Klebsiella pneumoniae, Enterobacter, Pseudomonas, and Serratia)

Gram-positive cocci (Staphylococcus aureus, group B streptococcus) in complicated UTIs

Most caused by bacteria that enter through the urethra

Causes of UTIs Associated with Stasis of Urine Flow #1

Anatomic obstructions

Urinary tract stones

Prostatic hyperplasia

Pregnancy

Malformations of the ureterovesical junction

Increased pressure resulting in reflux

Causes of UTIs Associated with Stasis of Urine Flow #2

Functional Obstructions

Neurogenic bladder

Infrequent voiding

Detrusor (bladder) muscle instability

Constipation

Protective Mechanisms

Washout phenomenon

Mucin layer

Local immune responses

Normal flora of the periurethral area in women

Prostate secretions in men

Characteristics of Acute Episode of Cystitis

Frequency of urination (as often as every 20 minutes)

Lower abdominal or back discomfort

Burning and pain on urination (dysuria)

Cloudy and foul-smelling urine on occasion

Special Considerations of UTI Patients

Sexually active women

Pregnant women

Age-related effects

Infants

Toddlers

Adolescents

Adults

Elderly

Diagnosis and Treatment of UTIs

Diagnosis based on symptoms and on examination of the urine for the presence of microorganisms

X-ray films, ultrasonography, and CT and renal scans are used to identify contributing factors.

Urine dipstick

Treatment of UTI is based on the pathogen causing the infection.

Question #2

Is the following statement True or False?

Static urine flow will predispose your patient to development of a UTI.

Answer to Question #2

True

Rationale: Static urine flow will predispose your patient to development of a UTI.

Characteristics of Glomerulonephritis

Immune mechanisms

Glomerular antibodies

Circulating antigen–antibody complexes

Characteristics

Hematuria with red cell casts

A diminished glomerular filtration rate (GFR)

Azotemia (presence of nitrogenous wastes in the blood)

Oliguria

Hypertension

Causes of Glomerulonephritis

Diseases that provoke a proliferative inflammatory response of the endothelial, mesangial, or epithelial cells of the glomeruli

The inflammatory process:

Damages the capillary wall

Permits red blood cells to escape into the urine

Produces hemodynamic changes that decrease the GFR

Cellular Changes in Glomerular Disease

Proliferative

Endothelial

Mesangial

Leukocyte

Crescent formation

Basement membrane thickening

Sclerosis

Fibrosis

Diffuse glomerular changes

Focal glomerular changes

Segmental glomerular changes

Mesangial changes

Urinary Changes in Glomerulonephritis

Proteinuria

Hematuria

Pyuria

Oliguria

Edema

Hypertension

Azotemia

Question #3

Glomerulonephritis will result from which of the following?

Basement membrane thickening

Sclerosis

Fibrosis

Hypercellularity

All of the above

Answer to Question #3

E. All of the above

Rationale: Each of these changes can lead to glomerulonephritis.

Types of Glomerular Diseases

Acute proliferative glomerulonephritis

Rapidly progressive glomerulonephritis

Nephrotic syndrome

Membranous glomerulonephritis

Minimal change disease (lipoid nephrosis)

Focal segmental glomerulosclerosis

IgA nephropathy

Chronic glomerulonephritis

Tubulointerstitial Disorders

Damage to the proximal, loop, or distal portion of the nephron

Acute tubular necrosis

Renal tubular acidosis

Pyelonephritis

The effects of drugs and toxins

Proximal and Distal Tubular Acidosis

Renal tubular acidosis

Proximal tubular disorders that affect bicarbonate reabsorption

Distal tubular defects that affect the secretion of fixed metabolic acids

Major Groups of Renal Neoplasms

Embryonic kidney tumors occurring during childhood

Wilms tumor

Onset at 3 to 5 years

In one or both kidneys

WT1 mutation on chromosome 11

Adult kidney cancers

Renal cell carcinoma