Renal Pathologyeducation good and at.ppt

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Alterations of Renal and Urinary Alterations of Renal and Urinary
Tract FunctionTract Function

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Urinary Tract ObstructionUrinary Tract Obstruction

Urinary tract obstruction is interference with the flow Urinary tract obstruction is interference with the flow
of urine at any site along the urinary tract.of urine at any site along the urinary tract.

Could be caused by many factors, including Could be caused by many factors, including
kidney stones, an enlarged prostate gland, or kidney stones, an enlarged prostate gland, or
urethral strictures.urethral strictures.

Obstructive uropathyObstructive uropathy - anatomic changes in the - anatomic changes in the
urinary system caused by obstruction.urinary system caused by obstruction.

Severity is based on location, completeness, and Severity is based on location, completeness, and
duration of blockage, whether one or both sides duration of blockage, whether one or both sides
of the urinary tract is involved, and the cause.of the urinary tract is involved, and the cause.

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Urinary Tract ObstructionUrinary Tract Obstruction

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Blockage affecting flow through structures Blockage affecting flow through structures
aboveabove the bladder. the bladder.

Causes dilation of the ureter (hydroureter); Causes dilation of the ureter (hydroureter);
renal pelvis, calyces, and the proximal renal renal pelvis, calyces, and the proximal renal
parenchyma (hydronephrosis); or all of these parenchyma (hydronephrosis); or all of these
(ureterohydronephrosis).(ureterohydronephrosis).

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UreterohydronephrosisUreterohydronephrosis

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Pathophysiology:Pathophysiology:

Sustained dilation leads to enlargement and Sustained dilation leads to enlargement and
fibrosis of portions of the nephron tubule fibrosis of portions of the nephron tubule
system.system.

The distal tubules are affected first followed by The distal tubules are affected first followed by
the proximal tubules. the proximal tubules.

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Pathophysiology:Pathophysiology:

This decreases the kidney's ability to This decreases the kidney's ability to
concentrate urine, causing an concentrate urine, causing an increaseincrease in in
urine volume. urine volume.

The affected kidney is unable to conserve The affected kidney is unable to conserve
sodium, bicarbonate, and water or to excrete sodium, bicarbonate, and water or to excrete
hydrogen or potassium, leading to metabolic hydrogen or potassium, leading to metabolic
acidosis and dehydration.acidosis and dehydration.

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Pathophysiology Pathophysiology (cont.)(cont.)

The glomeruli are damaged later in the The glomeruli are damaged later in the
process due to increased hydrostatic pressure process due to increased hydrostatic pressure
in the Bowman’s capsule.in the Bowman’s capsule.

This decreases the glomerular filtration rate. This decreases the glomerular filtration rate.

As glomerular damage becomes extreme, As glomerular damage becomes extreme,
urine volume urine volume decreasesdecreases and oligouria occurs. and oligouria occurs.

Irreversible damage occurs after about 4 Irreversible damage occurs after about 4
weeks of obstruction.weeks of obstruction.

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Compensatory hypertrophyCompensatory hypertrophy of the opposite of the opposite
kidney occurs to partially offset loss of kidney occurs to partially offset loss of
function of the obstructed kidney (or if one function of the obstructed kidney (or if one
kidney is removed). kidney is removed).

Postobstructive diuresisPostobstructive diuresis – high urine output – high urine output
that follows relief of the obstruction. This may that follows relief of the obstruction. This may
cause fluid and electrolyte imbalances. cause fluid and electrolyte imbalances.

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction

Kidney stonesKidney stones

NephrolithiasisNephrolithiasis – disease condition that – disease condition that
results in formation of kidney stones, results in formation of kidney stones,
also called calculi, renal stones or also called calculi, renal stones or
urinary stones.urinary stones.
•These are masses of crystals, These are masses of crystals,
protein, or other substances that form protein, or other substances that form
within the urinary tract.within the urinary tract.

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Kidney StonesKidney Stones

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Upper Urinary Tract ObstructionUpper Urinary Tract Obstruction
Kidney stonesKidney stones

Risk factors Risk factors - age, gender, race, - age, gender, race,
geographic location, seasonal factors, diet, geographic location, seasonal factors, diet,
and occupation.and occupation.

Dehydration is often a contributing factor.Dehydration is often a contributing factor.

Kidney stones are classified according to Kidney stones are classified according to
the minerals comprising the stones.the minerals comprising the stones.

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Kidney Stone FormationKidney Stone Formation

Kidney stones form when urine becomes Kidney stones form when urine becomes
supersaturated with the component supersaturated with the component
material. material.

The component precipitates out of solution The component precipitates out of solution
and forms a mass.and forms a mass.

Most are calcium oxalate or calcium Most are calcium oxalate or calcium
phosphate, but may also be struvite, uric phosphate, but may also be struvite, uric
acid or cystine.acid or cystine.

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Kidney Stone FormationKidney Stone Formation

Precipitation is most often due to changes Precipitation is most often due to changes
in urine pH; may also be caused by a in urine pH; may also be caused by a
change in body temperature, or increased change in body temperature, or increased
concentration of components.concentration of components.

Stones may remain in the renal sinus or Stones may remain in the renal sinus or
pass into the ureter, causing obstruction.pass into the ureter, causing obstruction.

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Kidney StonesKidney Stones

Most common cause of obstructive uropathy.Most common cause of obstructive uropathy.

Clinical manifestation Clinical manifestation – most common – most common
symptom is renal colic.symptom is renal colic.

Renal colic - moderate to severe pain often Renal colic - moderate to severe pain often
originating in the flank and radiating to the originating in the flank and radiating to the
groin, which usually indicates obstruction of groin, which usually indicates obstruction of
the renal pelvis or proximal ureter.the renal pelvis or proximal ureter.

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Kidney StonesKidney Stones
TreatmentTreatment – –

Increased fluid intake, decreased dietary Increased fluid intake, decreased dietary
intake of stone-forming substances, stone intake of stone-forming substances, stone
removal.removal.

Extracorporeal shock wave lithotripsy (ESWL)Extracorporeal shock wave lithotripsy (ESWL)

Procedure that uses ultrasonic waves to Procedure that uses ultrasonic waves to
shatter simple stones in the kidney or upper shatter simple stones in the kidney or upper
urinary tract so they can pass out of system. urinary tract so they can pass out of system.

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ACTIVITYACTIVITY
What are the benefits of increased fluid intake What are the benefits of increased fluid intake
for a person with kidney stones?for a person with kidney stones?

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Lower Urinary Tract ObstructionLower Urinary Tract Obstruction
Blockage involving the bladder, prostate or Blockage involving the bladder, prostate or
urethra.urethra.
Clinical manifestations Clinical manifestations – involve alterations in – involve alterations in
urination patterns, including:urination patterns, including:
Frequent daytime voiding or voiding during the Frequent daytime voiding or voiding during the
night (nocturia) night (nocturia)
Poor force or intermittency of urinary streamPoor force or intermittency of urinary stream
Bothersome urinary urgency, sometimes with Bothersome urinary urgency, sometimes with
hesitancyhesitancy
Incomplete bladder emptying or urinary Incomplete bladder emptying or urinary
retention retention

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Lower Urinary Tract ObstructionLower Urinary Tract Obstruction
Neurogenic bladderNeurogenic bladder

Bladder dysfunction caused by neurologic Bladder dysfunction caused by neurologic
disorders.disorders.

Due to a lesion in the central or peripheral Due to a lesion in the central or peripheral
nervous system that interferes with bladder nervous system that interferes with bladder
control.control.

Prevents normal emptying and causes a Prevents normal emptying and causes a
functional obstruction.functional obstruction.

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Lower Urinary Tract ObstructionLower Urinary Tract Obstruction
Physical obstructionPhysical obstruction

The neck of the bladder or the urethra by be The neck of the bladder or the urethra by be
blocked by:blocked by:

Kidney stonesKidney stones

TumorsTumors

Prostate enlargement (most common cause of Prostate enlargement (most common cause of
obstruction in males)obstruction in males)

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TumorsTumors
Renal cell carcinomaRenal cell carcinoma

Most common renal neoplasm, arising from Most common renal neoplasm, arising from
glandular or ductal structures. glandular or ductal structures.

Risk factorsRisk factors – male gender, tobacco use, – male gender, tobacco use,
obesity, and long-term analgesic use.obesity, and long-term analgesic use.

Clinical manifestations Clinical manifestations - hematuria (most - hematuria (most
common), flank pain, palpable flank mass, common), flank pain, palpable flank mass,
weight loss. weight loss.

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Renal Cell Carcinoma Renal Cell Carcinoma

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TumorsTumors
Bladder tumorsBladder tumors

Commonly composed of transitional epithelial cells Commonly composed of transitional epithelial cells

High rate of recurrence. High rate of recurrence.

Risk factorsRisk factors - being a man who smokes; exposure - being a man who smokes; exposure
to metabolites of aniline-based dyes; and women to metabolites of aniline-based dyes; and women
who take large amounts of phenacetin-containing who take large amounts of phenacetin-containing
analgesic drugs.analgesic drugs.

Most common in males older than 60 years.Most common in males older than 60 years.

Clinical manifestationsClinical manifestations - gross painless hematuria - gross painless hematuria
(blood in urine), possible flank pain, pelvic pain, (blood in urine), possible flank pain, pelvic pain,
frequent urination.frequent urination.

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Carcinoma of the BladderCarcinoma of the Bladder

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Causes of Urinary Tract InfectionCauses of Urinary Tract Infection

UTI is inflammation of the urinary epithelium UTI is inflammation of the urinary epithelium
caused by retrograde movement of bacteria caused by retrograde movement of bacteria
into the urethra and bladder.into the urethra and bladder.

More common in women, because of the More common in women, because of the
shorter length of the urethra.shorter length of the urethra.

Most frequently caused by Most frequently caused by Escherichia coliEscherichia coli
bacteria (80%) from fecal matter, although other bacteria (80%) from fecal matter, although other
organisms may also be involved including organisms may also be involved including
Candida albicans, Klebsiella, Proteus, Candida albicans, Klebsiella, Proteus,
Pseudomonas, Pseudomonas, andand Staphylococcus. Staphylococcus.

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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)

Defense mechanisms:Defense mechanisms:

Washing out of bacteria during urination.Washing out of bacteria during urination.

Acidic pH and bactericidal effects of urine.Acidic pH and bactericidal effects of urine.

Mucus secretion by epithelium traps bacteria.Mucus secretion by epithelium traps bacteria.

Closure of ureterovesical junction prevents Closure of ureterovesical junction prevents
reflux of urine into the ureters and kidneys.reflux of urine into the ureters and kidneys.

Recurring urinary tract infections are often the Recurring urinary tract infections are often the
result of bacteria that have developed result of bacteria that have developed
antibiotic resistance.antibiotic resistance.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute cystitisAcute cystitis

Inflammation of the bladder, usually due to Inflammation of the bladder, usually due to
a bacterial infection.a bacterial infection.

Clinical manifestations Clinical manifestations – frequent, urgent, – frequent, urgent,
or painful urination (dysuria), suprapubic or painful urination (dysuria), suprapubic
and low back pain; more serious cases and low back pain; more serious cases
exhibit hematuria, cloudy urine, and flank exhibit hematuria, cloudy urine, and flank
pain. pain.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute pyelonephritisAcute pyelonephritis
Infection of the ureters, renal pelvis, and Infection of the ureters, renal pelvis, and
renal parenchyma.renal parenchyma.
Causes:Causes:
Most commonly due to urinary tract Most commonly due to urinary tract
obstruction.obstruction.
Infection is usually E. coli if underlying Infection is usually E. coli if underlying
cause is obstruction or vesicoureteral reflux.cause is obstruction or vesicoureteral reflux.
Infections of Proteus or Pseudomonas may Infections of Proteus or Pseudomonas may
occur as a result of surgical procedures.occur as a result of surgical procedures.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute pyelonephritisAcute pyelonephritis
Pathophysiology:Pathophysiology:
Microorganisms ascending along the Microorganisms ascending along the
ureters or reach kidney through the ureters or reach kidney through the
bloodstream.bloodstream.
Inflammation is usually focal and irregular, Inflammation is usually focal and irregular,
primarily in the pelvis, calyces, and primarily in the pelvis, calyces, and
medulla. medulla.
White blood cells infiltrate the medulla White blood cells infiltrate the medulla
causing renal inflammation, renal edema, causing renal inflammation, renal edema,
and purulent urine. and purulent urine.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute pyelonephritisAcute pyelonephritis

Pathophysiology Pathophysiology (cont.)(cont.)
In severe infections, localized abscesses In severe infections, localized abscesses
may extend from the medulla into the may extend from the medulla into the
cortex. cortex.
Renal tubules are primarily affected; the Renal tubules are primarily affected; the
glomeruli usually are spared. glomeruli usually are spared.
Necrosis of renal papillae can develop. Necrosis of renal papillae can develop.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute pyelonephritisAcute pyelonephritis

Pathophysiology Pathophysiology (cont.)(cont.)

After the acute phase, healing occurs with After the acute phase, healing occurs with
deposition of scar tissue and atrophy of deposition of scar tissue and atrophy of
affected tubules. The number of bacteria affected tubules. The number of bacteria
decreases until the urine again becomes decreases until the urine again becomes
sterile. sterile.

Acute pyelonephritis rarely causes renal Acute pyelonephritis rarely causes renal
failure.failure.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Acute pyelonephritisAcute pyelonephritis

Clinical manifestations – Clinical manifestations – fever, chills, fever, chills,
frequent or painful urination (dysuria), frequent or painful urination (dysuria),
costovertebral angle tenderness; costovertebral angle tenderness;
suprapubic, low back, and flank pain.suprapubic, low back, and flank pain.

Treatment – Treatment – antibiotic therapyantibiotic therapy..

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Chronic pyelonephritisChronic pyelonephritis

Persistent or recurrent infection of the Persistent or recurrent infection of the
kidney leading to scarring.kidney leading to scarring.

May involve one or both kidneys.May involve one or both kidneys.

Causes:Causes:

Can be due to recurrent bouts of acute Can be due to recurrent bouts of acute
pyelonephritis.pyelonephritis.

More commonly occurs in patients with renal More commonly occurs in patients with renal
infections associated with some type of infections associated with some type of
obstructive pathologic condition, such as renal obstructive pathologic condition, such as renal
stones and vesicoureteral reflux.stones and vesicoureteral reflux.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Chronic pyelonephritisChronic pyelonephritis

Pathophysiology:Pathophysiology:

Chronic urinary tract obstruction starts a Chronic urinary tract obstruction starts a
process of progressive inflammation of the process of progressive inflammation of the
renal pelvis and calyces.renal pelvis and calyces.

Over time destruction of the tubules occurs, Over time destruction of the tubules occurs,
with atrophy or dilation and diffuse scarring.with atrophy or dilation and diffuse scarring.

This eventually impairs urine-concentrating This eventually impairs urine-concentrating
ability, leading to chronic renal failure.ability, leading to chronic renal failure.

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Types of Urinary Tract InfectionTypes of Urinary Tract Infection
Chronic pyelonephritisChronic pyelonephritis

Clinical manifestations - Clinical manifestations - early symptoms early symptoms
may include hypertension, urinary may include hypertension, urinary
frequency, dysuria, and flank pain. frequency, dysuria, and flank pain.
Progression leads to renal failure.Progression leads to renal failure.

Treatment Treatment is related to the underlying is related to the underlying
cause. Obstruction must be relieved. cause. Obstruction must be relieved.
Antibiotics may be given, with prolonged Antibiotics may be given, with prolonged
antibiotic therapy for recurrent infection.antibiotic therapy for recurrent infection.

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Chronic PyelonephritisChronic Pyelonephritis

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Glomerular DisordersGlomerular Disorders

A group of related diseases of the A group of related diseases of the
glomerulus that can be caused by immune glomerulus that can be caused by immune
responses, toxins or drugs, vascular responses, toxins or drugs, vascular
disorders, and other systemic diseases. disorders, and other systemic diseases.

Most glomerular diseases are the result of Most glomerular diseases are the result of
type II (cell lysis) or type III (immune type II (cell lysis) or type III (immune
complex deposition) hypersensitivity complex deposition) hypersensitivity
reactions directed against the glomerular reactions directed against the glomerular
membrane.membrane.

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Glomerular DisordersGlomerular Disorders

Damage to the glomerulus results in changes in Damage to the glomerulus results in changes in
GFR and urinary sediment changes:GFR and urinary sediment changes:

Nephrotic sediment - lots of protein, some lipids, Nephrotic sediment - lots of protein, some lipids,
limited or no blood (no hematuria)limited or no blood (no hematuria)

Nephritic sediment - varying degrees of protein, Nephritic sediment - varying degrees of protein,
hematuria with red and white blood cell castshematuria with red and white blood cell casts

Sediment of chronic glomerular disease - limited Sediment of chronic glomerular disease - limited
protein and hematuria, waxy & granular castsprotein and hematuria, waxy & granular casts

Severe glomerular disease may cause oliguria, Severe glomerular disease may cause oliguria,
hypertension, and renal failure.hypertension, and renal failure.

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Acute GlomerulonephritisAcute Glomerulonephritis

Commonly results from damage to the Commonly results from damage to the
glomerulus as a consequence of immune glomerulus as a consequence of immune
reactions after a group A beta-hemolytic reactions after a group A beta-hemolytic
streptococcal infection (acute streptococcal infection (acute
poststreptococcal glomerulonephritis).poststreptococcal glomerulonephritis).

Often occurs 7 to 10 days after a streptococcal Often occurs 7 to 10 days after a streptococcal
infection of the throat.infection of the throat.

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Acute GlomerulonephritisAcute Glomerulonephritis

Pathophysiology:Pathophysiology:

Streptococcal antigen-antibody complexes deposit Streptococcal antigen-antibody complexes deposit
in the glomerular basement membrane. in the glomerular basement membrane.

This activates complement and the release of This activates complement and the release of
inflammatory mediators that damage endothelial inflammatory mediators that damage endothelial
and epithelial cells lying on the basement and epithelial cells lying on the basement
membrane.membrane.

Thickening of basement membrane results in a Thickening of basement membrane results in a
decreased glomerular filtration rate (GFR).decreased glomerular filtration rate (GFR).

Damaged membrane allows RBCs and protein to Damaged membrane allows RBCs and protein to
leak into the urine.leak into the urine.

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Acute GlomerulonephritisAcute Glomerulonephritis
Clinical manifestationsClinical manifestations - hematuria, RBC casts, - hematuria, RBC casts,
proteinuria, decreased GFR, oliguria, proteinuria, decreased GFR, oliguria,
hypertension, edema; occasional ascites, or hypertension, edema; occasional ascites, or
pleural effusions.pleural effusions.

Edema occurs due to loss of plasma proteins into Edema occurs due to loss of plasma proteins into
the urine, which causes a decrease in plasma the urine, which causes a decrease in plasma
osmotic pressure.osmotic pressure.

Severe glomerulonephritis characteristically Severe glomerulonephritis characteristically
exhibits hematuria and protein loss of 3-5 g/day.exhibits hematuria and protein loss of 3-5 g/day.

Most individuals recover without significant loss Most individuals recover without significant loss
of renal function or recurrence of the disease.of renal function or recurrence of the disease.

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Goodpasture Syndrome Goodpasture Syndrome
A type of rapidly progressive A type of rapidly progressive
glomerulonephritis.glomerulonephritis.
A rare disease associated with antibody A rare disease associated with antibody
formation against both pulmonary capillary and formation against both pulmonary capillary and
glomerular basement membranes, and glomerular basement membranes, and
autoimmune destruction of the basement autoimmune destruction of the basement
membranes. membranes.
Occurs most often in men 20 to 30 years of Occurs most often in men 20 to 30 years of
age.age.

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Goodpasture Syndrome Goodpasture Syndrome
Often accompanied by pulmonary hemorrhage Often accompanied by pulmonary hemorrhage
and renal failure.and renal failure.
Typically, the glomerular injury is accompanied Typically, the glomerular injury is accompanied
by a rapid decline in glomerular function, by a rapid decline in glomerular function,
progressing to renal failure in a few weeks or progressing to renal failure in a few weeks or
months. months.
Poor prognosis if not diagnosed and treated Poor prognosis if not diagnosed and treated
early. early.

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ACTIVITYACTIVITY
a.a.Autoimmune attackAutoimmune attack
b.b.Bacterial infectionBacterial infection
c. Supersaturation of urinec. Supersaturation of urine
1. Kidney stones1. Kidney stones
2. Pyelonephritis2. Pyelonephritis
3. Glomerulonephritis3. Glomerulonephritis

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Nephrotic SyndromeNephrotic Syndrome
Excretion of 3.5 g or more of protein in the Excretion of 3.5 g or more of protein in the
urine per day.urine per day.
The protein loss is caused by glomerular The protein loss is caused by glomerular
injury.injury.
Primary nephrotic syndromePrimary nephrotic syndrome is due to is due to
certain types of glomerulonephritis.certain types of glomerulonephritis.
Secondary nephrotic syndromeSecondary nephrotic syndrome is due to is due to
systemic diseases, including diabetes systemic diseases, including diabetes
mellitus, renal disease, and systemic lupus mellitus, renal disease, and systemic lupus
erythematosus, and indicates a worsening erythematosus, and indicates a worsening
of these conditions.of these conditions.

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Nephrotic SyndromeNephrotic Syndrome

Pathophysiology:Pathophysiology:

As protein is spilled into the urine, the As protein is spilled into the urine, the
intravascular albumin levels become intravascular albumin levels become
abnormally low.abnormally low.

This reduces the intravascular osmotic This reduces the intravascular osmotic
pressure, which reduces amount of fluid pressure, which reduces amount of fluid
pulled out of the interstitial compartment.pulled out of the interstitial compartment.

Fluid shifts from the vessels and into the Fluid shifts from the vessels and into the
interstitial spaces, causing generalized interstitial spaces, causing generalized
edema. edema.

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Nephrotic SyndromeNephrotic Syndrome

Pathophysiology Pathophysiology (cont.)(cont.)

Hyperlipidemia and lipiduria result from the Hyperlipidemia and lipiduria result from the
compensatory increase in synthesis of compensatory increase in synthesis of
plasma proteins by the liver. The liver is plasma proteins by the liver. The liver is
unable to synthesize one type of plasma unable to synthesize one type of plasma
protein at a time, so lipoprotein levels protein at a time, so lipoprotein levels
increase along with albumin. increase along with albumin.

Loss of immunoglobulins may increase risk Loss of immunoglobulins may increase risk
of infection.of infection.

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Nephrotic SyndromeNephrotic Syndrome

Clinical manifestationsClinical manifestations – proteinuria, – proteinuria,
hypoalbuminemia, edema, hyperlipidemia, hypoalbuminemia, edema, hyperlipidemia,
lipiduria, and decreased vitamin D (due to lipiduria, and decreased vitamin D (due to
loss of serum transport proteins).loss of serum transport proteins).

In contrast to acute glomerulonephritis, In contrast to acute glomerulonephritis,
usually there is NOT hematuria (RBCs in usually there is NOT hematuria (RBCs in
urine).urine).

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Glomerulonephritis Glomerulonephritis

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ACTIVITYACTIVITY
Explain why is polyuria a frequent symptom of Explain why is polyuria a frequent symptom of
pyelonephritis, while oliguria is a frequent pyelonephritis, while oliguria is a frequent
symptom of glomerulnephritis.symptom of glomerulnephritis.

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Renal FailureRenal Failure

The kidneys have enough residual The kidneys have enough residual
capacity to adapt and prevent serious capacity to adapt and prevent serious
alterations in body chemistry until kidney alterations in body chemistry until kidney
function reaches 25% of normal. function reaches 25% of normal.

By this time much damage has occurred to By this time much damage has occurred to
renal tissues.renal tissues.

Renal insufficiencyRenal insufficiency - renal function is - renal function is
impaired to 25% of normal kidney function. impaired to 25% of normal kidney function.

Renal failureRenal failure - kidney function is - kidney function is
significantly less than 25% of normal.significantly less than 25% of normal.

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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

Usually accompanied by oliguria with an Usually accompanied by oliguria with an
elevated plasma BUN and plasma creatinine elevated plasma BUN and plasma creatinine
levels. levels.

Classifications:Classifications:

PrerenalPrerenal - caused by impaired renal blood - caused by impaired renal blood
flow.flow.
•Most common cause of ARF.Most common cause of ARF.
•Causes ischemia and necrosis of renal tissue. Causes ischemia and necrosis of renal tissue.
•GFR declines because of the decrease in GFR declines because of the decrease in
filtration pressure.filtration pressure.

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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

Intrarenal Intrarenal - most commonly caused by - most commonly caused by
acute tubular necrosis (ATN). acute tubular necrosis (ATN).

ATN is most often due to ischemia after ATN is most often due to ischemia after
surgery; also associated with sepsis, severe surgery; also associated with sepsis, severe
trauma or burns, and nephrotoxins like trauma or burns, and nephrotoxins like
radiocontrast media and some antimicrobials.radiocontrast media and some antimicrobials.

Postrenal Postrenal - associated with diseases that - associated with diseases that
obstruct the flow of urine from the kidneys. obstruct the flow of urine from the kidneys.

ARF occurs with bilateral obstructions (both ARF occurs with bilateral obstructions (both
kidneys affected).kidneys affected).

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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

Clinical progressionClinical progression - occurs in three phases: - occurs in three phases:

Oliguria phaseOliguria phase - begins within 1day of injury and - begins within 1day of injury and
lasts 1 to 3 weeks. Urine output is usually low (but lasts 1 to 3 weeks. Urine output is usually low (but
may vary); BUN and plasma creatinine may vary); BUN and plasma creatinine
concentrations increase . concentrations increase .

Diuretic phaseDiuretic phase - as renal function improves, urine - as renal function improves, urine
volume progressively increases. During the early volume progressively increases. During the early
diuretic phase, the tubules are still damaged and diuretic phase, the tubules are still damaged and
unable to adequately concentrate urine.unable to adequately concentrate urine.

Recovery phaseRecovery phase – BUN and creatinine return to – BUN and creatinine return to
normal.normal.

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Chronic Renal Failure Chronic Renal Failure

Chronic renal failure is a progressive, Chronic renal failure is a progressive,
irreversible loss of renal function. irreversible loss of renal function.

Develops as a complication of systemic Develops as a complication of systemic
diseases, such as hypertension, diabetes diseases, such as hypertension, diabetes
mellitus or system lupus erythematosus, or mellitus or system lupus erythematosus, or
as a complication of many renal diseases as a complication of many renal diseases
(i.e., chronic glomerulonephritis, chronic (i.e., chronic glomerulonephritis, chronic
pyelonephritis, or chronic obstructive pyelonephritis, or chronic obstructive
uropathies).uropathies).

All organs systems are affected by CRF. All organs systems are affected by CRF.

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Chronic Renal Failure Chronic Renal Failure
Pathophysiology:Pathophysiology:

Occurs through a complex interaction of factors, Occurs through a complex interaction of factors,
including proteinuria and angiotensin II.including proteinuria and angiotensin II.

Proteinuria contributes to tubulointerstitial injury Proteinuria contributes to tubulointerstitial injury
by accumulating in the interstitial space and by accumulating in the interstitial space and
triggering inflammation and progressive fibrosis triggering inflammation and progressive fibrosis
and scarring. and scarring.

Angiotension II causes vasoconstriction which Angiotension II causes vasoconstriction which
causes hypertension both in the kidneys and causes hypertension both in the kidneys and
throughout the body. This damages renal vessels, throughout the body. This damages renal vessels,
increases filtration and pushes more protein into increases filtration and pushes more protein into
the filtrate, contributing to the proteinuria.the filtrate, contributing to the proteinuria.

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Chronic Renal FailureChronic Renal Failure

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Chronic Renal Failure Chronic Renal Failure
Pathophysiology:Pathophysiology:

Over time both the renal tubules and glomeruli Over time both the renal tubules and glomeruli
are damaged, interfering with normal are damaged, interfering with normal
functions.functions.

Plasma creatinine levels gradually become Plasma creatinine levels gradually become
elevated as GFR declines; sodium is lost in elevated as GFR declines; sodium is lost in
the urine; potassium is retained; acidosis the urine; potassium is retained; acidosis
develops; calcium metabolism and phosphate develops; calcium metabolism and phosphate
metabolism are altered and erythropoietin metabolism are altered and erythropoietin
production is diminished. production is diminished.

Edema results from loss of protein in urine.Edema results from loss of protein in urine.

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Chronic Renal Failure Chronic Renal Failure

Stages:Stages:

Reduced renal reserveReduced renal reserve - GFR is about 50% of normal , - GFR is about 50% of normal ,
BUN level may be elevated.BUN level may be elevated.

Chronic renal insufficiencyChronic renal insufficiency - GFR is further reduced, - GFR is further reduced,
levels of serum creatinine and BUN are mildly levels of serum creatinine and BUN are mildly
elevated, but usually there are no systemic symptoms.elevated, but usually there are no systemic symptoms.

Chronic renal failureChronic renal failure - significant loss of renal function - significant loss of renal function
with systemic manifestations.with systemic manifestations.

End-stage renal failureEnd-stage renal failure - less than 10% of renal - less than 10% of renal
function remains; dialysis or kidney transplant is function remains; dialysis or kidney transplant is
required to sustain life.required to sustain life.

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Chronic Renal Failure Chronic Renal Failure
AzotemiaAzotemia – refers so increased serum urea levels – refers so increased serum urea levels
and, often, increased creatinine levels as well.and, often, increased creatinine levels as well.
 UremiaUremia - a syndrome of renal failure which includes - a syndrome of renal failure which includes
elevated blood urea and creatinine levels elevated blood urea and creatinine levels
accompanied by fatigue, anorexia, nausea, accompanied by fatigue, anorexia, nausea,
vomiting, pruritus, and neurologic changes.vomiting, pruritus, and neurologic changes.
These are due to the consequences of renal failure These are due to the consequences of renal failure
and azotemia, including retention of toxic wastes, and azotemia, including retention of toxic wastes,
deficiency states, acid-base imbalance and electrolyte deficiency states, acid-base imbalance and electrolyte
disorders. disorders.
Both azotemia and uremia indicate an accumulation Both azotemia and uremia indicate an accumulation
of nitrogenous waste products in the blood.of nitrogenous waste products in the blood.

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Chronic Renal Failure Chronic Renal Failure

Sequelae - alterations occur in all body Sequelae - alterations occur in all body
systems. A sampling of problems is given systems. A sampling of problems is given
below:below:

Osteomalacia and spontaneous bone fractures Osteomalacia and spontaneous bone fractures
due to failure of kidneys to active vitamin D.due to failure of kidneys to active vitamin D.

Anemia due to failure of kidneys to produce Anemia due to failure of kidneys to produce
adequate levels of erythropoietin.adequate levels of erythropoietin.

Nausea and vomiting due to inability of kidneys Nausea and vomiting due to inability of kidneys
to excrete the by-products of protein to excrete the by-products of protein
breakdown (ammonia and urea).breakdown (ammonia and urea).

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Chronic Renal Failure Chronic Renal Failure

Sequelae (cont.)Sequelae (cont.)

Pruritis (itching) due to accumulation of Pruritis (itching) due to accumulation of
calcium.calcium.

Sodium and water depletion due to Sodium and water depletion due to
kidney’s inability to reabsorb them.kidney’s inability to reabsorb them.

Metabolic acidosis occurs due to loss of Metabolic acidosis occurs due to loss of
renal excretion of hydrogen.renal excretion of hydrogen.

Potassium elevation due to kidney’s Potassium elevation due to kidney’s
inability to excrete it. inability to excrete it.

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Chronic Renal Failure Chronic Renal Failure

Management of Chronic Renal Failure Management of Chronic Renal Failure

Life-style changes to maintain homeostasis Life-style changes to maintain homeostasis
of fluid and electrolyte balance including: of fluid and electrolyte balance including:
•Protein restrictionProtein restriction
•Potassium restrictionPotassium restriction
•Nutritional interventions to assure adequate Nutritional interventions to assure adequate
caloric intakecaloric intake
•Electrolyte stabilization Electrolyte stabilization

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Chronic Renal Failure Chronic Renal Failure

Management of Chronic Renal Failure Management of Chronic Renal Failure

Dialysis - initiated based on the patient’s Dialysis - initiated based on the patient’s
signs and symptoms.signs and symptoms.
•Hyperkalemia and its potential cardiac Hyperkalemia and its potential cardiac
complications often is the most pressing complications often is the most pressing
factor in the decision to dialyze. factor in the decision to dialyze.
•Typically, when the GFR falls below 15, Typically, when the GFR falls below 15,
dialysis is indicated.dialysis is indicated.

Kidney transplant may ultimately be Kidney transplant may ultimately be
required.required.