Seminar on nephritis, nephrotic syndrome,bladder cancer

nephritis,nephrotic syndrome and CA bladder

1. Seminar on nephritis, nephrotic syndrome,bladder cancer Presented by:Ligi Xavier 1 yr MSc nursing

2. Nephritis Nephritis is inflammation of the nephrons in the kidneys Subtypes By main location of inflammation By cause

3. Interstitial nephritis Interstitial nephritis is a kidney disorder in which the spaces between the kidney tubules become swollen (inflamed). The inflammation can affect the kidneys' function, including their ability to filter waste.

4. Causes Allergic reaction to a drug (acute interstitial allergic nephritis) Analgesic nephropathy Long-term use of medications such as acetaminophen (Tylenol), aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDS). This is called analgesic nephropathy Side effect of certain antibiotics (penicillin, ampicillin , methicillin , sulfonamide medications, and others) Side effect of medications such as furosemide , and thiazide diuretics

5. Symptoms : Blood in the urine Fever Increased or decreased urine output Mental status changes (drowsiness, confusion, coma) Nausea, vomiting Rash Swelling of the body, any area Weight gain (from retaining fluid)

6. Investigations Arterial blood gases Blood chemistry BUN and blood creatinine levels Complete blood count Kidney biopsy Urinalysis Urine osmolality

7. Treatment Treatment focuses on the cause of the problem. Avoiding medications that lead to this condition may relieve the symptoms quickly. Limiting salt and fluid in the diet can improve swelling and high blood pressure. Limiting protein in the diet can help control the buildup of waste products in the blood ( azotemia ) that can lead to symptoms of acute kidney failure. If dialysis is necessary, it usually is required for only a short time. Corticosteroids or anti-inflammatory medications can help in some cases

8. Glomerulonephritis Glomerulonephritis is inflammation of the glomeruli . Also called glomerular disease, glomerulonephritis can be acute , a sudden attack of inflammation or chronic ,coming on gradually.

9. Types Thin Basement Membrane Disease Acute Nephritic Syndromes Non Proliferative Minimal change GN also known as Minimal Change Disease Focal Segmental Glomerulosclerosis (FSGS) Membranous glomerulonephritis

10. Membraneous glomerulonephritis

11. Proliferative IgA nephropathy (Berger's disease ) Post-infectious Membranoproliferative / mesangiocapillary GN Rapidly progressive glomerulonephritis Acute glomerulonephritis Chronic

12. RPGN

13. Causes Infections Post-streptococcal glomerulonephritis Bacterial endocarditis . Viral infections. Immune diseases Vasculitis

14. Pathophysiology Antigen Antigen – antibody product Leukocyte infitration of glomerulus Thikening glomerular filtration membrane Scarring and loss of glomerular filtration membrane Decreased GFR

15. Signs and symptoms primary presenting features are hematuria,edema,azotemia (concentration of nitrogenous wasteproducts in the blood), proteinuria Pink or cola-colored urine from red blood cells in your urine ( hematuria ) Foamy urine due to excess protein ( proteinuria ,<3g/day) High blood pressure (hypertension)

16. Cntd …………. Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen Fatigue from anemia or kidney failure Hypoalbunemia,hyperlipidemia,fatty casts in urine Blood urea nitrogen, creatine level may increase as urine output decreases. In severe conditions -headache, malaise, flank pain,dyspnea , cardiomegaly,pulmonary edema, neurological manifestations also occur.

17. Diagnostic studies History and physical examination Laboratory studies Urinalysis;reveal the presence of erythrocytes. CBC with WBC differencial BUN, creatine,albumin Complement levels and ASO titre:the finding of decreased complement components (c3 and CH50) indicates immune mediated response. Renal biopsy

18. Medical Management A ntibiotic Penicillin is the choice . Corticosteroids and immunosuppressive agents Dietary protein , sodiums restricted. Loop diuretics and antihypertensives to control hypertension Bedrest

19. Chronic glomerulonephritis Chronic glomerulonephritis sometimes develops after a bout of acute glomerulonephritis. It reflects the end stage of glomerular inflammatory disease. One of the inherited cause Alport syndrome , may also involve hearing or vision impairment

20. Pathophysiology Chronic glomerulonephritis may occur due to repeated episodes of acute glomerulonephritis, hypertensive nephrosclerosis,hyperlipidemia,glomerular sclerosis, chronic tubulointerstitial disease and amyloidosis.secondary diseases lupus nephritis,Good pastures syndrome. Kidneys are reduced to as little as one fifthof normal size (consisting largely of fibrous tissue).the cortex layer shrinks to 1-2mmin thickness or less.bands of scar tissue makes the surface of kidney irregular.glomeruli and tubules become scarred, and artery become thickened. The result is severe glomerular damage can result in ESRD .

21. Clinical manifestations BUN and creatinine values are increased Sudden severe nosebleed, stroke, Peripheral and periorbital edema loss of weight ocular findings:retinal hemorrhage, papilledema cardiomegaly,signs of heart failure peripheral neuropathy in later stages,pericarditis , pericardial friction rub

22. Assessment and diagnostic findings Urine test Blood tests Imaging tests Kidney biopsy.

23. Complications Acute kidney failure. Chronic kidney failure High blood pressure Nephrotic syndrome Hypertensive encephalopathy Heart failure Pulmonary edema

24. Treatment for an underlying cause Strep or other bacterial infection. Lupus or vasculitis IgA nephropathy Goodpasture's syndrome.

25. Nephrotic syndrome( nephrosis ) Results when the glomerulus is excessively permeable to plasma protein,causing proteinuria that leads to low plasma albumin and tissue edema Nephrotic syndrome can affect all age groups. In children, it is most common between ages 2 and 6. This disorder occurs slightly more often in males than females.

26. Causes Primary glomerular disease Membraneousproliferative glomerulonephritis Primary nephritic syndrome Focal glomerulonephritis Inherited nephritic diseases External causes SLE Diabetes mellitus Amyloidosis

27. Neoplasms Hodgkin’s lymphoma Solid tumoprs of lung,colon , stomach, breast, Leukemias Infections Bacterial:streptococcal , syphilis Viral:hepatitis,HIV Protozoal : malaria

28. Allergens Drugs Penicillamine NSAIDS Captopril

29. Pathophysiology Damaged glomerular capillary membrane Loss of plasma protein Hypoalbuminemia Decreased oncotic ressure Generalised edema Activation of RAAS Sodium retension edema

30. Clinical manifestations It comprises of cluster of clinical findings Marked increase in protein Hypoalbuminemia Edema Hyper lipidemia Other symptoms include: Foamy appearance of the urine Poor appetite Weight gain (unintentional) from fluid retention

31. Diagnostic measures Proteinuria : exceeding 3.5g/day is the hall mark of the diagnosis of nephritic syndrome. Albumin blood test Blood chemistry tests such as basic metabolic panel or comprehensive metabolic panel Blood urea nitrogen (BUN) Creatinine - blood test Creatinine clearance - urine test Urinalysis

32. Contd …….. Creatinine clearance - urine test Urinalysis Fats are often also present in the urine. Blood cholesterol and triglyceride levels may be high.

33. Treatment Keep blood pressure at or below 130/80 mmHg to delay kidney damage. Angiotensin -converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs ) are the medicines most often used. ACE inhibitors may also help decrease the amount of protein lost in the urine. corticosteroids Antineoplastic agents ( cyclophosphamide ), immunosuppressants ( azathioprine,chlorambucil , cyclosporine)

34. Treat high cholesterol to reduce the risk of heart and blood vessel problems. A low-fat, low-cholesterol diet is usually not very helpful for people with nephrotic syndrome. Medications to reduce cholesterol and triglycerides (usually statins ) may be needed . Low-protein diets may be helpful. Your health care provider may suggest eating a moderate-protein diet (0.5-0.6 gram of protein per kilogram of body weight per day). vitamin D supplements if nephrotic syndrome is long-term and not responding to treatment. Blood thinners may be needed to treat or prevent blood clots. Diuretics for severe edema

35. Complications Acute kidney failure Atherosclerosis and related heart diseases Chronic kidney disease Fluid overload, congestive heart failure , pulmonary edema Infections, including pneumococcal pneumonia Malnutrition Renal vein thrombosis Pulmonary emboli

36. Bladder cancer It is more common in people between the ages of 50 and 70yrs. it affects more men than women(4:1)

37. Types Transitional cell bladder cancer Non muscle invasive (superficial) bladder cancer Invasive bladder cancer   Squamous cell bladder cancer Adenocarcinoma of the bladder cell cancer of the bladder

38. Causes of Cancer of the Bladder smoking - is 2-6 times greater in smokers than in nonsmokers. Chemical exposure textile workers, Dry cleaners Dental workers Physicians Barbers,dye , leather, and rubber workers, plumbing, autowork , painters

39. Race - Caucasians have twice as high a risk of developing this cancer as people of African descent; Asians have the lowest risk Gender - men have a 2 to 3 times higher risk than women of developing bladder cancer haematobium  infection causes most cases of bladder SCC Age - most cases of bladder cancer are diagnosed in people over the age of 40 years previous use of certain chemotherapy medications, such as cyclophosphamide (often used in breast cancer and lymphoma treatment), can significantly increase the risk of later developing bladder cancer

40. Cancers arising from prostate,colon,rectum Radiation treatment of the pelvis Spinal cord injuries requiring long-term indwelling catheters - A 16- to 20-fold increase in the risk of developing SCC of the bladder Previous radiation to the pelvic area Family or personal history of bladder cancer Schistosomiasis :In many developing countries

41. Clinical features blood in the urine (most common) pain or burning sensation while urinating a feeling of urgency or needing to urinate immediately the feeling of not having emptied the bladder completely after urinating pain in the lower back

42. Irritative bladder symptoms such as dysuria , urgency, or frequency of urination occur in 20-30% of patients with bladder cancer. Although irritative symptoms may be related to more advanced muscle-invasive disease, carcinoma in situ (CIS) is the more likely cause. Patients with advanced disease can present with pelvic or bony pain, lower-extremity edema from iliac vessel compression, or flank pain from ureteral obstruction.

43. Diagnostic measures Urine studies include the following: Urinalysis with microscopy Urine culture to rule out infection, if suspected Voided urinary cytology Urinary tumor marker testing

44. Cystoscopy Cystoscopy in patients with CIS may reveal a characteristic red, velvety appearance that resembles an area of inflammation. In some cases, however, CIS is not visible on gross inspection

45. Imaging studies Computed Tomography Scanning Intravenous Pyelography Renal Ultrasonography Bone scans  determine if the cancer has spread to the bones. Chest X-rays  show if the cancer has spread to the lungs.

46. Other tests Complete Blood Count and Chemistry Panel

47. Staging The following is the TNM staging system for bladder cancer: CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium Ta - Papillary tumor confined to the epithelium T1 - Tumor invasion into the lamina propria T2 - Tumor invasion into the muscularis propria T3 - Tumor involvement of the perivesical fat T4 - Tumor involvement of adjacent organs such as the prostate, rectum, or pelvic sidewall N+ - Lymph node metastasis M+ - Metastasis

48. Management Surgical therapy Trans urethral resection with fulgration Laser photo coagulation Open loop resection with fulgration Cystectomy Urinary diversion

49. Trans urethral resection with fulgratio n Used for the diagnosis and treatment of superficial lesions with low recurrence rate. Also used to control the bleeding.

50. Laser photo coagulation Used to teat superficial bladder cancer

51. Open loop resection with fulgration it is used for the control of bleeding, for large superficial tumors and for multiple lesions.

52. cystectomy Cystectomy is surgery to remove the bladder. Partial cystectomy removes only part of the bladder. It is used to treat cancer that has invaded the bladder wall in just one area. Simple cystectomy removes all of the bladder. Radical cystectomy removes all of the bladder as well as nearby lymph nodes, part of the urethra, and nearby organs that may contain cancer.

53. Urinary diversion Urinary diversion is surgery that makes a new way for your body to store urine. This can be done with a pouch created inside your body from part of your intestines , called a continent reservoir. After cystectomy is performed, a urinary diversion must be created from an intestinal segment. Diversions can be incontinent( cutaneous ) and continent.

54. Cutaneous urinary diversions A. Conventional ileal conduit B.Cutaneous ureterostomy C.Vesicostomy D.Nephrostomy

55. Ileal conduit

56. Cutaneous ureterostomy

57. Nephrostomy

58. Continent urinary diversions A.Indiana pouch B.Continent ileal urinary diversions( Kock pouch C.Charleston pouch D.Ureterosigmoidostom y

59. Indiana pouch

60. Kock pouch

61. Ureterosigmoidostomy

62. Other urinary diversion procedures Camey procedure , uses a portion of the ileumas a bladder substitute. In this procedure, the isolated ileum serves as the reservoir for urine. It is anastomosed directly to theporion of the remaining urethra after cystectomy.this procedure permits emptying of the the bladder through the urethra. However , the camay procedure applies only to men because the entireurethra is removed when a cystectomy is performed for women

63. Orthotopic neobladder : is the constructions of a new bladder in the new anatomic positions of the bladder; with discharge of urine through the urethra. The reconstruction or neobladder can be derived from various segments of the intestine to create a low – pressure reservoir. An isolated segment of the distal ileum is often preferred

64. Cystectomy - complications Ileus Wound infection Sepsis Pelvic abscess Hemorrhage Wound dehiscence Bowel obstruction Enterocutaneous fistula Rectal injury

65. Urinary diversion-complications Complications of urinary diversion include the following: Hyperchloremic metabolic acidosis - If the ileum or colon is used Urinary tract infections (UTIs) Stomal-peristomal inflammation, hernia, or stenosis Urinary calculi Vitamin B-12 deficiency - For diversions affecting the terminal ileum Ureterointestinal stenosis leading to hydronephrosis

66. Radiation therapy Radiation treatment for bladder cancer uses high-energy X-rays to kill cancer cells and shrink tumors . It may be given after surgery. It may be used along with chemotherapy. Sometimes it is used instead of surgery or chemotherapy. External beam radiation comes from a machine outside the body. The machine aims radiation at the area where the cancer cells are found. Internal radiation uses needles, seeds, wires, or catheters that contain radioactive materials placed close to or directly into the bladder .

67. Intravesical therapy It is the instillation of immune stimulating agent into the bladder by urethral catheter. Usually BCG is used. It stimulates the immune system rather than directly act on the cancer cells in the bladder. If BCG fais , alpha interferon , valrubicin etc are used.

68. Chemtherapy Antineoplastics , Antimetabolite These agents inhibit cell growth and proliferation. They interfere with DNA synthesis by blocking the methylation of deoxyuridylic acid. Fluorouracil ( Adrucil )   Methotrexate ( Trexall , Rheumatrex )   Gemcitabine ( Gemzar )   Pemetrexed ( Alimta )  

69. Antineoplastics , Vinca Alkaloid Vinca alkaloids act on the G and S phases of mitosis, inhibiting microtubule formation and inhibiting DNA/RNA synthesis. Vinblastine ( Velban )

70. Antineoplastics , Anthracycline Anthracycline antineoplastics inhibit DNA and RNA synthesis by steric obstruction. They intercalate between DNA base pairs and trigger DNA cleavage by topoisomerase II. Doxorubicin ( Adriamycin , Caelyx , Rubex )

71. Valrubicin ( Valstar ) : It is indicated for intravesicular treatment of bladder carcinoma in situ (CIS) that is refractory to treatment with bacillus Calmette-Guérin (BCG). Antineoplastics , Alkylating Cisplatin   Carboplatin ( Paraplatin )   Ifosfamide ( Ifex )   Thiotepa ( Thioplex , TSPA)

72. Antineoplastics , Antimicrotubular These agents prevent cell growth and proliferation. They work by enhancing tubulin dimers , as well as by stabilizing existing microtubules and inhibiting their disassembly. Docetaxel ( Taxotere , Docefrez )

73. Chemotherapy – First Line - Gemcitabine – Cisplatin - Intensified MVAC Dose-intense MVAC + GCSF - Carboplatin – Gemcitabine Chemotherapy – Second Line - Paclitaxel – Carboplatin - Docetaxel - Ifosphamide

74. Neoadjuvant chemotherapy Indications for Neoadjuvant Chemotherapy 1. Clinical stage T2 – T4a 2. No nodal or metastatic disease 3. Urothelial histology only 4. Candidate for radical cystectomy Regimens: To receive 3-4 cycles Possible (not evaluated in RCT): 1. Gemcitabine + cisplatin / carboplatin 2. Dose-intense MVAC

75. Chemotherapeutic Regimens for Metastatic Bladder Cancer First-line, platinum-based combinations are active in locally advanced and metastatic urothelial carcinoma. Methotrexate , vinblastine , doxorubicin ( Adriamycin ), and cisplatin (MVAC) is a standard combination regimen for treatment of metastatic bladder cancer Gemcitabine and cisplatin (GC) is a newer regimen that has been shown to be as effective as MVAC but with less toxicity. GC is now considered a first-line treatment for bladder cance r

76. Nursing management preoperative period Assessment Nutritional assessment Advise tobacco cessation Assessment of activities of daily living functional status Determination of eligibility for financial support Inclusion of partner/family members to establish support mechanism Psychological assessment Provision of audio and visual information Provision of opportunity to meet similar patients Addressing religious and cultural issues Implementation of care plans Cardiopulmonary assessment Learning needs

77. Nursing diagnoses Anxiety related to surgical procedure Deficient knowledge about the surgical procedure and postoperative care

78. Post operative Nursing diagnoses Risk for impaired skin integrity related to problems in managing the urin collection appliance Acute pain related to surgical incision Disturbed body image related to urinary diversion Potential sexual dysfunction related to structural and physiologic alterations Deficient knowledge about the management of urinary function.

79. Interventions in post op period In the post operative period , urine volumes are monitored hourly. Through out the patient’s hospitalization, the nurse monitors closely for complications. A urine output below 3oml/h may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureterileal anastomosis . Hematuria may be noted in the first 48 hrs after the surgery.if the ureteral stents are not draining , the nurse may be instructed to carefully irrigate with 5-10 ml sterile normal saline solution.

80. Providing stoma and skin care Encouraging fluids and relieving anxiety Promoting home care Teaching patient self care Changing the appliance Controlling odor Managing ostomy appliance Contining care

81. Thank you