ACUTE GLOMERULONEPHRITIS

Inflammation of the glomerular capillaries.

Modifiable Non-modifiable
History of Group A Beta Hemolytic Streptococcal Children older than 2 yrs of age
infection if the throat
Impetigo
Acute viral infection ( URTIs, mumps, varicella
zoster virus, Epstein-Barr virus, Hepa B, HIV)
↓
Antigen (Group A beta hemolytic streptococcus)
↓
Deposition of antigen-antibody complex in the glomerulus
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Increased production of epithelial cells lining the glomerulus
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Leukocytes infiltrate the glomerulus
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Thickening of the glomerular filtration membrane
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Scarring and loss of glomerular filtration membrane
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Decreased glomerular filtration rate (GFR)
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Hematuria
Proteinuria
Inc BUN & Serum Crea
Oliguria
Edema
Inc blood pressure
Headache
Malaise
Flank pain
CVA tenderness

Treated Untreated
Relief of symptoms Hypertensive encephalopathy
Recovery ESRD

MEDICAL MANAGEMENT:
Agent of choice: Penicillin
Corticosteroids and immunosuppressive agents
CHON restriction in the diet, Na restriction when patient has HTN, edema and congestive heart failure
Loop diuretics & antihypertensives
NURSING MANAGEMENT:
Encourage liberal amount of CHO to provide energy and catabolism of protein.
Careful measuring of intake and output.
Fluids are given according to patient’s fluid losses and body weight.
Instruct patient to notify physician if any symptoms of renal failure occur such as fatigue, nausea,
vomiting, or diminishing urinary output.
NEPHROLITHIASIS
- from Greek νεφρός (nephros, "kidney") and λιθoς (lithos, "stone")) refers to the condition of having kidney
stones.

Males Intestinal disease, chronic diarrheal states

Family history of stone formation Irritable bowel disease
History of UTIs
History of gout
Hyperparathyroidism
Medications (Ephedrine, Guaifenesin,
Thiazide, Indinavir & Allopurinol)
Hypercalcemia
Low intake of water

↓
Supersaturation of urine with increased calcium - Low urinary flow
↓
Allowing crystallites to be deposited and trapped
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Formation of calculi and stones
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Urine (upon voiding) moves tiny stones to the ureter
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Large stones Tiny stones

↓ ↓
Blocks the ureter Spasms ----- Urine turbidity: cloudy
↓ ↓
Becomes nidus for bacteria Injury to the ureteral wall
↓ ↓
Urinary Tract infection Hematuria
↓ ↓
Causes inc in WBC Low Hgb count

Medical Management

Effective kidney stone prevention is dependent on the stone type and identification of risk factors for stone
formation. An individualized treatment plan incorporating dietary changes, supplements, and medications can be
developed to help prevent the formation of new stones. Certain conservative recommendations should be made
for all patients regardless of the underlying etiology of their stone disease. Patients should be instructed to
increase their fluid intake in order to maintain a urine output of at least 2,000 ml/day. Patients should also limit
their dietary oxalate and sodium intake, thereby decreasing the urinary excretion of oxalate and calcium. A
restriction of animal proteins is encouraged for patients with "purine gluttony" and hyperuricosuria.

Hypercalciuria (General)

Besides treating underlying disease, management of hypercalciuria includes:

 • Low calcium diet (about 400 mg calcium).
• Distilled water, if high calcium content in water supply
• Limit vitamin C (< 0.5g/day).
• High sodium intake
• Thiazide diuretics
• Cellulose phosphate
• Orthophosphate

Nursing Interventions

The nurse should:

• Perform pain assessments to include Visual Analog, numerical, or Wong-Baker scales as appropriate for
patient population to assess level of pain and effectiveness of outcome with pain interventions.
• Provide pharmacological education. Narcotics are usually used liberally, such as parenteral (IM/IV)
narcotics (ketorolac, [Toradol®], meperedine [Demerol®], morphine, and oral narcotics/analgesic
combinations (Department of the Navy Bureau of Medicine and Surgery, 2004). Use of narcotic
medication needs to be explained as well as side effects, such as nausea, vomiting, constipation, and
caution with driving or operating machinery.
• Review bowel patterns and suggest interventions to prevent constipation due to pain medication.
• Assess contributing factors of dehydration such as nausea, vomiting, and diarrhea and administer
antiemetics, such as metoclopramine (Reglan®), prochlorperazine (Compazine®), granisetron (Kytril®),
or ondansetron (Zofran®). Administer antidiarrheal agents such as loperamide (Imodium®),
diphenoxylate, atropine (Lomotil®), or paregoric and assess effectiveness of outcomes. If severe nausea
and vomiting occur, patients must be aware that prevention of dehydration and electrolyte imbalance,
may require IV hydration, prescription of anti-emetics, and solutions such as such as Gatorade® or
Pedialyte® to replace electrolytes lost via the GI tract.
• Assess for vital signs checking for orthostatic hypotension (lowering of blood pressure and increase in
pulse with positional changes) and monitoring patient weights.
• Encourage increases in daily fluid intake, especially water, and monitor outcomes of interventions
through patient voiding history and 24-hour urine reports. The most important lifestyle change to
prevent stones is drinking more fluids, especially water up to 2 quarts/day.
• Educate the patient on completing a voiding diary to track daily urine output.
• Educate the patient on the importance of completing laboratory tests ordered, especially 24-hour urines.
This can become an imposition on the patient's quality of life, especially if he is active and working.
• Educate the patient on collecting urine specimens and straining urine.
• Educate the patient on diagnostic testing, including required dietary or bowel preparation to reduce
anxiety.
 • Educate the patient on the importance of weight loss, maintaining weight loss, and daily exercise.
• Provide counseling on health promotion and maintenance, stressing the importance of followup care to
evaluate causes of stone formation in an effort to prevent future recurrences.

PYELONEPHRITIS
- an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek). If
the infection is severe, the term "urosepsis" is used interchangeably (sepsis being a systemic inflammatory
response syndrome due to infection).

Immunosuppression DM
Instrumentation of the urinary tract Pregnancy
Kidney stones Age
Urinary retention Gender

attachment of bacteria to the urethra

↓
Proliferation of bacteria in the urethra
↓
Urethritis
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Urethrovesical reflux
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Introduction of bacteria into the bladder
↓
Proliferation of bacteria in the bladder
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Inflammation of the bladder
↓
Cystitis
↓
Ureterovesical reflux
↓
Intorduction of bacteria into the ureter
↓
Inflammation of the ureter
↓
Ureteritis
↓
Infection ascends to the kidneys
↓
PYELONEPHRITIS
↓
fever
malaise
dysuria
flank pain
anemia
 Treated Untreated
↓
Recovery ESRD
hypertension
Kidney stone formation

Medical Care
• Supportive care
◦ Rest
◦ Antipyretics as needed
◦ Oral or parenteral pain medications as needed
◦ Oral or parenteral antiemetics as needed
◦ Urinary tract analgesics to relieve dysuria (up to 3 d)
◦ Intravenous or oral fluids to maintain hydration status
• Reasons for hospital admission
◦ Cannot tolerate oral intake
◦ Unstable social situation (eg, possibility of poor compliance or poor follow-up)
◦ Unstable vital signs
◦ Severe signs and symptoms
◦ Pregnancy
◦ Comorbid disorders that increase the complexity of management or the complication rate (eg,
diabetes mellitus, chronic lung disease, congenital or acquired immunodeficiency syndrome)
• Antibiotic selection
◦ Antibiotic selection is typically empirical, because the results of blood or urine cultures are
rarely available by the time a decision must be made.
◦ Initial selection should be guided by local antibiotic resistance patterns. Urine culture collected
at the initiation of therapy should be checked in 48 hours to determine antibiotic efficacy.
◦ When using an oral-only regimen, the initial dose should be administered at the time of the
evaluation.

Nursing Management:

The patient may require hospitalization or may be treated as an outpatient. When the patient is
hospitalized, fluid intake and output are carefully measured and recorded. Unless contraindicated, fluids are
encouraged 3-4L/day to dilute the urine, decrease burning on urination and prevent dehydration. The nurse
assesses the patient's temperature every 4 hrs and administer antipyretics and antibiotics as prescribed. Often the
patient is more comfortable on bed rest during the acute phase of the illness.
Patient teaching focuses on prevention of UTIs by consuming an adequate fluid intake, emptying the
bladder regularly and performing recommended perineal hygiene.

NEPHROTIC SYNDROME
is not a single disease- it is a syndrome. A syndrome is a set of symptoms and signs that occur together,
and which can be caused by one or more different diseases. Nephrotic syndrome can be caused by many
different diseases, some more serious than others.
The hallmark or main feature of nephrotic syndrome is that the kidneys leak a lot of CHON. what happens
is that filters in the kidneys become leaky and protein instead of remaining in the blood, leaks out in the urine.

Pathophysiology

Glomerular permeability

In a healthy individual, less than 0.1% of plasma albumin may traverse the glomerular filtration barrier.7
Controversy exists regarding the sieving of albumin across the glomerular permeability barrier. Specifically, it is
proposed that there is ongoing albumin passage into the urine, in many grams per day, with equivalent
substantial tubular uptake of albumin, the result being that the urine has 80 mg per day or less of daily albumin.8
This controversy is based on studies in experimental animals. However, studies of humans with tubular transport
defects suggest that the glomerular urinary space albumin concentration is 3.5 mg/L.9 With this concentration,
and a normal daily glomerular filtration rate (GFR) of 150 liters, one would expect no more than 525 mg per day
of albumin in the final urine. Amounts above that level point to glomerular disease.

The glomerular capillaries are lined by a fenestrated endothelium that sits on the glomerular basement
membrane, which in turn is covered by glomerular epithelium, or podocytes, which envelops the capillaries with
cellular extensions called foot processes. In between the foot processes are the filtration slits. These 3 structures
—the fenestrated endothelium, glomerular basement membrane, and glomerular epithelium—are the glomerular
filtration barrier. A schematic drawing of the glomerular barrier is seen in the image below.

Filtration of plasma water and solutes is extracellular and occurs through the endothelial fenestrae and filtration
slits. The importance of the podocytes and the filtration slits is shown by genetic diseases. Thus, in congenital
nephrotic syndrome of the Finnish type, the gene for nephrin, a protein of the filtration slit, is mutated, leading to
nephrotic syndrome in infancy . Similarly, podocin, a protein of the podocytes, may be abnormal in a number of
children with steroid-resistant focal glomerulosclerosis.

The glomerular structural changes that may cause proteinuria are (1) damage to the endothelial surface, (2)
damage to the glomerular basement membrane, and/or (3) damage of the podocytes. One or more of these
mechanisms may be seen in any one type of nephrotic syndrome. Albuminuria alone may occur, or, with greater
injury, leakage of all plasma proteins, (ie, proteinuria) may take place.

Proteinuria that is more than 85% albumin is selective proteinuria. Albumin has a net negative charge, and it is
proposed that loss of glomerular membrane negative charges could be important in causing albuminuria.
Nonselective proteinuria, being a glomerular leakage of all plasma proteins, would not involve changes in
glomerular net charge but rather a generalized defect in permeability. This construct does not permit clear-cut
separation of causes of proteinuria, except in minimal-change nephropathy, in which proteinuria is selective.

HYDRONEPHROSIS
is dilation of the renal pelvis and calyces of one or both kidneys due to an obstruction

OBstruction to the normal flow of urine

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Urine backs up
↓
Increase pressure in the kidney