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Renal FailureRenal failure is traditionally categorized as acute or

chronic. The former develops rapidly, often overdays, whereas the latter progresses slowly overmonths to years. Some causes overlap.

Acute Renal Failure (ARF)(Acute Kidney Injury)Renal failure is a rapid decrease in renal function

over days to weeks, causing an accumulation ofnitrogenous products in the blood (azotemia). Itoften results from major trauma, illness, or surgery

but is sometimes caused by a rapidly progressive,intrinsic renal disease. Symptoms include anorexia,nausea, and vomiting. Seizures and coma may occurif the condition is untreated.


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Chronic Kidney Disease (Chronic Renal

Failure) Chronic kidney disease is long-standing,

progressive deterioration of renal function.

Symptoms develop slowly and include anorexia,nausea, vomiting, stomatitis, dysgeusia, nocturia,lassitude, fatigue, pruritus, decreased mentalacuity, muscle twitches and cramps, water

retention, undernutrition, GI ulceration andbleeding, peripheral neuropathies, and seizures.


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Management:

Management: Volume Status

Normal Volume Status

Limit Fluid Intake to Urine Output + 300-500 ml/day Limit Sodium Intake to 2 grams per day

Volume Overloaded Limit Fluid intake to less than Urine Output

Limit Sodium Intake to less than 2 grams per day

Consider Loop Diuretic

Consider Dialysis Volume Depleted

First:RestoreVolume with Isotonic saline

Next: Limit Intake to Urine Output + 300-500 ml/day

Limit sodium intake to 2 grams per day

Treatment Control of underlying disorders

Possible restriction of dietary protein, phosphate, and K

Vitamin D supplements

Treatment of anemia and heart failure

Doses of all drugs adjusted as needed

Dialysis for severely decreased GFR, uremic symptoms, or sometimes hyperkalemia orheart failure


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Benign Prostatic Hyperplasia (BPH)(Benign

Prostatic HypertrophyBenign prostatic hyperplasia is nonmalignant

adenomatous overgrowth of the periurethral

prostate gland. Symptoms are those of bladderoutlet obstructionweak stream, hesitancy,urinary frequency, urgency, nocturia, incompleteemptying, terminal dribbling, overflow or urgeincontinence, and complete urinary retention.


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Management:

Patients should decrease fluid intake beforebedtime, moderate the consumption of alcoholand caffeine-containing products, and follow

timed voiding schedules.

Treatment

Avoidance of anticholinergics,sympathomimetics, and opioids

Use of-adrenergic blockers


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Prostitis(Prostatodynia)

Prostitis refers to a disparate group of disordersthat manifests with a combination of predominantly irritative or obstructive urinarysymptoms and perineal pain. Some cases result

from bacterial infection of the prostate gland andothers, which are more common, from a poorlyunderstood combination of noninfectiousinflammatory factors, spasm of the muscles ofthe urogenital diaphragm, or both.


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Bacterial prostitis can be acute or chronic and is

usually caused by typical urinary pathogens (eg,Klebsiella, Proteus, Escherichia coli and possibly byChlamydia. How these pathogens enter and infectthe prostate is unknown.Chronic infections may becaused by sequestered bacteria that antibiotics have

not eradicated.Nonbacterial prostitis can be inflammatory or

noninflammatory. The mechanism is unknown butmay involve incomplete relaxation of the urinary

sphincter and dyssynergic voiding. The resultantelevated urinary pressure may cause urine refluxinto the prostate (triggering an inflammatoryresponse) or increased pelvic autonomic activityleading to chronic pain without inflammation.


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Treatment

Treatment involves appropriate antibiotics plus

drainage by transurethral evacuation ortransperineal aspiration and drainage.


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Urinary Calculi(Nephrolithiasis; Stones; Urolithiasis)

Urinary calculi are solid particles in the urinarysystem. They may cause pain, nausea, vomiting,hematuria, and, possibly, chills and fever fromsecondary infection. Diagnosis is based on

urinalysis and radiologic imaging, usuallynoncontrast helical CT. Treatment is withanalgesics, antibiotics for infection, and,

sometimes, extracorporeal shock wave lithotripsyor endoscopic procedures.


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Management:

y Management:

Drink plenty of fluids

Water, lemonade, and most fruit juices can help dilute the substances in theurine that form kidney stones; avoid grapefruit juice and soft drinks

Dont eat too much animal protein

Diets high in animal protein are linked to increased calcium in the urine,which contributes to oxalate stones

Avoid foods with organic acids (oxalates) that can help stones form Limit your intake of spinach, rhubarb, beet greens, nuts, chocolate, tea, bran,

almonds, peanuts, and strawberries, which appear to significantly increaseurinary oxalate levels

Protect yourself with vitamin B6 and magnesium

Taking 50 mg a day of the supplement vitamin B6 with 200 to 400 mg a day of

the mineral magnesium (preferably in the form of magnesium citrate) caninhibit oxalate stone formation

Check out calcium

If your healthcare provider has determined that you do not over-absorbcalcium, take 800 mg a day of calcium (in the form of calcium citrate orcalcium citrate-malate) with meals


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Treatment

Analgesia

Facilitate calculus passage (e.g., with -receptor blockers or Ca channelblockers)

For persistent or infection-causing

calculi, removal using extracorporealshock wave lithotripsy or endoscopictechniques


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y Bacterial Urinary Tract Infections Bacterial UTIs can involve the urethra, prostate,

bladder, or kidneys. Symptoms may be absent orinclude urinary frequency and urgency, dysuria,

lower abdominal pain, and flank pain. Systemicsymptoms and even sepsis may occur with kidneyinfection. Diagnosis is based on analysis andculture of urine.Treatment is with antibiotics.

Among adults aged 20 to 50 yr, UTIs are about

50-fold more common in women. The incidenceincreases in patients > 50 yr, but the female: maleratio decreases because of the increasingfrequency of prostate disease.


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Urinary Incontinence

Urinary incontinence is involuntary loss of urine; some expertsconsider it present only when a patient thinks it is a problem. The

disorder is greatly underrecognized and underreported.Many patientsdo not report the problem to their physician, and many physicians donot ask about incontinence specifically. Incontinence can occur at anyage but is more common among the elderly and among women,affecting about 30% of elderly women and 15% of elderly men.

Urge incontinence is uncontrolled urine leakage (of moderate tolarge volume) that occurs immediately after an urgent, irrepressibleneed to void. Nocturia and nocturnal incontinence are common. Urgeincontinence is the most common type of incontinence in the elderlybut may affect younger people. It is often precipitated by use of adiuretic and is exacerbated by inability to quickly reach a bathroom. Inwomen, atrophic vaginitis, common with aging, contributes to thinningand irritation of the urethra and urgency.


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Stress incontinence is urine leakage due to abrupt increases in intra-abdominalpressure (eg, with coughing, sneezing, laughing, bending, or lifting). Leakage volume isusually low to moderate. It is the 2nd most common type of incontinence in women,largely because of complications of childbirth and development of atrophic urethritis.Stress incontinence is typically more severe in obese people because of pressure

from abdominal contents on the top of the bladder. Overflow incontinence is dribbling of urine from an overly full bladder. Volume is

usually small, but leaks may be constant, resulting in large total losses. Overflowincontinence is the 2nd most common type of incontinence in men.

Functional incontinence is urine loss due to cognitive or physical impairments (eg,due to dementia or stroke) or environmental barriers that interfere with control ofvoiding. For example, the patient may not recognize the need to void, may not know

where the toilet is, or may not be able to walk to a remotely located toilet. Neuralpathways and urinary tract mechanisms that maintain continence may be normal.

Mixed incontinence is any combination of the above types. The most commoncombinations are urge with stress incontinence and urge or stress with functionalincontinence.

Treatment Bladder training

Kegel exercises

Drugs

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