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  • 1. Name: Jane Cairo Address: 5 Brownfield Street Parkdale Vic 3194 La Trobe University School of Occupational Therapy Subject: Occupational Health & Safety Screening and Monitoring(OCT42OHC) Topic: Functional Occupational Health Assessment Kidney and Bladder Systems Lecturer: Jean Cromie Due Date: 15th October 2002 Date Sent:22nd October 2002(extension granted) Approximate Word Count: 1998
  • 2. Kidney/ Bladder system The kidney and bladder systems are the main organs in the urinary system that creates and stores urine to assist bodily excretion of wastes, and keep chemicals, electrolytes and water in the body balanced. This ensures body tissues remain appropriately hydrated (Glen, 1994). The Kidneys The kidneys are kidney bean shaped organs about the size of a person’s fists, and are near the middle of the back, just below the ribcage (NIDDK, 2002). Filtering units called nephrons in the kidneys remove urea from the blood, and there are a million in each kidney (NIDDK, 2001, Ross & Wilson 1983). The nephron consists of a ball formed of small blood capillaries, called a glomerulus and a small tube called a renal tubule. Initially waste products filter from the glomuruli to the renal tubule, forming a glomurular filtrate that passes through the renal tubules enabling the reabsorption of products and chemicals, such as sodium, phosphorous and potassium, for the body to still use. Further secretions from peritubular capillaries to renal tubules combine with the filtrate (Glen, 1994). The filtrate becomes urine that contains urea in the tubule that travels down the ureters to the bladder. Renal function is the actual work the kidneys perform. Two healthy kidneys equate to 100 percent renal function, where one health kidney would equate to 50 percent renal function (NIDDK, 2001). Two unhealthy kidneys could account for 60 percent renal function, and be steadily declining. Renal function dropping below 10 to 15 percent, needs renal replacement therapy to maintain life, which can be dialysis or transplantation. Apart from removing waste products the kidneys produces three important substances, which are: • erythropoietin (EPO) - which stimulates the bone marrow to make red blood cells • renin - which regulates blood pressure and the levels of vital salts • active form of Vitamin D - which helps maintain calcium for bones and for normal chemical balance in the body.
  • 3. The Bladder The bladder is a hollow muscular organ shaped like a balloon that sits in the pelvis area and is held in place by ligaments attached to other organs and the pelvic bones, and stores urine (DHS, 1999). When full it swells in size, and if healthy can hold 500mls for 2-5 hours (NIDDK, 2002). Circular muscles called sphincters keep the urine from leaking into the urethras until urination. As the bladder fills with urine, impulses travel along neuronal pathways to communicate with the brain that the bladder is full and needs emptying, so the urge to urinate intensifies. Occupational Risks and Predisposing Factors of Kidney Disorders Kidney disorders tend to have higher prevalence in industries where workers are exposed to asbestos and heavy metals (DHS, 2001 and Balter et al [Toxline], 1976). Nephrotoxic agents include lead, arsenic, cadmium, mercury, uranium, beryllium, solvents, haloganated hydrocarbons and pesticides. The route site of entry can vary, but once in the blood stream can damage the kidneys directly by damaging the nephron or indirectly as a systemic, prerenal toxicity (Lilis & Landrigan, 1995, and Waldron 2001). The dry cleaning industry has a higher incidence of renal pelvic cancer and the coke production industry have higher incidences of kidney cancer (McCredie & Stewart 1993, Waldron 2001). The DHS (2001), and Australian Kidney Foundation, indentifies the following conditions can increase occupational risk to kidney cancer:- • smoking • high cholesterol and diabetes • phenacitin (ingredient found in painkillers) • family history of kidney disease • male gender. Diabetes can later cause diabetes nephropathy, whereby unused glucose remains in blood causing irreparable damage to the nephrons, resulting in kidney disease (NIDDK, 2002). High blood pressure also causes damage in the smaller capillaries in the kidney, hence hindering the filtering of waste products.
  • 4. Occupational Risks & Predisposing Factors of Bladder Disorders Aromatic amines such as soot, tars, and polycyclic hydrocarbons have been shown to cause bladder cancer, which are substances found in dyes used in textile industry, and in mainstream and sidestream cigarette smoke (Lilis & Landrigan, 1995). Thus exposure to cigarette smoke can exacerbate the occupational hazards of these aromatic chemicals. Other varying health reactions to aromatic amine exposure can be due to different inherited polymorphisms, as some people can perform N-aceytlation of 2- naphythylamine, and other aromatic amines, whilst other people cannot (Waldron, 2001). Employees with slow N-acetylation activity are strongly correlated to being at more risk of bladder cancer. Occupational exposure to 4-Aminobiphenyl and benzidene are associated with the development of employee bladder cancer. Occupations that are recognised as presenting a carcinogenic risk for the bladder, are:- • manufacturing and use of dyes • manufacturing of auromine and para-Chloro-ortho-toluidine, • manufacturing of rubber, the production of synthetic latex, tyre curing, reclaiming and cable making • production of aluminium. Occupational Related Disorders of the Kidney/Bladder Systems Kidney Cancer – initial signs and symptoms may be blood in urine, a pain or ache in lower back, a lump in abdomen, tiredness, unexplained or sudden weight loss or fever (DHS, 2001 & Australian Kidney Foundation). Different types of kidney cancer include:- • renal cell carcinoma – starts in the lining of one or both kidneys. This type accounts for 80 percent of cases. • renal sarcoma – a rare type of kidney cancer. • transitional cell carcinoma – this cancer starts in the join between the kidney and the adjoining ureter.
  • 5. Renal Failure – factors that influence the speed of kidney failure are still not completely understood, but current research is focused on how protein in diet and cholesterol in blood affect kidney function. Signs and symptoms indicative of kidney disease are needing to urinate more or less, loss of appetite, nausea and vomiting, swelling of hands or feet may occur, feeling drowsy, inability to concentrate, skin darkening, swelling of extremities or puffy eyelids and muscle cramps (Australian Kidney Foundation, NIDDK 2002). Three types of renal failure are:- • acute renal failure (ARF) – happens quickly, such as an accident that injures the kidneys like suddenly losing a lot of blood or sudden damage caused by some drugs or poisons. Kidney function suddenly drops. • chronic kidney disease (CKD) – happens gradually, and is often called silent kidney disease for years before realisation that damage to renal function and kidneys has occurred. • end-stage renal disease (ESRD) – is total or near total renal failure, and people with this condition have to undergo dialysis or transplantation to stay alive. Bladder Cancer – in 80 percent of cases, bladder cancers are superficial, where small mushroom like growths occur (DHS, 2001). They are removed using a cystoscope to snip the tumor off, and then cauterised to prevent bleeding. Often growths reoccur so follow up cystoscopies are required. Other bladder cancers require treatment such as surgical removal of part of the bladder, chemotherapy and radiotherapy. Early symptoms of bladder cancer are blood in the urine, frequent urge to urinate and/or painful sensations whilst urinating (DHD, 2001 & NIDDK 2002).
  • 6. Diagnostic Tests Urine Test/Urinalysis – involves urinating into a special container so urine can be assessed for appearance, specific gravity, protein, albumin, creatinine, ketone bodies or blood (Glen, 1994, NIDDK 2002). Testing urine can measure the creatinine clearance, which is a measure of the rate of removal of creatinine from the blood by the kidneys renal function. The normal rate in men is 97 to137 ml/min, and in women is 88 to 128 mL/min (NIDDK, 2001). Urodynamic Tests – evaluates urine storage in the bladder and how urine flows from the bladder through to the urethra (NIDDK, 2002). A small tube called a catheter is inserted through the urethra to the bladder to fill with either water or gas. Another small tube is inserted into the rectum to measure the pressure placed on the bladder, when straining of coughing. Other bladder tests use x-ray dye instead of water, so x-ray pictures can be taken when the bladder fills and empties, to assist detection of abnormalities in the shape or function of the bladder. Physical Examination – physical well being such as blood pressure, pulse, temperature, respirations, physical appearance, outstanding symptomology, appearance and subjective feelings of well being are assessed, as well as palpitation of the kidneys and bladder (Australian Kidney Foundation and Kozier & Erb, 1983). Palpitation checks the kidney for contour, size and tenderness. Tenderness can indicate inflammation. If unable to palpate, which could be due to obesity or very firm abdominal muscles, kidney tenderness may be detected by jarring the costoverbal angle. Cystoscopy – a slender tube is inserted to the bladder via the urethra allowing visualization of any signs of bleeding (DHS, 2001) Blood Tests – Samples of blood are tested for presence of substances that should be absent (NIDDK, 2001). Some of these substances are:- * Creatinine - instead of being put in urine by kidneys to leave the body, sometimes it can stay in blood and build up to unhealthy levels if kidneys have problems. A normal creatinine range is 0.6 to 1.2 mg/dL, but variations can occur due to diet, genetic make up and sex (NIDDK,2001). * Blood Urea Nitrogen (BUN) – is urea, a compound containing nitrogen that is found in the blood. Urea is waste product that is produced after cells use protein from the
  • 7. blood. Urea should be present in the urine but if kidneys are inefficient then urea stays in the blood. If BUN is more than 20 mgm/dL the kidneys are not working optimally and this could be due to gradual renal failure, dehydration or heart failure. Computerised Tomography (CT Scan) – a special x-ray that gives a three dimensional picture of your internal organs (NIDDK, 2002, DHS, 2001). Magnetic Resonance Imaging (MRI Scan) – similar to the CT scan, but radio waves and a strong magnetic field are used to give a three dimensional picture. Ultrasound Scan – sound waves create a picture of the inside of the body. Intravenous Pylogram – an injected dye that makes kidneys more visible during an x-ray (DHS, 2001). Arteriogram – an injected dye into an artery to show up any tumors in arteries and veins around the kidneys. Occupational Health and Safety Assessment, Responsibilities, & Management Identification of occupational hazards of chemical agents that workers are exposed to in the workplace, and have a risk of causing disorders or disease of the bladder and kidneys. The establishment and reviewing of material safety data sheets(MSDS), to ensure they current on all substances, and being informed on present, past and relevant epidemiological studies on workers in similar industries. Risk Assessment completion would allow a baseline to evaluate work practices. A safety programme then to be developed involving:- • Prescreening all employees before being employed in industry to obtain information about current and state of health, lifestyle factors and genetic history. Smoking, diabetes and family history of renal disease would place future employees in high risk groups before exposure to industry hazards. • Ongoing monitoring of workplace environment to ensure any hazardous exposure levels are not exceeded and ensure protective devices are working efficiently to maintain safety. Occupational hygienists can monitor workplaces regularly, and advise of further precautions.
  • 8. • Eliminate risks of chemicals/hazards by not using chemical hazard where possible, if not then maximising on use of, Personal Protection Equipment(PPE), safe design/layout of workplace and equipment that removes hazards such as extractor that rids laboratory of airborne toxic fumes. • Monitoring employee’s health regularly, such as weekly urine tests to measure creatinine levels, with 3-6 monthly physical check ups. • Documentation and actual education for workers of risks involved in working in industry, how to effectively utilise PPE, work safely with chemical/hazards, and maintain a healthy lifestyle to assist avoidance of diabetes, high cholesterol and smoking. • To recognise kidney and bladder disorders occurring due to exposures in the workplace. Diagnosed disorders to be detailed in workplace register, and treatment to be organised with further preventative measures such as job rotation, or tasks that involve not working with chemicals. • Cost analysis of most economically effective way to maintain programme, as it may be more cost effective to do urine testing within company, and physical check ups and ultrasounds externally.
  • 9. References Australian Kidney Foundation (AKF). Kidney Health - Fact Sheet. [online]. Available: http://www.kidney.org.au.renal_resources/fact_sheets/print_kidney_health.htm. [.Accessed 11th October 2002] Balter, P., Muehrcke, R.C., Morris, A.M., Moles, J.B., & Lawrence, A. G. (Toxline- Abstract). (1976). Chronic Toxic Nephrapathies Diagnosis and Management. (Source: Annals of Clinical and Laboratory Science, Vol 6, No. 4. pages 306-311.) Item 8 of 105. [online]. Available: http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?/temp/~AAA3dai.o8.BODY Department of Human Services, Victorian Government (DHS). (2000).Bladder Cancer. Better Health Channel.[online] 23rd October 2000. Available: http://www.betterhealth.vic.gov.au.bhcv2/bharticles.nsf/{pages}/bladder cancer. [Accessed 9th October 2002]. Department of Human Services, Victorian Government. (DHS). (2001). Kidney Cancer. Better Health Channel. [online] April 2001. Available: http://www.betterhealth.vic.gov.au.bhcv2/bharticles.nsf/{pages}/kidney cancer. [Accessed 9th October 2002]. Department of Human Services, Victorian Government. (DHS). (1999). Urinary system. Better Health Channel. [online]. 13th October 1999. Available: http://www.betterhealth.vic.gov.au.bhcv2/bharticles.nsf/{urinary cancer. [Accessed 16th October 2002]. Glen, S. B. (1994). The Urinary System – An Illustrated Review of the the Urinary System. Harper Collins. HealthInsite. (2002). Diseases Which Affect the Kidneys. Commonwealth Government of Australia Initiative. [online]. Available: http://www.healthinsite.gov.au/content/internal/page.cfm ?ObJD=00012984-0340-1D2D- [Accessed 11th October 2002]. Kozier, B., & Erb, G. (1983). Fundamentals of Nursing – Concepts and Procedures. 2nd Ed. California, United States of America: Addison-Wesley Publishing Company. Chapter 28. pp 704-736. Lilis,R., & Landrigan, P. J.(Abstract –Toxline). (1995). Renal and Urinary Tract Disorders -Occupational Health. Recognising and Preventing Work Related Disease (Abstract). Toxline. [online]. 15th October 2002. Available: http://toxnet.nlm.nih.gov/cgi-bin/sis/download.txt. >[Accessed 16th October 2002].
  • 10. McCredie, M., & Stewart, J. H. (1993). Risk Factors for kidney cancer in New South Wales. IV. Occupation (Abstract from article published in British Journal of Industrial Medicine). [online]. Available: http://www.nosch.gov.au/ohsinformation/databases/ohslitpgm/ohslit/r/003513.htm. [Accessed: 16th October 2002]. Miller, B., & Keane,C., (1987). Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health. 4th ed. Philadelphia, United States of America: Saunders. National Kidney and Urologic Diseases Information Clearinghouse (NIDDK)., U.S. Department of Health and Human Services. (2002a). Your Kidneys and How They Work. [online]. February. Available: http://www.niddk.nih.gov/health/kidney/pubs/yourkids/index.htm>[Accessed 11 October 2002] National Kidney and Urologic Diseases Information Clearinghouse (NIDDK)., U.S. Department of Health and Human Services. (2002b). Your Urinary System and How it Works. [online]. March Available:http://www.niddk.nih.gov/health/urolog/pubs/yurinar/index.htm>[Accessed 11 October 2002]. National Occupational Health & Safety Commission (NOSHC).(2002). Kidney- HISTORY.[online].Available: http://www.nohsc.gov.au/OHSInformation/NOHSCPublications/fulltext/docs/h6/870.htm >[Accessed 16th October 2002]. Ross, K., & Wilson, J. (1981). Foundations of Anatomy and Physiology. 5th ed. New York, United States of America: Churchill Livingstone. Waldron, H. & Edling.C.(Eds). 2001. Occupational Health Practice (4th ed). Oxford, Boston: Butterworths.