Basic in nephrology

1. BASICS IN NEPHROLOGY

2. What Is Nephrology
 Nephrology is abranch of medical science that deals with diseasesofthe kidneys.
 Nephrology (from Greek nephros "kidney", combined with the suffix -logy, "the study
of") is a specialty of medicine and pediatrics that concerns itself with the study of
normal kidney function, kidney problems, the treatment of kidney problems and renal
replacement therapy (dialysis and kidneytransplantation).

3. Anatomy and physiology of urinary tract

4. Anatomy and physiology
 TheKidneys
 Hilum
 Medulla
 Pyramids
 Papilla
 Renal
Pelvis

5. Working of urinarytract

6. Nephrons
 Glomerulus
 Bowman’s capsule
 Proximal Tubule
 Loop of Henle
 Distal Tubule
 Collecting Duct

8. Function Of Kidneys
Functions of theKidneys
 Forming and Eliminating Urine
 Maintaining blood volume with proper balance of water, electrolytes, and
pH.
 Retaining key compounds such as glucose, while excreting wastes
such as urea.
 Controlling Arterial Blood Pressure
 Regulating Erythrocyte Development

9. Formation of Urine
 Glomerular Filtration
– GFR
 Reabsorption & Secretion
– Simple diffusion and osmosis
– Facilitated diffusion
– Active transport

10. Bladder cancer
Bladder cancer is the rapid, uncontrolled growth of abnormal
cells in the bladder. Cancer usually begins in the lining of the
bladder. The cancerous cells may spread through the lining into
the muscular wall of the bladder.
CAUSES:Thecauseof is not known
 Changes in the genetic material (DNA) of bladder
cells mayplay arole.
 Chemicals in the environment and cigarette
smoking.
 When the lining of the bladder is irritated for a long time, cell
changes that lead to cancer may occur
 Other causes may be like radiation treatment, having catheters in
place for a long time, or having the parasite that causes
schistosomiasis.

11. Symptoms:
 Blood or blood clots in the urine (hematuria)
 Pain during urination (dysuria)
 Urinating small amounts frequently.
 Frequent urinary tract infections (UTIs)
 Swelling in the lowerlegs.
 Agrowth in the pelvis near the bladder (pelvicmass)
Treatment:
 Surgeryto remove the cancer.
 Chemotherapy to destroy cancer cells using medicines.
 Radiation therapy to destroy cancer cells using high-dose X-raysor otherhigh-energy rays.
 Immunotherapy: This treatment causesyour body's natural defenses, known asyour
immune system, to attack bladder cancercells.

12. Stages Of Bladder Cancer
There are five stagesof bladder cancer,stages0 to IV:
Stage 0: Cancer cells are only on the surface of the inner layer of the bladder. This may be called
carcinoma in situ.
StageI: Cancerhas grown deeper into the inner layer but not into the muscle layer.
StageII: Cancerhasgrown into the muscle layer of the bladder.
Stage III: Cancer has grown through the muscle layer and into nearby organs, such asthe prostate,
uterus, or vagina.
Stage IV: Cancer has grown into the wall of the pelvis or the belly but not into any lymph nodes. Or
the cancer has spread into at least one lymph node or to another part of the body, such asthe liver,
lungs, or bones.

13. Impotence
Impotence is defined as the inability to achieve or maintain an erection to
perform intercourse or ejaculation.
There are two forms of impotence: primaryand secondary
PRIMARY: Men with primary impotence have never had sufficient erection
for satisfactory intercourse. This form of impotence is rare and is often
caused by extreme psychological conditions, such as intense fear of
intimacy, extreme feelings of guilt, and severeanxiety.
SECONDARY : The loss of erectile function after a period of normal
function, is more common. Men with secondary erection are typically
able to engagein intercourse only 25%of thetime.

14. Causes:
 Diseases
The major cause of impotence is disease. It is estimated that over 70% of all serious impotence
cases are the result of diabetes, kidney diseases, multiple sclerosis, endocrine disorders, vascular
diseases and high blood pressure, as well as neurological diseases. It is estimated that between
50%and 60%of diabetic men areimpotent.
 Medication
Prescribed drugs used to treat high blood pressure, ulcer, depression, prostate cancer, as well as
drugs to prevent baldnessor to aid dieting, canhaveside effects thatinclude impotence.
 Surgery
Surgery on the spinal cord, prostate, bladder, or pelvis can lead to impotence by damaging
essential nerves, tissues, muscles,or arteries needed.
 Cigarettesmoking, alcohol and narcoticsuse
 Hormonalimbalance
 Psychological factors
 Low self-esteem, depression, and especially stressandanxiety

15. Symptoms: Symptoms of EDinclude erections that are too soft for sexual intercourse, erections that
last only briefly, and an inability to achieve erections. Men who cannot have or maintain an erection
at least 75%of the time that they attempt sexare considered to have ED.
Treatment:
Erectile Dysfunction Vacuums: A vacuum constriction device (VCD) is an external pump with a
band on it that a man with erectile dysfunction can use to get and maintain an erection.
Penile Implants : A penile prosthesis is another treatment option for men with erectile dysfunction.
These devices are either malleable (bendable) or inflatable. The simplest type of prosthesis consists
of a pair of malleable rods surgically implanted within the erection chambers of the penis. With this
type of implant the penis is always semi-rigid and merely needs to be lifted or adjusted into the erect
position to initiate sex.
Erectile Dysfunction Surgery : Surgery can improve the blood flow to the penis, thus improving
erections.
Hormonal Therapy for Erection Problems : Testosterone, bromocriptine, and cabergoline are
hormonal treatments that may help with erectile dysfunction.

16. Kidney Diseases
 Most kidney diseases attack the nephrons. This damage
may leave kidneys unable to remove wastes. Causes
can include genetic problems, injuries, or medicines.
Person can be at greater risk if he is suffering from
diabetes, high BP, or a close family member with kidney
disease.
Kidney problem includes:
 Chronic kidney disease
 Cancer
 Cyst
 Stones
 Infection

17. Chronic kidney disease:
It is also known as chronic renal disease, is a progressive loss in kidney function over a period of
months or years. It means that your kidneys are damaged and can't filter blood asthey should. This
damage can cause wastes to build up in your body. It can also cause other problems that can harm
your health.
Causes:There canbe number of causes:
 Diabetes mellitus
 Others include idiopathic(ie unknown cause, often associated with small kidneys on
renal ultrasound), hypertension , andglomerulonephritis
 Congenital diseasesuchaspolycystic kidney disease
 Bilateral kidney stones
 pinworms infecting the kidney canalso causenephropathy.
 Mesoamerican nephropathy, a form of CKDu, is "a new form of kidney disease that could be
called agriculturalnephropathy

18. Symptoms:
Signsand symptoms of chronic kidney diseasedevelop over timeif kidney damageprogresses
slowly
 Nausea
 Vomiting
 Lossof appetite
 Fatigue and weakness
 Sleepproblems
 Changesin urine output
 Decreasedmental sharpness
 Muscle twitches andcramps

19. Symptoms continued:
 Hiccups
 Swelling of feet andankles
 Chest pain, if fluid builds up around the lining of the heart
 Shortness of breath, if fluid builds up in the lungs
 High blood pressure (hypertension) that's difficult tocontrol
Signsand symptoms of kidney diseaseare often nonspecific, meaning they canalso be caused
by other illnesses.

20. Treatment: Though, chronic kidney disease has no cure. In general, treatment consists of
measures to help control signs and symptoms, reduce complications, and slow progression of
thedisease.
Treatingcomplication: Treatmentsmayinclude:
High blood pressure medications : Medications to lower your blood pressure commonly
angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers — and to
preserve kidney function. High blood pressure medications can initially decrease kidney
function and changeelectrolyte levels.
Medications to lower cholesterol levels : Medications called statins to lower your cholesterol .
People with chronic kidney disease often experience high levels of bad cholesterol, which can
increase the risk of heartdisease.
Medications to treat anemia : Erythropoietin supplements aid in production of more red
blood cells, which may relieve fatigue and weaknessassociated with anemia .

21. Medications to relieve swelling: People with chronic kidney disease may retain fluids. This
can lead to swelling in the legs, as well as high blood pressure. Medications called diuretics
can help maintain the balance of fluids in your body.
Medications to protect your bones: Calcium and vitamin D supplements to prevent
weak bones and lower your risk offracture.
A lower protein diet to minimize waste products in your blood: As your body processes
protein from foods, it creates waste products that your kidneys must filter from your blood.
To reduce the amount of work your kidneys must do, your doctor may recommend eating
lessprotein.

22. Treatment for end-stage kidney disease: Kidneys can't keep up
with waste and fluid clearance on their own and you develop
complete or near-complete kidney failure, you have end-stage
kidneydisease.
Dialysis: Dialysis artificially removes waste products and extra fluid
from your blood when your kidneys can no longer do this. In
hemodialysis, a machine filters waste and excess fluids from your
blood. In peritoneal dialysis, a thin tube (catheter) inserted into
your abdomen fills your abdominal cavity with a dialysis solution
that absorbs waste and excess fluids. After a period of time, the
dialysis solution drains from your body, carrying the waste with it.
Kidney Ttransplant. Akidney transplant involves surgically placing a
healthy kidney from a donor into your body. Transplanted kidneys
can come from deceased or living donors. You'll need to take
medications for the rest of your life to keep your body from rejecting
the neworgan.

23. DIALYSIS:

24. Kidney cancer
It is also called asHypernephroma, Renal cellcarcinoma.
Renalcell cancer is a disease in which malignant (cancer) cells
form in tubules of the kidney.
Causes:
Riskfactors for renal cell cancer include thefollowing:
 Smoking
 Misusing certain pain medicines, including over-the-counter
pain medicines, for along time.
 Having certain genetic conditions, suchas
von Hippel-Lindau diseaseor hereditary
papillary renal cellcarcinoma.

25. Symptoms: Signs and symptoms may be caused by renal cell cancer or by other
conditions. There maybe no signsor symptoms in the early stages.
Signsand symptoms may appear asthe tumor grows.
 Blood in the urine.
 Apain in the side that doesn't goaway.
 Lossof appetite
 Weight lossfor no knownreason.
 Anemia
sizeof tumor : pea,nut. alnut,and lime

26. Treatment:Fivetypes of standard treatment areused:
Surgery: Surgery to remove part or all of the kidney is often used to treat renal cell cancer.
Thefollowing types of surgery may be used:
Partial nephrectomy: A surgical procedure to remove the cancer within the kidney and some of
the tissue around it. Apartial nephrectomy may be done to prevent loss of kidney function when
the other kidney is damaged or hasalready beenremoved.
Simple nephrectomy:Asurgical procedure to remove the kidneyonly.
Radical nephrectomy: A surgical procedure to remove the kidney, the adrenal gland,
surrounding tissue, and, usually, nearby lymph nodes.
Radiation therapy: Radiation therapy is a cancer treatment that uses high- energy x-rays or
other types of radiation to kill cancer cells or keep them from growing. There are two types of
radiation therapy. External radiation
therapy uses a machine outside the body to send radiation toward the cancer. Internal
radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or
catheters that are placed directly into ornear the cancer.

27. Chemotherapy:Chemotherapy is acancer treatment that usesdrugs to stopthe
growth of cancer cells, either by killing the cells or by stopping them from dividing
Biologic therapy: Biologic therapy is a treatment that uses the patient's immune system
to fight cancer. Substances made by the body or made in a laboratory are used to boost,
direct, or restore the body's natural defenses against cancer. This type of cancer treatment
is also called biotherapy orimmunotherapy.
Targeted therapy: Targeted therapy with antiangiogenic agents are used to treat advanced
renal cell cancer. Antiangiogenic agents keep blood vessels from forming in a tumor,
causing the tumor to starve and stop growing or to shrink. MonoclonaL antibodies and
kinase inhibitors are two types of antiangiogenic agents used to treat renal cellcancer.
 New types oftreatment are being tested in clinical trials.
 Patients may want to think about taking part in aclinical trial.
 Patients can enter clinical trials before, during, or after starting their cancer treatment.
 Follow-up tests maybe needed.

28. Kidney cysts
Acyst is afluid-filled sac.There are two types of kidneycysts.
Polycystic kidney disease (PKD) runs in families. In PKD, the cysts take
the place of the normal tissue. They enlarge the kidneys and make them
work poorly, leading to kidney failure. When PKDcauses kidneys to fail -
which usually happens after many years - people need dialysis or kidney
transplantation. PKDalso causes cysts in other parts of the body, such as
the liver.
Acquired cystic kidney disease (ACKD) usually happens in people who
are on dialysis. Unlike PKD, the kidneys are normal sized, and cysts do
not form in other parts of the body. People with ACKD already have
chronic kidney disease when they develop cysts. ACKD often has no
symptoms. In most cases, the cysts are harmless and do not need
treatment.

29. Symptoms:
Symptoms of PKDinclude
 Pain in the back and lower sides
 Headaches
 Urinary tract infections
 Blood in the urine
Treatment: Simple kidney cyst causes no signs or symptoms and doesn't interfere with your
kidney function, you may notneed treatment.
 Puncturing and draining the cyst, then filling it with alcohol. Rarely, to shrink the cyst,
doctor inserts a long, thin needle through skin and through the wall of the kidney cyst. Then
the fluid is drained from the cyst. doctor may fill the cyst with an alcohol solution to prevent it
from reforming
 Surgery to remove the cyst. A large or symptomatic cyst may require surgery to drain and
remove it. Toaccess the cyst, the surgeon makes several small incisions in your skin and inserts
special tools and a small video camera. While watching a video monitor in the operating room,
the surgeon guides the tools to the kidney and uses them to drain the fluid from the cyst. Then
the walls of the cyst are cut or burned away.

30. Kidney Stones
 A kidney stone is a solid piece of material that forms
in the kidney from substances in the urine.
 It may be as small as a grain of sand or as large as
a pearl. Most kidney stones pass out of the body
without help from a doctor.
 But sometimes a stone will not go away. It may get
stuck in the urinary tract, block the flow of urine and
cause great pain.
 Kidney stones (renal lithiasis, nephrolithiasis) are
small, hard mineral deposits that form inside your
kidneys. The stones are made of mineral and acid
salts.

31. Types of kidney stones
 Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium
oxalate. Oxalate is a naturally occurring substance found in food. Some fruits and vegetables,
as well as nuts and chocolate, have high oxalate levels. Your liver also produces oxalate.
Dietary factors, high doses of vitamin D, intestinal bypass surgery and several metabolic
disorders canincrease the concentration of calcium or oxalate in urine.
 Struvite stones. Struvite stones form in response to an infection, such as a urinary tract
infection. These stones can grow quickly and become quite large, sometimes with few
symptoms or littlewarning.
 Uric acid stones. Uric acid stones can form in people who don't drink enough fluids or who
lose too much fluid, those who eat a high-protein diet, and those who have gout. Certain
genetic factors also may increase your risk of uric acidstones.
 Cystine stones. These stones form in people with a hereditary disorder that causes the
kidneys to excrete too much of certain amino acids (cystinuria).

32. Causes :
Kidney stones may form when the normal balance of water, salts, minerals, and other substances
found in urine changes. Most kidney stones are calcium-type-they form when the calcium levels
in your urine change.
Thingsthat changeyour urine balanceinclude:
 Not drinking enough water. When you don't drink enough water, the salts, minerals, and
other substances in the urine can stick together and form a stone. This is the most common
causeof kidneystones.
 Medical conditions. Many medical conditions can affect the normal balance and cause stones
to form. Examplesinclude gout and inflammatory bowel disease, suchasCrohn's disease.
 More commonly, kidney stones can run in families, as stones often occur in family members
over severalgenerations.
 An rare cases, a person forms kidney stones because the parathyroid glands produce too
much of ahormone. Thisleads tohigher calcium levels and possibly calcium kidneystones.

33. Treatment:
There canbe many ways:
 If a kidney stone seems small enough, your doctor may recommend you take pain medicine
and wait for the stone to passout of the body on its own.
 Drugs known asalpha-blockers relax the walls of the ureter. Thiswidens the passagessoa
stone canfit through moreeasily.
 The most common medical procedure for treating kidney stones is known as extracorporeal
shock wave lithotripsy (ESWL). This therapy uses high-energy shock waves to break a kidney
stone into little pieces.Thesmall pieces canthen move through the urinary tractmore easily.
 When a stone has made its way out of the kidney and is close to the bladder, the most
common procedure is ureteroscopy. A thin tube is passed through the urinary tract to the
location of the stone.

34. Symptoms:
Akidney stone usually remains symptomless until it movesintothe ureter. When symptoms of
kidney stones become apparent, they commonly include:
 Severepain in the groin and/orside
 Blood in urine
 Vomiting and nausea
 White blood cells or pus in the urine
 Reducedamount of excreted urineexcreted
 Burning sensation during urination
 Persistent urge to urinate
 Feverand chills if there is aninfection

35. Urinary tract infection
A urinary tract infection (UTI) can occur in any part of the urinary tract.
Bacteria cause the vast majority of UTIs. Fungi or viruses can also cause
UTIs. Infection involving the kidneys, ureters, bladder, or urethra. These are
the structures that urine passes through before being eliminated from the
body.
 Urinary tract infection is second only to respiratory infection as the
most common type of infection.
 About 40% of women and 12% of men have a urinary tract infection at
some
time in theirlife

36. Causes:
Anything that reduces bladder emptying or irritates the urinary tract can cause UTIs. The culprit in
at least 90% of uncomplicated infections is a type of bacteria called Escherichia coli,better know
asE.coli. These bacteria normally live in the bowel (colon) and around the anus.
 The culprit in at least 90%of uncomplicated infections is a type of bacteria calledEscherichia
coli ,better know as E. coli. These bacteria normally live in the bowel (colon) and around
the anus.
 People with medical conditions that cause incomplete bladder emptying (for example, spinal
cord injury or bladder decompensation after menopause)
 People with suppressed immune systems: Examples of situations in which the immune
Esystem is suppressed are HIV/AIDS and diabetes. People who take immunosuppressant
medications such aschemotherapy for cancer also are atincreased risk.
 Women who are sexually active: Sexual intercourse can introduce larger numbers of bacteria
into the bladder. Urinating after intercourse seems to decrease the likelihood of developing a
urinary tract infection.
 Women who use adiaphragm for birth control

37. Symptoms:
Symptomsof UTIdepend upon what part of the urinary tract is infected. Lower
UTIsare infections of the urethraand bladder. Their symptoms include:
 Burning With Urination
 Increased Frequency Of Urination With ScantAmounts Of Urine Being
Passed
 BloodyUrine
 CloudyUrine
 Urine That Looks Like Cola OrTea
 Strong Odour ToUrine
 Pelvic Pain(Women)
 Rectal Pain (men)

38. Upper UTIs.
Theseare potentially life threatening,if bacteria move from the infected kidney
into the blood. Thiscondition is called sepsis.Sepsiscancausedangerously low
blood pressures,shock,and death.
Symptomsof upper UTIinclude:
 Pain and tenderness in the upper back andsides
 Chills
 Fever
 Nausea
 Vomiting
Treatment: Antibiotics are usedto treat UTIs.Lower UTIscanbe treatedwith
oral antibiotics. Upper UTIsrequire intravenousantibiotics.
 Sometimes, bacteria develop resistance to antibiotics. Urine cultures canhelp
your doctor select an effective antibiotictreatment.

39. Mastectomy
Amastectomy is surgery to remove one or both breast partially orcompletely.A
mastectomy is usually carried out to treatbreast cancer.
Typesof mastectomy:
Total Mastectomy
Preventive Mastectomy
Partial Mastectomy
RadicalMastectomy
Modified RadicalMastectomy

40. Total Mastectomy: Also called simple mastectomy, with this procedure, your doctor removes your
entire breast, including the nipple. But your lymph nodes, the small glands that are part of your
immune system, aren’t removed.
Preventive Mastectomy: Women who have a high risk of breast cancer may choose to have a
,preventive mastectomy also called prophylactic mastectomy. Studies show that women with a high
risk of breast cancer may be as much as 90% less likely to get the disease after preventive
mastectomy. Some women who've had breast cancer in one breast will decide to have a preventive
mastectomyto remove the other breast.
Partial Mastectomy: Women with stage I or stage II breast cancer may have this procedure. It’s
is a breast-conserving method in which the tumor and the tissue surrounding it are all that’s
removed. The surgery is followed by radiation therapy to the remaining breast tissue. With
radiation therapy, powerful X-rays target the breasttissue.

41. Radical Mastectomy: Aradical mastectomy is the complete removal of the breast, including the
nipple. The surgeon also removes the overlying skin, the muscles beneath the breast, and the
lymph nodes. Because radical mastectomy isn't more effective than other less extreme forms of
mastectomy, it's rarely performedtoday.
Modified Radical Mastectomy: Aless traumatic and more widely used procedure is the modified
radical mastectomy (MRM). With the modified radical mastectomy, the entire breast is removed
as well as the underarm lymph nodes. But chest muscles are left intact. The skin covering the
chest wall may or may not be left intact. The procedure may be followed with breast
reconstruction.
Side effects: the post-surgical pain and the obvious change in the shape of the breast(s), possible
side effects of a mastectomy include wound infection, hematoma (buildup of blood in the wound),
and the seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed,
additional side effects may occur.

42. Nocturia
Nocturia is a condition in which you wake up during the night
because you have to urinate. This condition becomes more
common as people age and occurs in both men and women,
sometimes for differentreasons.
Normally, you should be able to sleep six to eight hours during the
night without having to get up to go to the bathroom. People who
have nocturia wake up more than once a night to urinate. This can
causedisruptions in anormal sleepcycle.

43. Causes:
There are three waysin which nocturia canbecaused:
 Byproblems of fluid balance
 Byneurological diseasesaffecting bladder control
 Bydisorders of the lower urinarytract (LUT)
Fluid imbalance
 Excessfluid intake - includingalcohol
 Diabetes mellitus (DM)
 Diabetesinsipidus
 Hypercalcaemia
 Renalfailure (more likely inchronic kidney diseaserather than acute kidney injury)

44. Neurological causes of Nocturia
Thebladder is controlled via the brain, spinal cord tracts, sacral segmentsS2-S4 and
peripheral nerves.Therefore, many neurological conditions affect bladder function.
Theneurology may causeretention of urine, which either results in frequency and true
nocturia, or leads to overflow incontinence, which maybe misinterpreted as nocturia.
LUTcausesof nocturia:
Thisis a'low nocturnal bladder capacity', which canbe classified asdueto:
– Bladder outflowobstruction (where chronic retention in effect lowers any additional
bladdercapacity):
– Prostatic disease: benign prostatic hypertrophy, prostate cancer
– Urethral disease - this occurs both in men and inwomen[8]

45. Causes continued:
 Bladder overactivity
 Sensoryurgency
 Urinary tractinfection
 Inflammation - eg, interstitial cystitis
 Malignancy
 Pregnancy

46. TREATMENT:
Interventions:
 Restrict fluids in the evening (especially coffee, caffeinated beverages, and
alcohol).
 Time intake of diuretics (take mid- to late afternoon, six hours before bedtime).
 Takeafternoon naps.
 Elevate the legs(helps prevent fluid accumulation).
 Wear compression stockings (helps prevent fluid accumulation).
Medications:
 Anticholinergic medications: reduce symptoms of overactivebladder
 Bumetanide (Bumex), Furosemide (Lasix): diuretics that assist in regulating
urine production
 Desmopressin (DDAVP):helps the kidneys produce lessurine