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Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 1
Alterations of Renal and Urinary
Tract Function
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 2
Urinary Tract Obstruction
 Urinary tract obstruction is an interference
with the flow of urine at any site along the
urinary tract
 The obstruction can be caused by an anatomic
or functional defect
• Obstructive uropathy
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 3
Urinary Tract Obstruction
(cont’d)
 Severity based on:
 Location
 Completeness
 Involvement of one or both upper urinary tracts
 Duration
 Cause
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 4
Upper Urinary Tract Obstruction
 Hydroureter
 Hydronephrosis
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 5
Urinary Tract Obstruction
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 6
Upper Urinary Tract Obstruction
 Compensatory hypertrophy and
hyperfunction
 Obligatory growth
 Compensatory growth
 Postobstructive diuresis (nephrogenic
diabetes insipidus)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 7
Upper Urinary Tract Obstruction
(cont’d)
 Kidney stones
 Calculi or urinary stones
• Masses of crystals, protein, or other substances that
form within and may obstruct the urinary tract
 Risk factors:
• Gender
• Race
• Geographic location
• Seasonal factors
• Fluid intake
• Diet
• Occupation
 Kidney stones are classified according to the
minerals that make up the stone
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 8
Kidney Stone Formation
 Supersaturation of one or more salts
 Presence of a salt in a higher concentration
than the volume able to dissolve the salt
 Precipitation of a salt from liquid to solid
state
 Temperature and pH
 Growth into a stone via crystallization or
aggregation
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 9
Kidney Stone Formation
(cont’d)
 Other factors affecting stone formation:
 Crystal growth-inhibiting substances
 Particle retention
 Matrix
 Stones:
 Calcium oxalate or calcium phosphate
 Struvite stones
 Uric acid stones
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 10
Kidney Stones
 Manifestation
 Renal colic
 Evaluation
 History
 Stone and urine analysis
 Intravenous pyelogram (IVP) or kidney, ureter,
bladder x-ray (KUB)
 Spiral abdominal CT
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 11
Kidney Stones (cont’d)
 Treatment:
 High fluid intake
 Decreasing dietary intake of stone-forming
substances
 Stone removal
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 12
Lower Urinary Tract Obstruction
 Neurogenic bladder
 Dyssynergia
• Detrusor hyperreflexia-overactive
• Detrusor areflex-underactive
 Overactive bladder syndrome (OBS)
• Frequency, urgency, nocturia
 Obstruction
• Urethal stricture, prostate enlargement, pelvic organ
prolapse
• Partial obstruction of bladder outlet or urethra
 Low bladder wall compliance
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 13
Tumors
 Renal tumors
 Renal adenomas
 Renal cell carcinoma (RCC)
 Bladder tumors
 Transitional cell carcinoma (most common)
 Gross, painless hematuria
 Most common in males older than 60 years
and smokers
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 14
Urinary Tract Infection (UTI)
 UTI is inflammation of the urinary
epithelium caused by bacteria
 Acute cystitis
 Painful bladder syndrome/interstitial
cystitis
 Acute and chronic pyelonephritis
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 15
Urinary Tract Infection (UTI)
(cont’d)
 Most common pathogens
 Escherichia coli
 Virulence of uropathogens
 Host defense mechanisms
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 16
Urinary Tract Infection (UTI)
(cont’d)
 Acute cystitis
 Cystitis is an inflammation of the bladder
 Manifestations:
• Frequency
• Dysuria
• Urgency
• Lower abdominal and/or suprapubic pain
 Treatment:
• Antimicrobial therapy
• Increased fluid intake
• Avoidance of bladder irritants
• Urinary analgesics
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 17
Urinary Tract Infection (UTI)
(cont’d)
 Interstitial cystitis
 Nonbacterial infectious cystitis
 Manifestations:
• Most common in women 20 to 30 years old
• Bladder fullness, frequency, small urine volume,
chronic pelvic pain
 Treatment
• No single treatment effective, symptom relief
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 18
Urinary Tract Infection (UTI)
(cont’d)
 Pyelonephritis
 Acute pyelonephritis
• Acute infection of the renal pelvis interstitium
 Vesicoureteral reflux, E. coli, Proteus, Pseudomonas
 Chronic pyelonephritis
• Persistent or recurring episodes of acute
pyelonephritis that lead to scarring
• Risk of chronic pyelonephritis increases in
individuals with renal infections and some type of
obstructive pathologic condition
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 19
Chronic Pyelonephritis
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 20
Glomerular Disorders
 Glomerulonephritis
 Inflammation of the glomerulus
• Immunologic abnormalities (most common)
• Drugs or toxins
• Vascular disorders
• Systemic diseases (secondary)
• Viral causes
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 21
Glomerulonephritis
 Mechanisms of injury
 Deposition of circulating soluble antigen-
antibody complexes, often with complement
fragments (Type III hypersensitivity)
 Antibodies reacting in situ against planted
antigens within the glomerulus (Type II
hypersensitivity–cytotoxic)
 Nonimmune (drugs, toxins, ischemia)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 22
Glomerulonephritis (cont’d)
 Manifestations:
 Two major symptoms if severe
• Hematuria with red blood cell casts
• Proteinuria exceeding 3 to 5 g/day with albumin
(macroalbuminuria) as the major protein
 Oliguria
 Hypertension
 Edema
 Nephrotic sediment
 Nephritic sediment
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 23
Glomerulonephritis (cont’d)
 Types:
 Membranous nephropathy/glomerulonephritis
 Rapidly progressing glomerulonephritis
• Antiglomerular basement membrane disease
(Goodpasture syndrome)
 Chronic glomerulonephritis
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 24
Glomerulonephritis (cont’d)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 25
Nephrotic Syndrome
 Excretion of 3.5 g or more of protein in the
urine per day
 The protein excretion is caused by
glomerular injury
 Findings:
 Hypoalbuminemia
 Edema
 Hyperlipidemia and lipiduria
 Vitamin D deficiency
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 26
Nephrotic Syndrome (cont’d)
 Membranous glomerulonephritis
 Focal glomerulosclerosis
 Minimal change disease (lipoid nephrosis)
 Nephritic syndrome
 Hematuria
 Mild proteinuria
 Immune injury
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 27
Acute Kidney Injury (AKI)
 Renal insufficiency
 Renal failure
 End stage renal failure (ESRF)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 28
Acute Kidney Injury (AKI)
(cont’d)
 Prerenal
 Most common cause of ARF
 Caused by impaired renal blood flow
 GFR declines because of the decrease in
filtration pressure
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 29
Acute Kidney Injury (AKI)
(cont’d)
 Intrarenal
 Acute tubular necrosis (ATN) is the most
common cause of intrarenal renal failure
• Postischemic or nephrotoxic
• Oliguria
 Postrenal
 Occurs with urinary tract obstructions that
affect the kidneys bilaterally
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 30
Acute Kidney Injury (AKI)
(cont’d)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 31
Acute Kidney Injury (AKI)
(cont’d)
 Initiation phase
 Kidney injury is evolving
 Prevention of injury is possible
 Maintenance phase
 Established kidney injury and dysfunction
 Urine output is lowest during this phase and serum
creatinine and blood urea nitrogen both increase
 Recovery phase
 Injury repaired and normal renal function reestablished
 Diuresis common
 Decline in serum creatinine and urea
 Increase in creatinine clearance
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 32
Chronic Kidney Disease (CKD)
 Progressive loss of renal function that
affects nearly all organ systems
 Associated with HTN, diabetes, intrinsic
kidney disease
 Stages:
 Normal (GFR >90mL/min)
 Mild (GFR 60-89mL/min)
 Moderate (GFR 30-59mL/min)
 Severe (GFR 15-29mL/min)
 End stage (GFR less than 15)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 33
Chronic Kidney Disease (CKD)
(cont’d)
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 34
Chronic Kidney Disease (CKD)
(cont’d)
 Proteinuria and uremia
 Due to glomerular hyperfiltration
 Damages interstitial tissue of kidney via
inflammation
 Creatinine and urea clearance
 GFR falls
 Plasma creatinine increases
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 35
Chronic Kidney Disease (CKD)
(cont’d)
 Fluid and electrolyte balance
 Sodium and water balance
• Sodium excretion increases with obligatory water
excretion leading to sodium deficit and volume loss
• Concentration and dilution ability diminishes
 Potassium balance
• Tubular secretion increases early
• Once oliguria sets in, potassium retained
 Acid-base balance
• Metabolic acidosis when GFR 30%-40%
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 36
Chronic Kidney Disease (CKD)
(cont’d)
 Fluid and electrolyte balance
 Calcium, phosphate, bone
• Reduced renal phosphate excretion, decreased
renal synthesis of 1,25-(OH)2 vitamin D3, and
hypocalcemia.
• Fractures
 Protein, carbohydrate, fat metabolism
 Anemia
• Lethargy, dizziness, and low hematocrit are common
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 37
Chronic Kidney Disease (CKD)
(cont’d)
 Alterations seen in following systems:
 Cardiovascular
 Pulmonary
 Hematologic
 Immune
 Neurologic
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 38
Chronic Kidney Disease (CKD)
(cont’d)
 Gastrointestinal
 Endocrine and reproduction
 Integumentary
Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 39
Signs and Symptoms of Kidney
Failure

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Alterations and renal

  • 1. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 1 Alterations of Renal and Urinary Tract Function
  • 2. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 2 Urinary Tract Obstruction  Urinary tract obstruction is an interference with the flow of urine at any site along the urinary tract  The obstruction can be caused by an anatomic or functional defect • Obstructive uropathy
  • 3. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 3 Urinary Tract Obstruction (cont’d)  Severity based on:  Location  Completeness  Involvement of one or both upper urinary tracts  Duration  Cause
  • 4. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 4 Upper Urinary Tract Obstruction  Hydroureter  Hydronephrosis
  • 5. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 5 Urinary Tract Obstruction
  • 6. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 6 Upper Urinary Tract Obstruction  Compensatory hypertrophy and hyperfunction  Obligatory growth  Compensatory growth  Postobstructive diuresis (nephrogenic diabetes insipidus)
  • 7. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 7 Upper Urinary Tract Obstruction (cont’d)  Kidney stones  Calculi or urinary stones • Masses of crystals, protein, or other substances that form within and may obstruct the urinary tract  Risk factors: • Gender • Race • Geographic location • Seasonal factors • Fluid intake • Diet • Occupation  Kidney stones are classified according to the minerals that make up the stone
  • 8. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 8 Kidney Stone Formation  Supersaturation of one or more salts  Presence of a salt in a higher concentration than the volume able to dissolve the salt  Precipitation of a salt from liquid to solid state  Temperature and pH  Growth into a stone via crystallization or aggregation
  • 9. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 9 Kidney Stone Formation (cont’d)  Other factors affecting stone formation:  Crystal growth-inhibiting substances  Particle retention  Matrix  Stones:  Calcium oxalate or calcium phosphate  Struvite stones  Uric acid stones
  • 10. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 10 Kidney Stones  Manifestation  Renal colic  Evaluation  History  Stone and urine analysis  Intravenous pyelogram (IVP) or kidney, ureter, bladder x-ray (KUB)  Spiral abdominal CT
  • 11. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 11 Kidney Stones (cont’d)  Treatment:  High fluid intake  Decreasing dietary intake of stone-forming substances  Stone removal
  • 12. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 12 Lower Urinary Tract Obstruction  Neurogenic bladder  Dyssynergia • Detrusor hyperreflexia-overactive • Detrusor areflex-underactive  Overactive bladder syndrome (OBS) • Frequency, urgency, nocturia  Obstruction • Urethal stricture, prostate enlargement, pelvic organ prolapse • Partial obstruction of bladder outlet or urethra  Low bladder wall compliance
  • 13. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 13 Tumors  Renal tumors  Renal adenomas  Renal cell carcinoma (RCC)  Bladder tumors  Transitional cell carcinoma (most common)  Gross, painless hematuria  Most common in males older than 60 years and smokers
  • 14. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 14 Urinary Tract Infection (UTI)  UTI is inflammation of the urinary epithelium caused by bacteria  Acute cystitis  Painful bladder syndrome/interstitial cystitis  Acute and chronic pyelonephritis
  • 15. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 15 Urinary Tract Infection (UTI) (cont’d)  Most common pathogens  Escherichia coli  Virulence of uropathogens  Host defense mechanisms
  • 16. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 16 Urinary Tract Infection (UTI) (cont’d)  Acute cystitis  Cystitis is an inflammation of the bladder  Manifestations: • Frequency • Dysuria • Urgency • Lower abdominal and/or suprapubic pain  Treatment: • Antimicrobial therapy • Increased fluid intake • Avoidance of bladder irritants • Urinary analgesics
  • 17. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 17 Urinary Tract Infection (UTI) (cont’d)  Interstitial cystitis  Nonbacterial infectious cystitis  Manifestations: • Most common in women 20 to 30 years old • Bladder fullness, frequency, small urine volume, chronic pelvic pain  Treatment • No single treatment effective, symptom relief
  • 18. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 18 Urinary Tract Infection (UTI) (cont’d)  Pyelonephritis  Acute pyelonephritis • Acute infection of the renal pelvis interstitium  Vesicoureteral reflux, E. coli, Proteus, Pseudomonas  Chronic pyelonephritis • Persistent or recurring episodes of acute pyelonephritis that lead to scarring • Risk of chronic pyelonephritis increases in individuals with renal infections and some type of obstructive pathologic condition
  • 19. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 19 Chronic Pyelonephritis
  • 20. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 20 Glomerular Disorders  Glomerulonephritis  Inflammation of the glomerulus • Immunologic abnormalities (most common) • Drugs or toxins • Vascular disorders • Systemic diseases (secondary) • Viral causes
  • 21. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 21 Glomerulonephritis  Mechanisms of injury  Deposition of circulating soluble antigen- antibody complexes, often with complement fragments (Type III hypersensitivity)  Antibodies reacting in situ against planted antigens within the glomerulus (Type II hypersensitivity–cytotoxic)  Nonimmune (drugs, toxins, ischemia)
  • 22. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 22 Glomerulonephritis (cont’d)  Manifestations:  Two major symptoms if severe • Hematuria with red blood cell casts • Proteinuria exceeding 3 to 5 g/day with albumin (macroalbuminuria) as the major protein  Oliguria  Hypertension  Edema  Nephrotic sediment  Nephritic sediment
  • 23. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 23 Glomerulonephritis (cont’d)  Types:  Membranous nephropathy/glomerulonephritis  Rapidly progressing glomerulonephritis • Antiglomerular basement membrane disease (Goodpasture syndrome)  Chronic glomerulonephritis
  • 24. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 24 Glomerulonephritis (cont’d)
  • 25. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 25 Nephrotic Syndrome  Excretion of 3.5 g or more of protein in the urine per day  The protein excretion is caused by glomerular injury  Findings:  Hypoalbuminemia  Edema  Hyperlipidemia and lipiduria  Vitamin D deficiency
  • 26. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 26 Nephrotic Syndrome (cont’d)  Membranous glomerulonephritis  Focal glomerulosclerosis  Minimal change disease (lipoid nephrosis)  Nephritic syndrome  Hematuria  Mild proteinuria  Immune injury
  • 27. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 27 Acute Kidney Injury (AKI)  Renal insufficiency  Renal failure  End stage renal failure (ESRF)
  • 28. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 28 Acute Kidney Injury (AKI) (cont’d)  Prerenal  Most common cause of ARF  Caused by impaired renal blood flow  GFR declines because of the decrease in filtration pressure
  • 29. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 29 Acute Kidney Injury (AKI) (cont’d)  Intrarenal  Acute tubular necrosis (ATN) is the most common cause of intrarenal renal failure • Postischemic or nephrotoxic • Oliguria  Postrenal  Occurs with urinary tract obstructions that affect the kidneys bilaterally
  • 30. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 30 Acute Kidney Injury (AKI) (cont’d)
  • 31. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 31 Acute Kidney Injury (AKI) (cont’d)  Initiation phase  Kidney injury is evolving  Prevention of injury is possible  Maintenance phase  Established kidney injury and dysfunction  Urine output is lowest during this phase and serum creatinine and blood urea nitrogen both increase  Recovery phase  Injury repaired and normal renal function reestablished  Diuresis common  Decline in serum creatinine and urea  Increase in creatinine clearance
  • 32. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 32 Chronic Kidney Disease (CKD)  Progressive loss of renal function that affects nearly all organ systems  Associated with HTN, diabetes, intrinsic kidney disease  Stages:  Normal (GFR >90mL/min)  Mild (GFR 60-89mL/min)  Moderate (GFR 30-59mL/min)  Severe (GFR 15-29mL/min)  End stage (GFR less than 15)
  • 33. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 33 Chronic Kidney Disease (CKD) (cont’d)
  • 34. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 34 Chronic Kidney Disease (CKD) (cont’d)  Proteinuria and uremia  Due to glomerular hyperfiltration  Damages interstitial tissue of kidney via inflammation  Creatinine and urea clearance  GFR falls  Plasma creatinine increases
  • 35. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 35 Chronic Kidney Disease (CKD) (cont’d)  Fluid and electrolyte balance  Sodium and water balance • Sodium excretion increases with obligatory water excretion leading to sodium deficit and volume loss • Concentration and dilution ability diminishes  Potassium balance • Tubular secretion increases early • Once oliguria sets in, potassium retained  Acid-base balance • Metabolic acidosis when GFR 30%-40%
  • 36. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 36 Chronic Kidney Disease (CKD) (cont’d)  Fluid and electrolyte balance  Calcium, phosphate, bone • Reduced renal phosphate excretion, decreased renal synthesis of 1,25-(OH)2 vitamin D3, and hypocalcemia. • Fractures  Protein, carbohydrate, fat metabolism  Anemia • Lethargy, dizziness, and low hematocrit are common
  • 37. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 37 Chronic Kidney Disease (CKD) (cont’d)  Alterations seen in following systems:  Cardiovascular  Pulmonary  Hematologic  Immune  Neurologic
  • 38. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 38 Chronic Kidney Disease (CKD) (cont’d)  Gastrointestinal  Endocrine and reproduction  Integumentary
  • 39. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 39 Signs and Symptoms of Kidney Failure