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03 July 2012 - dalam NURSING Oleh carentule-fkp11




1.1    Background

Genitourinary is a system that focuses on the urinary tracts of males and females, and on the reproductive system of males. The knowledge about it called urology. Medical professionals specializing in the field of urology are called urologists and are trained to diagnose, treat, and manage patients with urological disorders. The organs of urology compound by kidneys, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate and penis). Both urologists and general surgeons operate on the adrenal glands. In men, the urinary system overlaps with the reproductive system, and in women, the urinary tract opens into the vulva. In both sexes, the urinary and reproductive tracts are close together, and disorders of one, often affect the other.

Urology combines management of medical (i.e. non-surgical) problems such as urinary tract infections and benign prostatic hyperplasia, as well as surgical problems such as the surgical management of cancers, the correction of congenital abnormalities, and correcting stress incontinence.

Nowadays, kidney disease is a world-wide public health problem because of its increasing incidence and prevalence of kidney failure. In Indonesia, approximately there are 100 chronic kidney disease patients per 1 million people per year. Hemodialysis is one of ways to prolong CKD patient’s life that should be done recurrently and for a long time. However, hemodialysis causes loss of nutrients leading to high prevalence of malnutrition among CKD patients. Until today intradialysis diet therapy which can replace loss of nutrients particularly protein has not been initiated as part of diet therapy in Indonesian hospitals. To improve nutritional status and minimize mortality rate, oral intradialysis diet therapy with proper formula is needed.

In this SCL-Peer, we will explain about kidney desease. The pathophisiology, types, etiology, and clininical appearances about it will be explained. The diagnostic assessment and the theraphy will be get accros that can make as a book review to get good intervention.


1.2    Purpose

1.2.1        to Explain about Anatomy and Physiology the Genitourinary System

1.2.2        to Explain about the Pathophysiology of Kidney Disease

1.2.3        to Explain about the Types and Clasification of Kidney Disease

1.2.4        to Explain about the Etiology of Kidney Disease

1.2.5        to Explain about the clinical Appearance of Kidney Disease

1.2.6        to Explain about the Diagnostic Assessment of  Kidney Disease

1.2.7        to Explain about the Therapy of Kiney Disease


1.3    Function

These SCL-peer can be used for;

  1. Student college

Students get knowledge of the Genitourinary System, especially for those who majored in health.

  1. Lector / Lecturer

Lecturers can provide assessments associated with this assignment. In addition, this task is also useful in reviewing memory lecturer.






2.1    Anatomy and Physiology the Genitourinary System 

2.1.2             Kidney


Kidney is a gland, it lies in wall behind of kavum abdominalis and behind the peritoneum, at both sides of third vertebra lumbalis. Nthe form of kidney is like a nut. There are two kidneys, left and right. Right kidnkey is few lower than left kidney, coused by big dexter hepatitis lobus. Commonly, man`s kidney is longer than woman`s kidney. Adult kidney average approximately 11 cm in length and 5 to 7.5 cm in width and are 2.5 cm thick. Affixing the kidneys in position behind the parietal peritoneum are a mass of parirenal fat (adipose capsule) and connective tissue called Gerota`s (subserosa) fascia. A fibrous capsule (renal capsule) form the external covering of the kidney itself, except the hilum. The kidney is further protected by layers of muscle of the back, flank and abdomen, as well as laters of fat, subcutaneous tissue and skin.

The functioning unit of the kidney is the nephron. Each kidney contains more than one million of these units. Each kidney is divided into three major areas: the cortex, medulla, and pelvis. The cortex of kidney lies just under the fibrous capsule, and portions of it extend down into the medullary layer to form the renal columns or cortical tissue that separates the pyramids. The medulla is divided into 8 to 18 cone-shaped masses of collecting ducts called renal pyramids. The renal pelvis narrows as it reaches the hilus and becomes the proximal end of the ureter.

Located in the cortex of the kidney is a double walled cup, called the glomelural or Bowman capsule. Inside of the capsule is glomerulus, a tuft of nonanastomosing capillaries fed by an afferent arteriole and drained by an afferent arteriole. The kidney has many functions:

  1. Be a part important in expendituring of body`s toxin
  2. Maintain balance of liquid
  3. Keep balance acid and basa in the boby
  4. Release the finish result of metabolism from protein ureum, ammonia and creatinine.


2.1.2             Ureter

Ureter consist of two pipes, each duct is connected from kidney to vesika urinaria, length ± 25-35 cm with surface 0.5 cm. Ureters lie in the extraperitonial. Connective tissue and descend vertically along the muscle toward the pelvic cavity. After dipping into the pelvic cavity, the ureters course anteriorly to join the bladder in its posterolateral aspect. At each ureterovesical junction, the ureters runs obliquely through the bladder wall for about 1.5 to 2 cm before into the lumen of bladder.

There are three points of potential obstruction: (1) at the ureteropelvic junction, (2) the pelvic brim (where ureters cross iliac arteries), (3) at the ureterovesical junction. The ureter is much narrower at these points. Calcully typically lodge here because it is difficult for then to pass through this narrow passage away. This anatomic are arranged usually function as a valve that prevents the backward flow, or reflux, of urine in to the kidney. Each ureter has definite elastic chacacteristic and is made of three tissue layer: (1) an inner mucosa (traditional epithelial membrane) lining the lumen, (2) a muscular layer, and (3) a fibrous outer layer. When cancer of the bladder or ureter is diagnosed, there is potensial for reccurence in either structure. Half it clients with ureteral cancer experience spread of the cancer to the bladder. Only about 3 percent of clients with bladder cancer with spread of the cancer to the ureter. The musculatory is generally designated as inner longitudinal and outer circular.

However, along most of the ureter, the muscle fibers actually run obliquely and blend with one another to form a mesh like tissue. The muscle arrangement allows urine to be propelled down the ureter by peristaltic action. This peristalsys is probably regulated by a myogenic pacemaker located near the renal calices. Wall coat of ureter generate movements of peristaltic every five minutes that will push urine come into to vesica urinaria. The chief function of the ureter is to transport urine form the renal pelvis to the bladder. Peristaltic waves accurring from one to five time per minute move the urine down the ureter into the bladder trough the ureteovesical junction. Although there is controversy about the mechanism that initiates this contraction, it appears that there are pacemaker sites located in the calies, and that waves are propagated along the ureters from muscle cell to muscle cell by means of intracellular junction. Generally, this contraction move from the kidney toward the bladder, but retrograde peristalsis can occur.

Recall that the main function of the ureterovesical nunction is to prevent the backflow of urine to the kidney during voiding or when the bladder becomes over distended. Thus, this structure prevents damage to renal tissue from pressure and from the implantation of microorganism that would ordinarily be washed out of thr bladder. In addition to its anatomic placement, the valve works because of the lack of smooth muscle in its wall just proximal to its entry into the bladder. Thus, the usual intravesical pressure tends to keep the valve collapsed exceptwhen urine is spurting through it. During micturition, the ureters are closed off by the muscular contractions of the bladder.


2.1.3             Bladder or Vesica Urinaria

Vesica urinaria works as relocation of urine. This organ`s form is like pear fruit. Its located behind the simphysis pubica in flank cavity. Vesica urinaria can shrink like a rubber balloon. The bladder wall has several tissue layers. The internal lining of the vesica is transitional epithelium with some mucous-secreting glands. Then there are three ill defined muscle layers. The inner and outer layers tend to have fibers runner longitudinally, whereas those of the middle layer are circular. The fibers these layers exchange with each other frequently so that the result is a mesh like muscle layer called the detrusor muscle. This arrangement allows the bladder wall to be elastic while maintaining strength.

The superior and lateral aspects of the bladder are served by the superior vesical artery, branching from the umbilical artery and illiacal artery. The inferior vesical artery, supplying underside of the bladder, may arise independently or in common with the middle rectal artery. The veins draining the bladder pass to the internal iliac trunk. Innervations for the bladder comes from the hypogastric sympathetic, pelvic parasympathetic, and pudendal somatic nerves. The bladder stores urine received from the ureters until it is passed from the body. There is a slight increase in the intravesical  pressure for approximately the accumulation of the first 25 ml. then the pressure stairs relatively stable until about 400 to 500 ml have been collected. Accommodation disturbance occurs because of the slow stretching of the detrusor muscle. The pressure curve rises markedly as the bladder fills with more than 500 ml and soars as micturition is initiated.

Electromyographic (EMG) tracings did not measures or demonstrate activity of the bladder muscle releated to filing but rather the increased electrical response of the urethral sphincter to increased bladder pressure and volume. The bladder is composed of smooth muscle, where as the urethral sphincter is composed of streated muscle and is the only area commonly monitored by the EMG.

Micturition, also called urination and voiding, is the act of emptying the bladder. As the bladder fills and the muscle fibers expand, stretch receptors in the bladder wall are stimulated. The first urge to void is felt at about 150 ml and a marked filing of fullness usually occurs around 400 ml, although this level can be increased or decreased through habit pattern. Impulses are sent to the sacral patition of the spinal cord, where the micturition reflex is initiated, causing bladder to contract and the urethral sphincter to open. As the bladder musculature contracts, the pressure forces the urine out through the urethra. The bladder muscle fibers extend longitudinally down the urethra, and as they contracts, they shorten the urethra and pull the bladder down toward a point of fixation at the distal portion of the pubis. Unless the reflex is mediated at this point, urination occurs immediately.

The impulses initiating the micturition reflex are also sent to the cerebral cortex. After a period of succesfull toilet training in early childhood, the external sphincter usually under voluntary control. If the client feels that environmental conditions are not fight for urination. The external sphincter contract, stopping the flow of urine. The micturition reflex also can be initiated by the cerebrale cortex.


2.1.4             Urethra

The urethra is tube that starts at the base of the bladder and extends to the surface of the body. Length at men about 13.7-16.2 cm consist of:

  1. Prostatica urethra
  2. Membranosa urethra
  3. Spongiosa urethra

Length of woman`s urethra is about 3.7-6.2 cm (Taylor) or 3-5 cm (Lewis). Sphincter urethra located in upside vagina, among vagina and clitoris and urethra here only as channel of excretion.

Wall of urethra consist of:

  1. Artless muscle coat, representing artless muscle continuation of bladder
  2. Coat of submucous
  3. Coat of mucous

The urethra blood supply is provided primarily by the internal pudendal artery and urethral artery. The supply of blood supplemented by those vessels feeding the surrounding anatomic structures. Innervation arises from sources similar to those supplying the bladder.

Urethra is the pathway through which the urine normally leaves the body. The detrusor contraction during micturition is preceded for both five seconds by a significant fall of pressure within the urethra. This facilitates movement of urine from the bladder, with its hinger pressure, into the urethra. Following the act of micturition, the female urethra empties by gravity, whereas the male urethra empties by several contraction of the bulbocavernosus muscle.

The urethra ends in the meatus, which under voluntary control in the adult. When voiding is not appropriate, the external sphincter contracts, holding back the flow of urine until the reflex stimulation ceases.


2.1.5             Urine

Urine is form in the nephron by three process : (1) filtration, (2) reabsoption, (3) secretion. Filtration is the passage of the liquid throught a filtering membrane as the result of a pressure differential. In the kidney, this take place in the glomerulus.

  1. 1.    Filtration 

The glomerulus is a semipermeable membrane that allows free passage of water and electrolytes to across. However, it is usually impermeable to molecular substances, such as albumin and other plasma proteins, which are too large to pass through the membrane. The glomerular filtration rat (GFR) is the amount of glomelurus filtration that accurs within a given period of time. The GFR occur when this pressure gradiant is altered (1) in the glomerular capillaries, (2) in Bowman capsule, (3) in ureteral abstruction. The kidney does not have some resistance to change in systemic blood pressure through autoregulation. Autoregulation also enables GFR remain relatively stable over a range of arterial blood pressure readings varying form 70-200 mmHg.

Changes in the total area of the capillary glomerular bed modify the structures filtering the blood. This change usually involve a reduction in the functioning area and they result from glomerully destroying diseases or partial nephrectomy. The result of the filtration process repretion the first stage in the formation urine. The compotition of this ultrafiltrate is proximately 94 percent water and 6 percent solutes.

  1. 2.    Reabsorption 

Although the kidneys initially filter 180 liters per day, this does not represent the daily urine output of the normal adult. Reabsorption takes place through active transport and passive diffusion and osmosis. Active transport is a process in which substances are moved across the tubular membranes into the interstitial space by the expenditure of metabolic energy. Once in the interstitial tissue, these substances are picked up by the capillaries. Water passively moves across the semipermeable tubular membrane by diffusion, according to the concentration gradient. As solutes are transported into the interstitial spaces, the concentration of solutes outside the tubules rises, causing water to shift out of the tubules system.

Sone substances are poorly reabsorbed through the tubular membranes. These include urea, phosphate, sulfate, uric acid, nitrate, and phenols, all waste product that need to be axcreted from the body.

  1. 3.    Secretion 

In addition to reapsobtion, tubular cells are also capable of secretion. Secretion. Is a chemical activity allowing transport of substances from the blood into the tubules. The two physiology elements most involved in this process are potassium and hydrogen, although ammonia and uric acid also included. Some drug metabolites are excritid through this mechanism, such as acetaminophen, probenecid, and penicillin.

Nature of physic urine consist of :

  1. Amount of excretion within 24 hours ± 1500 cc depends on inclusion (dilution intake) and other factor.
  2. Color : transparent to yellow and when let will become turbid
  3. Color turn yellow depends on concentration, diet of drugs, etc.
  4. Aroma, typical aroma when let by long will smell ammonia.
  5. Specific gravity 1.015-1.020.
  6. Reaction of acid, if sometimes later become alkalis, also depends on the diet.

Urine compositions are :

1)        Consist about 95 % water.

2)        Vitamins result of protein metabolism, sour of urea, and ammonia of creatinin.

3)        Electrolyte, natrium, calcium, NH3, bicarbonate, sulphate, and phosphate.

4)        Pigmen and bilirubin of urobilin.

5)        Toxin.

6)        Hormone.

Marking of normal urine:

a)         Mean in one day 1-2 liter, but different each other as according to amount of dilution which enter.

b)        Its color of transparent orange without sediment.

c)         Its aroma sharply.

d)        Its reaction a little acid to litmus with mean pH 4.5-8.


2.2    Pathophysiology 

Acute renal failure (ARF) is a syndrome characterized by an abrupt and reversible kidney dysfunction. The spectrum of inciting factors is broad: from ischemic and nephrotoxic agents to a variety of endotoxemic states and syndrome of multiple organ failure. The pathophysiology of ARF includes vascular, glomerular and tubular dysfunction which, depending on the actual offending stimulus, vary in the severity and time of appearance. Hemodynamic compromise prevails in cases when noxious stimuli are related to hypotension and septicemia, leading to renal hypoperfusion with secondary tubular changes. Nephrotoxic offenders usually result in primary tubular epithelial cell injury, though endothelial cell dysfunction can also occur, leading to the eventual cessation of glomerular filtration. This latter effect is a consequence of the combined action of tubular obstruction and activation of tubuloglomerular feedback mechanism. In the following pages we shall review the existing concepts on the phenomenology of ARF including the mechanisms of decreased renal perfusion and failure of glomerular filtration, vasoconstriction of renal arterioles, how formed elements gain access to the renal parenchyma, and what the sequel are of such an invasion by primed leukocytes.


2.3    Types & Clasification 

2.3.1             Acute Kidney Injury

Acute kidney injury (AKI), previously called acute renal failure (ARF) is a rapid loss of kidney function. It’s causes are numerous and include low blood volume from any cause, exposure to substances harmful to the kidney, and obstruction of the urinary tract. AKI is diagnosed on the basis of characteristic laboratory findings, such as elevated blood urea nitrogen and creatinine, or inability of the kidneys to produce sufficient amounts of urine. AKI may lead to a number of complications, including metabolic acidosis, high potassium levels, uremia, changes in body fluid balance, and effects to other organ systems. Management includes supportive care, such as renal replacement therapy, as well as treatment of the underlying disorder.

Acute kidney injury is diagnosed on the basis of clinical history and laboratory data. A diagnosis is made when there is rapid reduction in kidney function, as measured by serum creatinine, or based on a rapid reduction in urine output, termed oliguria.

Introduced by the Acute Kidney Injury Network (AKIN), specific criteria exist for the diagnosis of AKI :

  1. Rapid time course (less than 48 hours)
  2. Reduction of kidney function
  • Rise in serum creatinine, defined by either:
    • Absolute increase in serum creatinine of ≥0.3 mg/dl (≥26.4 μmol/l)
    • Percentage increase in serum creatinine of ≥50%
    • Reduction in urine output, defined as <0.5 ml/kg/hr for more than 6 hours

The RIFLE criteria, proposed by the Acute Dialysis Quality Initiative (ADQI) group, aid in the staging of patients with AKI:

  1. Risk: GFR decrease >25%, serum creatinine increased 1.5 times or urine production of <0.5 ml/kg/hr for 6 hours
  2. Injury: GFR decrease >50%, doubling of creatinine or urine production <0.5 ml/kg/hr for 12 hours
  3. Failure: GFR decrease >75%, tripling of creatinine or creatinine >355 μmol/l (with a rise of >44) (>4 mg/dl) OR urine output below 0.3 ml/kg/hr for 24 hours
  4. Loss: persistent AKI or complete loss of kidney function for more than 4 weeks
  5. End-stage renal disease: complete loss of kidney function for more than 3 months


2.3.2             Chronic Kidney Disease

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis.

Chronic kidney disease is identified by a blood test for creatinine. Higher levels of creatinine indicate a lower glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows that the kidney is allowing the loss of protein or red blood cells into the urine. To fully investigate the underlying cause of kidney damage, various forms of medical imaging, blood tests and often renal biopsy (removing a small sample of kidney tissue) are employed to find out if there is a reversible cause for the kidney malfunction. Recent professional guidelines classify the severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).

There is no specific treatment unequivocally shown to slow the worsening of chronic kidney disease. If there is an underlying cause to CKD, such as vasculitis, this may be treated directly to slow the damage. In more advanced stages, treatments may be required for anemia and bone disease. Severe CKD requires renal replacement therapy, which may involve a form of dialysis, but ideally constitutes a kidney transplant. 


2.4    Etiology 

2.4.1             Acute Kidney  Disease

The causes of acute kidney injury are commonly categorized into prerenal, intrinsic, and postrenal.

  1. a.         Prerenal

Prerenal causes of AKI (pre-renal azotemia) are those that decrease effective blood flow to the kidney. These include systemic causes, such as low blood volume, low blood pressure, and heart failure, as well as local changes to the blood vessels supplying the kidney. The latter include renal artery stenosis, which is a narrowing of the renal artery that supplies the kidney, and renal vein thrombosis, which is the formation of a blood clot in the renal vein that drains blood from the kidney.Renal ischaemia ultimately results in functional disorder, depression of GFR, or both. These causes the inadequate cardiac output and hypovolemia or vascular diseases causing reduced perfusion of both kidneys.

  1. b.        Intrinsic

Sources of damage to the kidney itself are dubbed intrinsic. Intrinsic AKI can be due to damage to the glomeruli, renal tubules, or interstitium. Common causes of each are glomerulonephritis, acute tubular necrosis (ATN), and acute interstitial nephritis (AIN), respectively. A cause of intrinsic acute renal failure is tumour lysis syndrome.

  1. c.         Postrenal

Postrenal AKI is a consequence of urinary tract obstruction. This may be related to benign prostatic hyperplasia, kidney stones, obstructed urinary catheter, bladder stone, bladder, ureteral or renal malignancy. It is useful to perform a bladder scan or a post void residual to rule out urinary retention. In post void residual, a catheter is inserted immediately after urinating to measure fluid still in the bladder. 50-100ml suggests neurogenic bladder. A renal ultrasound will demonstrate hydronephrosis if present. A CT scan of the abdomen will also demonstrate bladder distension or hydronephrosis, however, in case of acute renal failure, the use of IV contrast is contraindicated. On the basic metabolic panel, the ratio of BUN to creatinine may indicate post renal failure.


2.4.2             Chronic Kidney Disease

Kidney failure is triggered by disease or a hereditary disorder in the kidneys. Both kidneys are typically affected. The four most common causes of chronic kidney failure include:

  1. Diabetes. Diabetes mellitus (DM), both insulin dependant (IDDM) and non-insulin dependant (NIDDM), occurs when the body cannot produce and/or use insulin, the hormone necessary for the body to process glucose. Long-term diabetes may cause the glomeruli, the filtering units located in the nephrons of the kidneys, to gradually lose functioning.
  2. Glomerulonephritis. Glomerulonephritis is a chronic inflammation of the glomeruli, or filtering units of the kidney. Certain types of glomerulonephritis are treatable, and may only cause a temporary disruption of kidney functioning.
  3. Hypertension. High blood pressure is unique in that it is both a cause and a major symptom of kidney failure. The kidneys can become stressed and ultimately sustain permanent damage from blood pushing through them at an excessive level of pressure over a long period of time.
  4. Polycystic kidney disease. Polycystic kidney disease is an inherited disorder that causes cysts to be formed on the nephrons, or functioning units, of the kidneys. The cysts hamper the regular functioning of the kidney.

Other possible causes of chronic kidney failure include kidney cancer, obstructions such as kidney stones, pyelonephritis, reflux nephropathy, systemic lupus erythematosus, amyloidosis, sickle cell anemia, Alport syndrome, and oxalosis. Initially, symptoms of chronic kidney failure develop slowly. Even individuals with mild to moderate kidney failure may show few symtpoms in spite of increased urea in their blood. Among the 


2.5    Clinical Appearance 

Symptoms can vary from person to person. Someone in early stage kidney disease may not feel sick or notice symptoms as they occur. When kidneys fail to filter properly, waste accumulates in the blood and the body, a condition called azotemia. Very low levels of azotaemia may produce few, if any, symptoms. If the disease progresses, symptoms become noticeable (if the failure is of sufficient degree to cause symptoms). Renal failure accompanied by noticeable symptoms is termed uraemia

Symptoms of kidney failure include:

  1. a.        High levels of urea in the blood, which can result in:
  • Vomiting and/or diarrhea, which may lead to dehydration
  • Nausea
  • Weight loss
  • Nocturnal urination
  • More frequent urination, or in greater amounts than usual, with pale urine
  • Less frequent urination, or in smaller amounts than usual, with dark coloured urine
  • Blood in the urine
  • Pressure, or difficulty urinating
  • Unusual amounts of urination, usually in large quantities
  1. b.        A build up of phosphates in the blood that diseased kidneys cannot filter out may cause:
  • Itching
  • Bone damage
  • Nonunion in broken bones
  • Muscle cramps (caused by low levels of calcium which can be associated with hyperphosphatemia)
  1. c.         A build up of potassium in the blood that diseased kidneys cannot filter out (called hyperkalemia) may cause:
  • Abnormal heart rhythms
  • Muscle paralysis
  1. d.        Failure of kidneys to remove excess fluid may cause:
  • Swelling of the legs, ankles, feet, face and/or hands
  • Shortness of breath due to extra fluid on the lungs (may also be caused by anemia)
  1. e.         Polycystic kidney disease, which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause:
  • Pain in the back or side
  1. Healthy kidneys produce the hormone erythropoietin which stimulates the bone marrow to make oxygen-carrying red blood cells. As the kidneys fail, they produce less erythropoietin, resulting in decreased production of red blood cells to replace the natural breakdown of old red blood cells. As a result, the blood carries less hemoglobin, a condition known as anemia. This can result in:
  • Feeling tired and/or weak
  • Memory problems
  • Difficulty concentrating
  • Dizzines
  • Low blood pressure
  1. Proteins are usually too big to pass through the kidneys, but they can pass through when the glomeruli are damaged. This does not cause symptoms until extensive kidney damage has occurred after which symptoms include:
  • Foamy or bubbly urine
  • Swelling in the hands, feet, abdomen, or face
  1. h.        Other symptoms include:
  • Appetite loss, a bad taste in the mouth
  • Difficulty of sleeping
  • Darkening of the skin
  • Excess protein in the blood
  • With high dose penicillin, renal failure patients may experience seizures


2.6    Diagnostic Assessment 

  1. Problem: Accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney.

  Etiology: Chronic kidney failure occurs when disease or dis- order damages the kidneys so that they can no longer adequately remove fluids and wastes from the body or maintain proper levels of kidney-regulated chemicals in the bloodstream.

  1. Problem: Social Interaction

Etiology: Difficult to determine condition, for example unable go to some place, maintain the function in family. Insufficient or excessive quantity or ineffective quality of social exchange.

  1. Problem: Elimination of urine

Etiology: Decrease of urine frequency, oliguria, anuria.

  1. Problem: Imbalanced nutrition/ fluids

Etiology: Increase of body weight in a few time (edema), decrease of body weight (malnutrition), anorexia, vomit.

  1. Problem: Accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney.

  Etiology: Chronic kidney failure occurs when disease or dis- order damages the kidneys so that they can no longer adequately remove fluids and wastes from the body or maintain proper levels of kidney-regulated chemicals in the bloodstream.

  1. Problem: Social Interaction

Etiology: Difficult to determine condition, for example unable go to some place, maintain the function in family. Insufficient or excessive quantity or ineffective quality of social exchange.

  1. Problem: Elimination of urine

Etiology: Decrease of urine frequency, oliguria, anuria.

  1. Problem: Imbalanced nutrition/ fluids

Etiology: Increase of body weight in a few time (edema), decrease of body weight (malnutrition), anorexia, vomit.


2.7    The Therapy 

2.7.1             Hemodialysis

a.        Purpose

Hemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.

Dialysis can replace part of the function of your kidneys. Diet, medications, and fluid limits are often needed as well. Your diet, fluids, and the number of medications you need will depend on which treatment you choose.

b.        How Hemodialysis Works

Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean your blood. The dialyzer is a canister connected to the hemodialysis machine.


During treatment, your blood travels through tubes into the dialyzer, which filters out wastes, extra salt, and extra water. Then the cleaned blood flows through another set of tubes back into your body. The hemodialysis machine monitors blood flow and removes wastes from the dialyzer.

Hemodialysis is usually done three times a week. Each treatment lasts from 3 to 5 or more hours. During treatment, you can read, write, sleep, talk, or watch TV.

c.         Getting Ready

1)        Arteriovenous fistula. Several months before your first hemodialysis treatment, an access to your bloodstream will need to be created. You may need to stay overnight in the hospital, but many patients have their access created on an outpatient basis. This access provides an efficient way for blood to be carried from your body to the dialyzer and back without causing discomfort. The two main types of access are a fistula and a graft.

2)        A surgeon makes a fistula by using your own blood vessels; an artery is connected directly to a vein, usually in your forearm. The increased blood flow makes the vein grow larger and stronger so it can be used for repeated needle insertions. This kind of access is the preferred type. It may take several weeks to be ready for use.

3)        A graft connects an artery to a vein by using a synthetic tube. It doesn't need to develop as a fistula does, so it can be used sooner after placement. But a graft is more likely to have problems with infection and clotting.



Catheter for temporary access. Before dialysis, needles are placed into the access to draw out the blood.

If your kidney disease has progressed quickly, you may not have time to get a permanent vascular access before you start hemodialysis treatments. You may need to use a catheter-a small, soft tube inserted into a vein in your neck, chest, or leg near the groin-as a temporary access. Some people use a catheter for long-term access as well. Catheters that will be needed for more than about 3 weeks are designed to be placed under the skin to increase comfort and reduce complications.

d.        Who Performs Hemodialysis

Hemodialysis is most often done in a dialysis center by patient care technicians who are supervised by nurses. Medicare pays for three hemodialysis treatments each week. If you choose in-center treatment, you will have a fixed time slot three times per week on Monday-Wednesday-Friday or Tuesday-Thursday-Saturday. If you do not get the time slot you want at first, you can ask to be put on a waiting list for the time slot you prefer. For a special event, you may be able to trade times with someone else. You will want to think about the dialysis schedule if you work or have children to care for. Some centers offer in-center nocturnal dialysis. This treatment is done for a longer period at night, while you sleep at the center. Getting more dialysis means fewer diet and fluid limits, and this treatment leaves your days free for work, child care, hobbies, or other tasks.

You can choose to learn how to do your own hemodialysis treatments at home. When you are the only patient, it is possible to do longer or more frequent dialysis, which comes closer to replacing the steady work healthy kidneys do. Daily home hemodialysis (DHHD) is done 5 to 7 days per week for 2 to 3 hours at a time, and you set the schedule. If your health plan will pay for more than three treatments, you might do the short treatments in the mornings or in the evenings. Nocturnal home hemodialysis (NHHD) is done 3 to 6 nights per week while you sleep. Either DHHD or NHHD will allow a more normal diet and fluids, with fewer blood pressure and other medications. Most programs want people doing hemodialysis at home to have a trained partner in the home while they do treatments. Learning to do home hemodialysis is like learning to drive a car-it takes a few weeks and is scary at first, but then it becomes routine. The dialysis center provides the machine and training, plus 24-hour support if you have a question or problem. New machines for home dialysis are smaller and easier to use than in-center ones.

You have a choice of dialysis centers, and most towns have more than one center to choose from. You can visit a center to see if it has the treatments you want or the time slot you need. Some centers will let you use a laptop or cell phone or have visitors, and others will not.

e.         Possible Complications

Vascular access problems are the most common reason for hospitalization among people on hemodialysis. Common problems include infection, blockage from clotting, and poor blood flow. These problems can keep your treatments from working. You may need to undergo repeated surgeries in order to get a properly functioning access.

Other problems can be caused by rapid changes in your body's water and chemical balance during treatment. Muscle cramps and hypotension-a sudden drop in blood pressure-are two common side effects. Hypotension can make you feel weak, dizzy, or sick to your stomach.

You'll probably need a few months to adjust to hemodialysis. Side effects can often be treated quickly and easily, so you should always report them to your doctor and dialysis staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and take your medicines as directed.

f.          Pros and Cons

Each person responds differently to similar situations. What may be a negative factor for one person may be a positive one for another. See a list of the general advantages and disadvantages of in-center and home hemodialysis below.

1)   In-Center Hemodialysis 


  • Facilities are widely available.
  • Trained professionals are with you at all times.
  • You can get to know other patients.
  • You don't have to have a partner or keep equipment in your home.


  • Treatments are scheduled by the center and are relatively fixed.
  • You must travel to the center for treatment.
  • This treatment has the strictest diet and fluid limits of all.
  • You will need to take-and pay for-more medications.
  • You may have more frequent ups and downs in how you feel from day to day.
  • It may take a few hours to feel better after a treatment.

2)   Home Hemodialysis


  • You can do it at the times you choose-but you still must do it as often as your doctor orders.
  • You don't have to travel to a center.
  • You gain a sense of independence and control over your treatment.
  • Newer machines require less space.
  • You will have fewer ups and downs in how you feel from day to day.
  • Home hemodialysis is more work-friendly than in-center treatment.
  • Your diet and fluids will be much closer to normal
  • You can take along new, portable machines on car trips, in campers, or on airplanes.
  • You can spend more time with your loved ones.


  • You must have a partner.
  • Helping with treatments may be stressful to your family.
  • You and your partner need training.
  • You need space for storing the machine and supplies at home.
  • You may need to take a leave of absence from work to complete training.
  • You will need to learn to put in the dialysis needles.
  • Daily and nocturnal home hemodialysis are not yet offered in all locations.


2.7.2             Peritoneal Dialysis

a.        Purpose

Peritoneal dialysis is another procedure that removes wastes, chemicals, and extra water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.

b.        How Peritoneal Dialysis Works

A mixture of minerals and sugar dissolved in water, called dialysis solution, travels through a catheter into your belly. The sugar-called dextrose-draws wastes, chemicals, and extra water from the tiny blood vessels in your peritoneal membrane into the dialysis solution. After several hours, the used solution is drained from your abdomen through the tube, taking the wastes from your blood with it. Then your abdomen is refilled with fresh dialysis solution, and the cycle is repeated. The process of draining and refilling is called an exchange.


c.         Getting Ready

Before your first treatment, a surgeon places a catheter into your abdomen or chest. The catheter tends to work better if there is adequate time-usually from 10 days to 2 or 3 weeks-for the insertion site to heal. Planning your dialysis access can improve treatment success. This catheter stays there permanently to help transport the dialysis solution to and from your abdomen.

d.        Types of Peritoneal Dialysis

Three types of peritoneal dialysis are available.

1)        Continuous Ambulatory Peritoneal Dialysis (CAPD)

CAPD requires no machine and can be done in any clean, well-lit place. With CAPD, your blood is always being cleaned. The dialysis solution passes from a plastic bag through the catheter and into your abdomen, where it stays for several hours with the catheter sealed. The time period that dialysis solution is in your abdomen is called the dwell time. Next, you drain the dialysis solution into an empty bag for disposal. You then refill your abdomen with fresh dialysis solution so the cleaning process can begin again. With CAPD, the dialysis solution stays in your abdomen for a dwell time of 4 to 6 hours, or more. The process of draining the used dialysis solution and replacing it with fresh solution takes about 30 to 40 minutes. Most people change the dialysis solution at least four times a day and sleep with solution in their abdomens at night. With CAPD, it's not necessary to wake up and perform dialysis tasks during the night.

2)        Continuous Cycler-assisted Peritoneal Dialysis (CCPD)

CCPD uses a machine called a cycler to fill and empty your abdomen three to five times during the night while you sleep. In the morning, you begin one exchange with a dwell time that lasts the entire day. You may do an additional exchange in the middle of the afternoon without the cycler to increase the amount of waste removed and to reduce the amount of fluid left behind in your body.

3)        Combination of CAPD and CCPD

If you weigh more than 175 pounds or if your peritoneum filters wastes slowly, you may need a combination of CAPD and CCPD to get the right dialysis dose. For example, some people use a cycler at night but also perform one exchange during the day. Others do four exchanges during the day and use a minicycler to perform one or more exchanges during the night. You'll work with your health care team to determine the best schedule for you.

e.         Who Performs Peritoneal Dialysis

Both types of peritoneal dialysis are usually performed by the patient without help from a partner. CAPD is a form of self-treatment that needs no machine. However, with CCPD, you need a machine to drain and refill your abdomen.

f.          Possible Complications

The most common problem with peritoneal dialysis is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contamination occurs as the catheter is connected or disconnected from the bags. Infection is less common in presternal catheters, which are placed in the chest. Peritonitis requires antibiotic treatment by your doctor.

To avoid peritonitis, you must be careful to follow procedures exactly and learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor or nurse immediately so that peritonitis can be treated quickly to avoid additional problems.

g.        Pros and Cons

Each type of peritoneal dialysis has advantages and disadvantages.

1)   CAPD


  • You can do it alone.
  • You can do it at times you choose as long as you perform the required number of exchanges each day.
  • You can do it in many locations.
  • You don't need a machine.
  • You won't have the ups and downs that many patients on hemodialysis feel.
  • You don't need to travel to a center three times a week.


  • It can disrupt your daily schedule.
  • It is a continuous treatment, and all exchanges must be performed 7 days a week.

2)   CCPD


  • You can do it at night, mainly while you sleep.
  • You are free from performing exchanges during the day.


  • You need a machine.
  • Your movement at night is limited by your connection to the cycler.


2.7.3             Kidney Transplantation

a.        Purpose

Kidney transplantation surgically places a healthy kidney from another person into your body. The donated kidney does enough of the work that your two failed kidneys used to do to keep you healthy and symptom free.

b.        How Kidney Transplantation Works

A surgeon places the new kidney inside your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the donated kidney, which makes urine, just like your own kidneys did when they were healthy. The new kidney may start working right away or may take up to a few weeks to make urine. Unless your own kidneys are causing infection or high blood pressure, they are left in place.

Kidney transplantation.

Getting Ready

The transplantation process has many steps. First, talk with your doctor because transplantation isn't for everyone. You could have a condition that would make transplantation dangerous or unlikely to succeed.

You may receive a kidney from a deceased donor-a person who has recently died-or from a living donor. A living donor may be related or unrelated-usually a spouse or a friend. If you don't have a living donor, you're placed on a waiting list for a deceased donor kidney. The wait for a deceased donor kidney can be several years.

The transplant team considers three factors in matching kidneys with potential recipients. These factors help predict whether your body's immune system will accept the new kidney or reject it.

  • Blood type. Your blood type (A, B, AB, or O) must be compatible with the donor's. Blood type is the most important matching factor.
  • Human leukocyte antigens (HLAs). Your cells carry six important HLAs, three inherited from each parent. Family members are most likely to have a complete match. You may still receive a kidney if the HLAs aren't a complete match as long as your blood type is compatible with the organ donor's and other tests show no problems with matching.
  • Cross-matching antigens. The last test before implanting an organ is the cross-match. A small sample of your blood will be mixed with a sample of the organ donor's blood in a tube to see if there's a reaction. If no reaction occurs, the result is called a negative cross-match, and the transplant operation can proceed.

c.         The Time Kidney Transplantation Takes

How long you'll have to wait for a kidney varies. Because there aren't enough deceased donors for every person who needs a transplant, you must be placed on a waiting list. However, if a voluntary donor gives you a kidney, the transplant can be scheduled as soon as you're both ready. Avoiding the long wait is a major advantage of living donation.

The surgery takes 3 to 4 hours. The usual hospital stay is about a week. After you leave the hospital, you'll have regular follow-up visits.

In a living donation, the donor will probably stay in the hospital about the same amount of time. However, a new technique for removing a kidney for donation uses a smaller incision and may make it possible for the donor to leave the hospital in 2 to 3 days.

Between 85 and 90 percent of transplants from deceased donors are working 1 year after surgery. Transplants from living relatives often work better than transplants from unrelated or deceased donors because they're usually a closer match.

d.        Possible Complications

Transplantation is the closest thing to a cure. But no matter how good the match, your body may reject your new kidney. A common cause of rejection is not taking medication as prescribed.

Your doctor will give you medicines called immunosuppressants to help prevent your body's immune system from attacking the kidney, a process called rejection. You'll need to take immunosuppressants every day for as long as the transplanted kidney is functioning. Sometimes, however, even these medicines can't stop your body from rejecting the new kidney. If this happens, you'll go back to some form of dialysis and possibly wait for another transplant.

Immunosuppressants weaken your immune system, which can lead to infections. Some medicines may also change your appearance. Your face may get fuller; you may gain weight or develop acne or facial hair. Not all patients have these problems, though, and diet and makeup can help.

Immunosuppressants work by diminishing the ability of immune cells to function. In some patients, over long periods of time, this diminished immunity can increase the risk of developing cancer. Some immunosuppressants can cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. Whe

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pada : 19 March 2015

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