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GENITOURINARY SYSTEM

571

3.

Diuretic phase is the period from the time urine output is

less than 400 ml in 24 hours to the time the BUN level stops rising.

4.

The late or recovery period is the time between falling to

stabilizing (i.e., within normal range) BUN levels.

5.

The convalescent phase occurs when urine output and

BUN levels are stable within normal ranges. This phase may last

several months and may ultimately progress to CRE

Clinical manifestations of ARF include the following8-' L

• Acid-base imbalance

• Hyperkalemia or hypokalemia

• Infection

• Hyperphosphatemia

• Hemodynamic instability, including hypovolemia and hypertension

• Anemia

Management of ARF includes any of the following8-' L

• Treatment of the primary etiology, including ami-infective

agents if applicable

• Hydration (intravenous fluids and osmotics [proteinsJ)

• Diuretics

• PeritOneal dialysis, hemodialysis, continuous renal replacemem

therapy (Refer to Renal Replacement Therapy.)

• Transfusions and blood products

• Nutritional support

Chronic Renal Failure

CRF is an irreversible reduction in renal function that occurs as a

slow, insidious process from the permanent destruction of nephrons.

The renal system has considerable functional reserve, and as many as

50% of the nephrons can be destroyed before symptoms occur. Progression of CRF to complete renal failure is termed elld stage rellO!

disease (ESRD), which requires dialysis for patient survivaI.8.9.12

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AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

CRF can resulr from primary renal disease or orher sysremic diseases. Primary renal diseases rhar cause CRF are polycysric kidney disease, chronic glomerulonephriris, chronic pyelonephriris, and

chronic urinary obstruction. The two primary systemic diseases that

cause CRF are rype 2 diaberes and hypcrtension.1J Orher sysremic diseases rhar can resulr in CRF include gour, sysremic lupus erythemarosus, amyloidosis, and nephrocalcinosis. Complicarions of CRF are similar ro rhose of ARF bur can also include decreased bone densiry as

a result of decreased activation of vitamin D, which impairs inrescinal

absorption of calcium, resulting in low serum calcium levels. Patients

wirh CRF can also experience episodes of ARF in siruarions when

they are noncompliant with their management, when their management proves insufficient, or both.8.9,12.14.15

Management of CRF may consist of conservative management or

renal replacemenr rherapy.l.

Conservative management includes the following8.9.'2.16:

• Nutritional support, dietary modifications

• Antacids, anticonvulsant, antihypertensive, anti-infective, and

antiemetic agents for sympromatic management of complications

from CRF

Renal replacement therapy consists of the foliowings.'Jz.I.;

•

Perironeal dialysis or hemodialysis ro maintain Auid and elecrro

Iyte balance

• Renal transplantation (See Chapter 12.)

Pyelonephritis

Pyelonephritis is an acute or chronic inflammarory response in the

kidney, particularly the renal pelvis, from bacrerial, fungal, or viral

infection. It can be classified as acute or chronic.

ACt/te Pyelonephritis

Acute pyelonephritis is frequently associated with concurrent cystitis

(bladder infection). The common causative agents are bacterial,

including Escherichia coli, Protells, Klebsiella, Enterobacter, and

Pseudomonas. Predisposing factors for acute pyelonephritis include

urine reAux from rhe urerer to rhe kidney (vesicollreteral reflllx), kidney srones, pregnancy, neurogenic bladder, carherer or endoscope

GENITOURINARY SYSTE.M

573

insertion, and female sexual trauma. Women are more prone to acute

pyelonephritis than men,',I6,17 Spontaneous resolution of acute pyelonephritis may occur in some cases without intervention.

Signs and symptoms of acute pyelonephritis may include the

following,,16-18:

• Sudden onset of fever and chills

• Tenderness with deep palpatory pressure of one or both costovertebral areas

• Flank or groin pain

• Urinary frequency

• Dysuria, hematuria, pyuria (presence of white blood cells [leukocytes])

Management of acute pyelonephritis may consist of any of the

following"I7,18:

• Antibiotic therapy commonly includes ciprofloxacin (Cipro), ampicillin (Omnipen) or trimethoprimlsulfamethoxazole (Bactrim, Septra), A 7-day course of ciprofloxacin has been shown to be the most effective treatment for women with acute pyelonephritis thus far.19

• Ureteral reimplanrarion for children with chronic vesicoureteral

reflux.20

Chrollic Pyelollephritis

Chronic pyelonephritis is recurrem or persistent inflammation and

scarring of one or both kidneys as a result of autoimmune infection.

Chronic pyelonephritis can also result from kidney stones or acute

pyelonephritis and may lead to CRE Specific eriologies are difficult to

diagnose.9,16-18,21

Signs and symptoms of chronic pyelonephritis include the

following,,17,18:

• Hypertension

• Mild and vague dysuria, urinary frequency, and flank pain

• Renal insufficiency (decreased urine output), possibly progressing to failure

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AClffE CARE I-tANDUOOK FOR i'HYSICAL THERAPISTS

• Pyuria (white blood cells in the urine), hemaruria (blood in

urine)

Management of chronic pyelonephritis includes any of the

following9.17.18.21 :

•

Treatment of primary etiology (if diagnosed)

•

Anti-infective agents similar to those mentioned with AR"� for a

short or prolonged treatment

Glomerulonephritis

Glomerulonephritis is an inflammation of the glomerular portion of

the kidney that can result from immunologic abnormalities, drug Ot

toxin effects, vascular disorders, or systemic disorders. Definitive etiology may be difficult to ascertain in some cases. Glomerulonephritis can be classified according to cause, pathologic lesions, disease progression, or clinical presentation. This section discusses the common types of glomerulonephritis.9

Immunoglobulin A Nephropathy (Berger's Disease)

Immunoglobulin (Ig) A nephropathy is the most common cause of

glomerulonephritis, with 25-40% of cases progressing to renal

failure within 20 to 25 years of onset.22.23 IgA nephropathy is an

abnormality of immune system regulation that results in deposition of IgA (antibody) complexes within the glomeruli, ultimately resulting in a reduction of glomerular filtration. Hepatic cirrhosis,