TOPIC: POSTRENAL AKI due to BILATERAL URETERAL OBSTRUCTION

CONCEPT MAP

ANATOMY AND PHYSIOLOGY (MAV & ZAHRA)

The kidneys perform several vital functions within the urinary system. Firstly, they
filter gallons of fluid from the bloodstream daily, processing this filtrate to allow for the
elimination of wastes and excess ions in urine while returning necessary substances to the
blood in precise proportions. Although the lungs and skin contribute to excretion, the kidneys
are primarily responsible for removing nitrogenous wastes, toxins, and drugs from the body.
Additionally, the kidneys produce the enzyme renin, which is crucial for blood pressure
regulation, and erythropoietin, a hormone that stimulates red blood cell production in
response to low oxygen levels.

The bladder, on the other hand, serves as a reservoir for urine, allowing for temporary
storage until it is convenient to void. It contracts during urination to expel urine through the
urethra, while stretch receptors in the bladder signal the brain when it is full, creating the
sensation of urgency. Together, the kidneys and bladder ensure the effective elimination of
waste and the maintenance of fluid and electrolyte balance in the body.

KIDNEYS

The kidneys are essential organs in the human body, responsible for filtering blood,
regulating fluid balance, and maintaining homeostasis. Their complexity arises from their
structure, which consists of several key parts, each contributing to their overall function.

1. Cortex - The cortex is the outer layer of the kidney, which is rich in blood vessels and
contains the renal corpuscles.

a. Function: It is primarily involved in the filtration of blood. The renal

corpuscles, which include the glomeruli and Bowman's capsules, are located
here. The cortex is where the initial stages of urine formation occur, as it
filters waste products and excess substances from the blood.

2. Medulla - The medulla is the inner region of the kidney, consisting of renal pyramids
that contain the loops of Henle and collecting ducts.

a. Function: The medulla plays a crucial role in concentrating urine. It reabsorbs

water and electrolytes, helping to maintain the body’s fluid balance. The
structure of the loops of Henle allows for the creation of a concentration
gradient, which is essential for the kidneys' ability to concentrate urine.
 3. Nephrons - Nephrons are the functional units of the kidney, with each kidney
containing about one million nephrons. Each nephron consists of several parts:

a. Glomerulus: A network of capillaries where blood filtration occurs.

b. Bowman's Capsule: A cup-like structure that encases the glomerulus and

collects the filtrate.

c. Proximal Convoluted Tubule (PCT): The first segment of the renal tubule,
where reabsorption of water, ions, and nutrients occurs.

d. Loop of Henle: A U-shaped segment that extends into the medulla, playing a
crucial role in concentrating urine and reabsorbing water and sodium.

e. Distal Convoluted Tubule (DCT): The segment following the loop of Henle,
where further reabsorption of sodium and water occurs, and secretion of
potassium and hydrogen ions takes place.

f. Collecting Duct: The final segment where urine is collected from multiple
nephrons and plays a key role in water reabsorption regulated by antidiuretic
hormone (ADH).

4. Renal Pelvis - The renal pelvis is a funnel-shaped structure that collects urine from
the collecting ducts.

a. Function: It serves as a reservoir for urine before it is transported to the

ureters. The renal pelvis channels urine into the ureters, which carry it to the
bladder for storage.

5. Ureters - Ureters are muscular tubes that connect the kidneys to the bladder.

a. Function: They transport urine from the kidneys to the bladder through
peristaltic movements, ensuring that urine flows in one direction.

6. Renal Arteries and Veins - The renal arteries supply oxygenated blood to the
kidneys, while the renal veins drain deoxygenated blood away from the kidneys.

a. Function: The renal arteries are crucial for delivering blood that needs to be
filtered, while the renal veins remove blood after waste products have been
filtered out.

BLADDER

The urinary bladder is a hollow, spherical-shaped organ that serves as a reservoir for
urine, typically holding between 500 to 700 mL (about two cups) of urine in most
individuals. When the bladder fills and the need to urinate arises, the muscles in the bladder
contract, while the sphincter muscles in the urethra relax, facilitating the flow of urine out of
the body. This coordinated action allows for the controlled elimination of waste, highlighting
the bladder's crucial role in the urinary system.

The bladder is situated in the lower part of the abdomen and is anchored in place by
bands of tissue known as ligaments, which connect it to surrounding organs and the pelvic
bone. In individuals assigned male at birth (AMAB), the bladder is positioned between the
pubic bone at the front and the rectum at the back. In contrast, in individuals assigned female
at birth (AFAB), the bladder is located in front of the vagina and uterus. The structure of the
bladder consists of four main parts:

1. Dome (Apex): This is the top-front portion of the bladder that faces the abdominal
wall.

2. Base (Fundus): The base is the bottom-back part of the bladder.

3. Body: The body of the bladder is the area that lies between the dome and the base,
serving as the main storage area for urine.

4. Neck: The bladder neck is located at the base and consists of a narrow band of
muscles that connect the bladder to the urethra, playing a crucial role in the regulation
of urine flow.

REFERENCE/S:

Nurseslabs. (n.d.). Urinary system: Anatomy and physiology. Nurseslabs.

https://nurseslabs.com/urinary-system/

National Institute of Diabetes and Digestive and Kidney Diseases. (2021). Your kidneys and
how they work. U.S. Department of Health and Human Services.

https://www.niddk.nih.gov/health-information/kidney-disease/kidneys-how-they-work

Cleveland Clinic. (n.d.). Bladder. https://my.clevelandclinic.org/health/body/25010-bladder

ETIOLOGY (YEN)

Postrenal acute kidney injury (AKI) occurs when urinary tract obstruction impairs
urine flow, leading to increased kidney pressure and reduced renal function. In the case of JL,
the primary cause of postrenal AKI is bilateral ureteral obstruction due to prostate cancer,
compounded by several underlying conditions.

Prostate cancer is a leading cause of postrenal obstruction in older men. As the tumor
grows, it can compress the bladder neck, urethra, or ureters, leading to urinary retention.
Direct invasion by the tumor or external compression from enlarged lymph nodes can
obstruct urine flow, resulting in hydronephrosis and increased intrarenal pressure, which
impairs kidney filtration. In JL's case, his prostate cancer and a recent digital rectal
examination indicating an enlarged prostate suggest that the malignancy obstructed the
bladder outlet, contributing to bladder distension and bilateral obstruction.

Radiation therapy is a common treatment for prostate cancer, it can have delayed
effects, such as fibrosis and scarring of the ureters, leading to ureteral strictures. These
strictures impede urine passage, causing urinary retention and increased back pressure on the
kidneys. JL’s radiation therapy six months prior likely contributed to the development of
strictures, exacerbating the pressure on his kidneys and leading to postrenal AKI.

Hydronephrosis occurs when urine flow is obstructed, causing dilation of the renal
pelvis and calyces due to urine buildup. Prolonged hydronephrosis can damage renal tissue
and reduce kidney function. The accumulated urine increases pressure within the kidneys,
compressing renal blood vessels and further impairing blood flow. JL’s renal ultrasound
confirming bilateral hydronephrosis underscores its role in the etiology of his postrenal AKI.

Chronic kidney disease (CKD) is characterized by a progressive loss of renal

function, with patients exhibiting reduced capacity to manage acute stressors. JL’s stage 3
CKD leaves him more vulnerable to further declines in kidney function due to any acute
insult, such as obstructive uropathy. This pre-existing condition diminishes his renal reserve,
hastening the onset of AKI in the context of his bilateral obstruction.

Bladder distension occurs when urine cannot be expelled due to obstruction, leading
to backpressure that affects the ureters and kidneys. In JL’s case, the palpable distended
bladder indicates significant urinary retention, further aggravating pressure on the kidneys
and contributing to his bilateral ureteral obstruction and AKI.

Hyperkalemia, or elevated potassium levels in the blood, often results from impaired
renal function. In AKI, the kidneys' ability to excrete excess potassium is compromised,
leading to dangerous levels that can cause cardiac complications. JL’s elevated serum
potassium level of 6.0 mEq/L indicates his kidneys are failing to adequately manage
potassium excretion, reflecting the severity of his renal impairment caused by bilateral
obstruction.

References:

1. What is prostate cancer? | Types of prostate cancer. (n.d.). American Cancer Society.
https://www.cancer.org/cancer/types/prostate-cancer/about/what-is-prostate-cancer.ht
ml

2. Acute Kidney Injury (AKI). (n.d.). National Kidney Foundation.

https://www.kidney.org/kidney-topics/acute-kidney-injury-aki

3. Kala, J., MD. (n.d.). Radiation Nephropathy: Practice Essentials, etiology,

pathophysiology. https://emedicine.medscape.com/article/243766-overview?form=fpf
 4. Hydronephrosis. (2024, May 1). Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/15417-hydronephrosis

5. Chronic Kidney Disease (CKD) - NIDDK. (n.d.-b). National Institute of Diabetes and
Digestive and Kidney Diseases.
https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-
ckd#:~:text=Chronic%20kidney%20disease%20(CKD)%20means,family%20history
%20of%20kidney%20failure.

PATHOPHYSIOLOGY
References:

Gameiro, J., Jorge, S., & Lopes, J. A. (2020). Acute kidney injury associated with urinary
tract obstruction: Epidemiology, pathophysiology, and clinical approach. Clinical
Kidney Journal, 13(2), 213-221. https://doi.org/10.1093/ckj/sfz073
Liu, B. C., Tang, T. T., Lv, L. L., & Lan, H. Y. (2020). Renal tubulointerstitial injury: A
driving force toward chronic kidney disease. Kidney International, 98(5), 955-967.
https://doi.org/10.1016/j.kint.2020.04.040
Kazory, A., & Ronco, C. (2021). Uremic syndrome: Role of the heart and the kidneys.
Cardiorenal Medicine, 11(3), 100-112. https://doi.org/10.1159/000510854

DIAGNOSTIC EXAMINATIONS

-czan-

LABORATORY PATIENT’S NORMAL VALUE/ INDICATION OF

EXAMINATION RESULT RANGE THE RESULT

Serum Creatinine 5.0 mg/dL 1.5 mg/dL High - significant

decline in kidney
filtration rate

Blood Urea 70 mg/dL 7 to 20 mg/dL Elevated - acute

Nitrogen kidney injury

Electrolytes Potassium: 6.0 Potassium: 3.5 -5.0 Potassium:

mEq/L, Sodium: 135 mEq/L
- Potassium mEq/L High -
Sodium: 135 - 145 Hyperkalemia
- Sodium mEq/L
Sodium: Normal

Urinalysis Hematuria, no - Blood: Negative or + Blood in

significant trace amounts (should urine
proteinuria not be present in
significant amounts)

- Protein: Negative or
trace amounts
 Renal Ultrasound Bilateral No evidence of Excess urine
hydronephrosis and hydronephrosis, no accumulation,
a distended bladder abnormal masses
Renal Obstruction

DIAGNOSTIC PATIENT’S NORMAL VALUE/ INDICATION OF

EXAMINATION RESULT RANGE THE RESULT

MEDICAL MANAGEMENT

1. Relief of Obstruction -

Nursing Intervention:

· Insert a Foley catheter to relieve bladder distension and allow urine drainage.

Rationale:

In post renal AKI, the obstruction prevents urine from exiting the body, causing
hydronephrosis and renal dysfunction. Insertion of a Foley catheter immediately
decompresses the bladder, restores urine flow, and alleviates pressure on the kidneys,
preventing further damage.
Nursing Intervention:

· Monitor the volume, color, and quality of urine once the Foley catheter is in place.

Rationale:

This helps assess the return of kidney function and whether the obstruction has been
successfully relieved. Observing for hematuria (blood in the urine) may also indicate trauma
or ongoing issues related to prostate cancer.

Nursing Intervention:

· Notify urology for further evaluation (bilateral ureteral stent or nephrostomy tube
placement).

Rationale:

Stents or nephrostomy tubes are necessary for a long-term solution to the obstruction.
Urology will determine the most appropriate method for bypassing the obstruction and
preventing recurrence.

2. Fluid Management -

Nursing Intervention:

· Strict monitoring of intake and output (I/O).

Rationale:

Monitoring I/O helps ensure proper fluid balance. Too much fluid could worsen kidney
function by causing overload, especially in a patient with underlying chronic kidney disease,
while too little could exacerbate AKI due to decreased renal perfusion.

Nursing Intervention:

· Administer intravenous fluids (IVF) as ordered, titrated based on the patient’s hydration
status and urine output.

Rationale:

IV fluids help maintain hydration and renal perfusion. Careful adjustment is required to avoid
fluid overload, which is critical given JL's CKD and hypertension.
Nursing Intervention:

· Assess daily weights and monitor for signs of fluid overload, such as edema or crackles
in the lungs.

Rationale:

Daily weights provide an accurate assessment of fluid balance, and early detection of fluid
overload can prevent complications like heart failure or pulmonary edema, which are risks
due to JL’s underlying hypertension and CKD.

3. Electrolyte Management -

Nursing Intervention:

· Monitor serum potassium and other electrolytes frequently.

Rationale:

Hyperkalemia is a potentially life-threatening complication of AKI due to impaired

potassium excretion. Monitoring electrolytes will guide the need for interventions to correct
these imbalances.

Nursing Intervention:

Administer medications as ordered for hyperkalemia (e.g., sodium polystyrene sulfonate,

insulin with glucose).

Rationale:

These medications help lower potassium levels. Sodium polystyrene sulfonate removes
potassium through the gastrointestinal tract, while insulin with glucose shifts potassium into
cells, temporarily lowering serum levels and reducing the risk of cardiac arrhythmias.

Nursing Intervention:

Place the patient on continuous cardiac monitoring.

Rationale:

Hyperkalemia increases the risk of cardiac arrhythmias, including life-threatening conditions

such as ventricular fibrillation. Continuous monitoring allows for the immediate detection
and intervention of cardiac dysrhythmias.
4. Renal Function Monitoring -

Nursing Intervention:

· Monitor serum creatinine and BUN daily to assess the progression of AKI.

Rationale:

Elevated creatinine and BUN levels indicate decreased kidney function. Monitoring these
values helps track the kidney’s recovery following the relief of obstruction and guide ongoing
care decisions.

Nursing Intervention:

· Monitor urine output hourly, especially after Foley catheter insertion.

Rationale:

Urine output is a direct indicator of kidney function. A return to normal urine production
suggests that the kidneys are recovering, while a lack of improvement may indicate ongoing
obstruction or irreversible damage.

5. Supportive Care -

Nursing Intervention:

· Provide pain relief as ordered (e.g., analgesics) and assess pain levels regularly.

Rationale:

Effective pain management will improve the patient’s comfort and reduce distress.
Abdominal pain from bladder distension or ureteral obstruction can be significant and may
persist even after the obstruction is relieved.

Nursing Intervention:

· Educate the patient and family about the underlying cause of AKI and the importance of
follow-up care.

Rationale:

Understanding the link between prostate cancer, ureteral obstruction, and AKI can help JL
and his family make informed decisions regarding treatment. Educating them on the
importance of follow-up with urology and nephrology is crucial for preventing recurrence
and managing long-term kidney health.

6. Consultations and Interdisciplinary Care

Nursing Intervention:

· Facilitate urology and nephrology consultations and provide timely updates on JL’s
condition.

Rationale:

Coordination with specialists is essential for comprehensive care. Urology will manage the
obstruction, while nephrology will monitor kidney function and ensure that the AKI is treated
appropriately. Nurses play a key role in facilitating communication between these teams and
ensuring that the patient’s care plan is followed.

References:

Mayo Clinic. (2024, January 26). Ureteral obstruction: Diagnosis and treatment. Mayo
Clinic. https://www.mayoclinic.org

Zeidel, M. L., et al. (2021). Clinical manifestations and diagnosis of urinary tract obstruction
and hydronephrosis. In UpToDate.

American Academy of Family Physicians. (2020). Acute kidney injury: Diagnosis and
management. https://www.aafp.org

Kidney Disease: Improving Global Outcomes (KDIGO). (2021). 2021 Clinical practice
guideline for the management of acute kidney injury. Kidney International Supplements,
11(1).

Wang, H., et al. (2020). Fluid management in acute kidney injury. Journal of Intensive Care
Medicine, 35(, 838-844. https://doi.org/10.1177/0885066620938525

Mayo Clinic. (2024, January 26). Ureteral obstruction: Diagnosis and treatment. Mayo
Clinic. https://www.mayoclinic.org

Berns, J. S., & Hsu, C. Y. (2022). Hyperkalemia in acute kidney injury. In UpToDate.

Flack, C., et al. (2021). Management of hyperkalemia in patients with chronic kidney disease
and heart failure. Journal of the American College of Cardiology, 78(20), 2027-2036.
https://doi.org/10.1016/j.jacc.2021.09.007
Kidney Disease: Improving Global Outcomes (KDIGO). (2021). 2021 Clinical practice
guideline for the management of acute kidney injury. Kidney International Supplements,
11(1).

American Academy of Family Physicians. (2020). Acute kidney injury: Diagnosis and
management. https://www.aafp.org

Thomsen, T., et al. (2023). Pain management in patients with kidney disease. Journal of Pain
Research, 16, 1237-1250. https://doi.org/10.2147/JPR.S396747

Mayo Clinic. (2024, January 26). Ureteral obstruction: Diagnosis and treatment. Mayo
Clinic. https://www.mayoclinic.org

American Academy of Family Physicians. (2020). Acute kidney injury: Diagnosis and
management. https://www.aafp.org

Yu, A. S. L., et al. (2022). Ureteral obstruction in prostate cancer patients. Brenner &
Rector’s The Kidney (11th ed.).
 NURSING MANAGEMENT

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS

Subjective Cues: Ineffective Renal OBJECTIVE INTERVENTIONS RATIONALE INDEPENDENT After the 8 hours of
Tissue Perfusion OUTCOMES nursing intervention,
INDEPENDENT
The patient related to blockage INDEPENDENT 1. Record vital signs the patient was able
reported having in both ureters After the 8 1. Assess and every 2 hours and to:
severe lower hours of nursing monitor vital 1. Hypertension assess trends. Report
secondary to
abdominal pain, he interventions, and tachycardia any significant 1. Exhibited increased
prostate cancer as signs, especially
is experiencing the patient will can indicate increases in blood urine output of at least
evidenced by blood pressure
difficulty urinating be able to: ongoing impaired pressure or heart rate. 30 mL/hour
bladder distension and heart rate,
and intermittent renal perfusion or
above the every 2 hours.
hematuria which 1. Exhibit fluid overload. 2. Document urine 2. Showed a reduction
symphysis pubis,
progresses to increased urine 2. Monitor urine output every hour, in bladder distension
lower abdominal 2. Monitoring
anuria upon output of at least output hourly. noting any changes. and reported decreased
tenderness, urine output is
admitting. 30 mL/hour Report if output lower abdominal
hematuria, anuria, essential in
3. Perform a remains below 30 tenderness, as
prostatic 2. Show a evaluating renal
Objective Cues: bladder mL/hour. evidenced by a
enlargement, reduction in function and the
assessment, decrease in bladder size
- Distended swelling of both bladder effectiveness of 3. Assess bladder size
including and reduced discomfort
bladder palpable kidneys, distension and interventions to and tenderness every 4
palpation for on palpation.
above the pubic hypertension, report decreased distension and relieve hours. If distension
symphysis. hypercreatininemia lower abdominal monitoring for obstruction. persists, escalate care. 3. Demonstrated
, hyperkalemia, and tenderness, as improved renal
discomfort.
elevated BUN. evidenced by a 3. A distended 4. Use an I&O chart to function markers, with
decrease in bladder suggests document all oral and serum creatinine, blood
- Lower abdominal bladder size and 4. Monitor continued intravenous fluid intake urea nitrogen, and
tenderness reduced intake and obstruction, as well as urine output. potassium levels
discomfort on output hourly. impacting renal Encourage the patient returning to normal
- Serum creatinine: palpation. perfusion. to report any changes ranges.
5.0 mg/dL 5. Encourage in urinary patterns, and
3. Demonstrate the patient to 4. Accurate review the records
- BUN: 70 mg/dL. improved renal rest in a monitoring of regularly to assess
function markers, comfortable intake and output trends and notify the
- Potassium: 6.0 with serum position that is crucial for healthcare team of any
mEq/L creatinine, blood reduces evaluating renal abnormalities.
(hyperkalemia). urea nitrogen, abdominal function, fluid
and potassium discomfort, status, and 5. Assist the patient in
- Renal ultrasound
levels returning preferably identifying any finding a position that
shows bilateral
to normal ranges. semi-Fowler’s signs of fluid minimizes pain and
hydronephrosis.
position. overload or maximizes circulation.
- Patient shows dehydration,
DEPENDENT DEPENDENT
signs of confusion which can
1. Administer indicate
1. Observe the 14
Vital Signs: worsening renal
prescribed rights of drug
medications, perfusion or
BP: 160/95 mmHg administration.
including complications.
Monitor the patient for
Temp: 37.3⁰C diuretics and therapeutic effects and
5. Reducing
analgesics, as adverse reactions.
discomfort and
HR: 105 bpm ordered by the Document the
optimizing
physician. administration details
RR: 22 bpm positioning can
improve comfort in the patient's medical
2. Insert a foley
record.
catheter as
ordered by the and renal 2. Follow sterile
physician. perfusion. technique, ensuring
proper placement and
3. Administer DEPENDENT securing the catheter to
Intravenous prevent displacement
Fluids as 1. It helps
while monitoring for
ordered by the promote urine
urine output hourly.
physician. production,
reducing fluid 3. Verify the
4. Administer overload and physician's orders for
prescribed managing the type and volume of
medications hypertension, intravenous fluids,
such as sodium while analgesics establish IV access
polystyrene provide pain using aseptic
sulfonate or relief, enhancing technique, and set the
insulin with patient comfort infusion rate as
glucose to and allowing for prescribed. Monitor the
manage better infusion for correct
hyperkalemia as participation in flow and any signs of
ordered by the care and recovery. fluid overload or
physician. adverse reactions, and
2. It alleviates
document the IV Fluid
5. Monitor bladder
administration in the
serum distension, which
patient’s medical
creatinine, can help relieve
record.
blood urea discomfort and
nitrogen (BUN), prevent 4. Observe the 14
and electrolyte complications rights of drug
levels as
ordered by the associated with administration.
physician. urinary retention. Monitor the patient’s
vital signs and
COLLABORATIVE 3. It is essential to
potassium levels before
maintain and after
1. Consult with
hydration, support administration,
the urologist for
renal function, documenting all
further
and correct relevant details in the
evaluation and
electrolyte medical record.
possible ureteral
imbalances,
stent or
especially in 5. Obtain blood
nephrostomy
patients with samples for laboratory
tube placement.
impaired renal testing as ordered and
tissue perfusion. document serum
creatinine, BUN, and
4. These electrolyte levels in the
medications help patient's chart. Review
lower elevated laboratory results
potassium levels, promptly and report
which can reduce any abnormal values to
the risk of serious the healthcare provider.
complications
such as cardiac COLLABORATIVE
arrhythmias in
patients with 1. Coordinate with the
renal impairment. urology team for
prompt intervention
5. Regular and ensure all
monitoring of
renal function diagnostic information
markers is is provided.
essential for
evaluating the
effectiveness of
treatment
interventions,
detecting any
deterioration in
kidney function,
and guiding
further
management of
the patient's
condition.

COLLABORATIVE

1. A urologist can
perform
interventions to
remove the
obstruction and
improve renal
perfusion.