Renal Rundown: From Anatomy to Infection

Loretta Swift

Alright, welcome back to NSG4052 Renal, everybody. Loretta here—and I've got James A. Bond with me as usual. Today, we're hitting the essentials, starting at the very beginning with renal anatomy and physiology. James, I think a lot of people kind of gloss over just how incredible the basic plumbing of our bodies is.

James A. Bond

Absolutely, Loretta. The way I think about it: you have your upper urinary system—which is just your two kidneys and those narrow little ureters. They handle pretty much all the filtering and drain work. Then, of course, the lower urinary tract: your bladder, which is like the holding tank, and your urethra—that final stretch where urine leaves the body. Simple, but quite the engineering marvel, really.

Loretta Swift

Yeah, and—I mean, so many students memorize those parts, but what they really do is what matters. Kidneys regulate your body's fluid volume, electrolyte levels, waste excretion, blood pressure, they even juggle hormone production—erythropoietin comes to mind, for those red blood cells—and activate vitamin D, believe it or not.

James A. Bond

Spot on. And don't forget the acid-base balance gig. Kidneys are not just glorified filters. They're constantly adjusting, making sure the blood stays within that sweet pH zone—roughly 7.35 to 7.45.

Loretta Swift

And you know, I still remember my first internship. I had this patient with weird labs and nobody could figure out why her urine was so foamy. The nephron physiology finally clicked for me—understanding that microstructure changed my whole approach. I realized, wow, when the nephron—the functional unit—misfires, you get protein in the urine. Changed how I explained things to patients, too.

James A. Bond

That’s a strong example, Loretta. Once you see how all the bits fit, patient care makes a lot more sense. And we’ll keep circling back to those fundamentals as we dig into more complicated disorders today.

James A. Bond

So, let’s follow the journey of urine formation, shall we? It all starts with filtration at the glomerulus—that’s your GFR, or glomerular filtration rate. About 125 mL per minute is typical for a healthy adult, right?

Loretta Swift

Right, and what’s important for students is that "normal urine" shouldn’t have blood, platelets, or big proteins. The rest—water, electrolytes, and waste—gets filtered in, reabsorbed, secreted, or excreted as needed. The tubules do a ton of work. Think of them as picky shoppers—deciding what stays and what goes!

James A. Bond

Exactly. And when it comes to regulating blood pressure and volume, the kidneys call in the big guns: RAAS and ADH. The renin-angiotensin-aldosterone system kicks off when your pressure or fluid drops. Renin starts a chain, making angiotensin II, which clamps down on blood vessels and triggers aldosterone to hang onto sodium and water.

Loretta Swift

And then ADH, antidiuretic hormone, comes in when you need to hold onto water. Like, when you’re dehydrated after a night shift—your pituitary gland tells the kidneys, "Lock that water down!"

James A. Bond

That’s the bit students forget: these hormones act quickly, and if there’s any dysfunction—say, a patient is making too much or too little ADH, or the RAAS system’s in overdrive—you might see symptoms like sudden blood pressure spikes, confusion, or swelling. Abnormal filtration can show up as edema or proteinuria, for example.

Loretta Swift

Yeah, it pays to keep an eye on those subtle changes, especially in our older patients.

Loretta Swift

So diagnostics: you’ve got urinalysis at the top of the list—looking for things like protein, blood, or infection. Then you’ve got blood work: BUN, creatinine, and creatinine clearance. Imaging pops up for tougher cases. But—here’s the kicker—when we talk about older adults, things get trickier because kidney size and function drop with age, don’t they, James?

James A. Bond

They certainly do. By the time someone hits 90, they might’ve lost 10 percent of their kidney size and weight compared to when they were 30. GFR starts dropping at forty, and their hormone levels change too—decreased ability to concentrate urine, altered elimination of electrolytes. Women get more infections and incontinence because of reduced muscle support. Men, well, the prostate often comes into play, complicating things further.

Loretta Swift

Which leads me to a classic scenario: we had this 82-year-old patient come in totally confused—not talking, couldn’t tell us what was wrong. Her family thought she’d had a stroke. But a quick urinalysis showed infection signs: leukocytes, nitrites, bacteria, all that. Turns out, her only real symptom of a UTI was confusion. With older folks, we always have to keep infections on the radar, even if they don’t have typical urinary symptoms.

James A. Bond

Right. And let’s not forget about creatinine clearance—great for assessing renal function, especially since BUN can be thrown off by dehydration or medications. Serial labs, careful history, and knowing those age-related changes make a difference.

Loretta Swift

And don’t be shy about using your bedside assessment skills, either. Sometimes it’s not about a fancy test—it’s about connecting the dots when things look just a little "off."

James A. Bond

Speaking of infections—UTIs are the most common healthcare-associated infections, especially catheter-associated ones, or CAUTIs. Most are caused by E. coli, but we do see other bugs, particularly in facilities with lots of device use. Anything that messes with the normal one-way flow, like reflux or stasis, can drive up risk.

Loretta Swift

And, let’s not forget classic risk factors: being female, older age, pregnancy, diabetes, catheter use—it’s quite the list. Pathophysiology varies too: lower tract infections include cystitis (the bladder) and urethritis. Upper tract? That’s your pyelonephritis—the infection’s climbed up to the kidneys themselves. Manifestations differ: burning, frequency, urgency, and sometimes fever or chills. But, older adults? They might just get confused or more incontinent. No textbook symptoms.

James A. Bond

I had a patient once who just… stopped eating and seemed listless. Classic ‘silent’ UTI in an elderly gentleman. And you’ve seen a few CAUTI outbreaks, haven’t you Loretta?

Loretta Swift

Oh yeah, at the nursing home, we had a rough patch where CAUTIs cropped up all over. We realized staff were rushing peri-care and not always following best catheter technique. We reset, did tons of education—removing unnecessary catheters, using aseptic methods, hand hygiene. Things improved, but it was a wake-up call to how small lapses make big problems.

James A. Bond

It’s a systemic issue. And the nursing interventions? Education, fluids, proper hygiene, avoiding irritants like caffeine or citrus, tracking symptoms for complications. Plus, being smart with antibiotic use—tailoring to the infection, not just throwing meds at it.

Loretta Swift

Now, shifting gears a bit—glomerulonephritis. Inflammation right at the filtering units—the glomeruli—which can be caused by things like infections, immune triggers, even drug exposure. I keep telling students: If you spot proteinuria, hematuria, and maybe some edema? Worry about the glomerulus.

James A. Bond

Definitely. Acute forms often follow infections, like a recent bout of strep throat—especially in kids. You get that classic 1-6 week lag after recovery, and then, suddenly, facial puffiness, dark urine, and hypertension. Chronic forms? More insidious—progresses to kidney failure over years, sometimes without any obvious prior history.

Loretta Swift

And nephrotic syndrome is a close cousin. Basically, massive protein loss through the urine. That’s where you see full-body swelling—anasarca—foamy urine, and sometimes blood clots from that hypercoagulable state. Treatment always circles around the cause: sometimes antibiotics for infection, supportive care, even dietary tweaks and anticoagulants as needed.

James A. Bond

Yeah, and the scary bit with chronic glomerulonephritis is it can fly under the radar until you’re facing end-stage renal disease. That’s why mild symptoms or abnormal labs—protein, blood, casts in the urine—shouldn’t be brushed off.

James A. Bond

And then you land in the world of obstructions—urine can’t get where it needs to go, so pressure builds up, risking kidney damage and infection. Causes run the gamut: BPH (enlarged prostate), congenital issues, strictures, tumors, and, everyone’s favorite—kidney stones.

Loretta Swift

Oh, kidney stones—the infamous “kidney stone dance”! Patients in agony, can’t sit still, sweating, pale—sometimes vomiting. Stones form for all sorts of reasons: dehydration, diet, genetics, high or low urine pH. The pain’s sudden and severe, radiating from the back to the groin, and sometimes there’s blood in the urine. Diagnosis is done with imaging, urinalysis, checking stone composition—if you can catch one, that is.

James A. Bond

And let’s not forget, hydration education is crucial for both prevention and treatment. Patients always ask, "What can I do to stop this happening again?"—and honestly, water is the least expensive prevention there is. Some stones will pass spontaneously, but bigger or stubborn ones? Might need lithotripsy or surgical removal. Managing pain often involves NSAIDs and sometimes opioids. Plus, addressing the underlying cause—like dietary changes if needed.

Loretta Swift

And for nurses, we’ve gotta remember that even minor obstructions can cause big problems: infections, urine backflow, and long-term kidney damage if left unchecked.

Loretta Swift

Last but not least, let’s wrap with bladder dysfunction. Incontinence is everywhere, especially with older adults, but it’s not just "one thing"—there’s stress, urge, overflow, and mixed types. Treating it is all about the details: we start with behavioral strategies like bladder training, scheduled toileting, and pelvic floor exercises. Medications and, in some cases, devices or surgery, come later.

James A. Bond

Spot on, and let’s not leave out acute and chronic urinary retention. Acute retention—that’s a "drop everything and fix this now" emergency. Sometimes it’s as simple as inserting a catheter, though long-term, we look for the underlying reason, be it BPH, medications, or neurologic disease. Chronic retention, on the other hand, needs a more measured approach: bladder scans, retraining, sometimes intermittent catheterization, or a surgical fix for stubborn cases.

Loretta Swift

That’s where the DRIP mnemonic comes in: Delirium, Retention/Restricted mobility, Infection/Inflammation/Impaction, and Pharmaceuticals or Polyuria. I once had a patient who kept wetting the bed at 2 a.m. Found out he just needed scheduled toileting and some tweaks to his evening medications. Problem solved—no more embarrassment, no more falls.

James A. Bond

And of course, catheter care—always a hot topic, given CAUTI risks. It’s never just about convenience. We’ve got to weigh long-term risks and prioritize removing catheters as soon as safely possible.

Loretta Swift

Absolutely. Well, that about covers our renal rundown for today. James, always a pleasure digging into the details with you.

James A. Bond

Likewise, Loretta. Next time, we’ll dig deeper into some unique renal syndromes, so keep those questions coming. And drink some water for us!