Case Study Part 3: Renal Failure
Clinical Course Day 2:
You call the hospitalist regarding the labs above and the following orders are placed: Decrease the IV fluids, D/C insulin drip, Start insulin sliding scale with glucometer readings every 2 hours, increases oxygen to 4 Liters O2 per NC with titration to maintain SpO2 >92%, Lasix 40mg IV x 1 now. You inform him that the newest vital signs are: T:100.9; HR: 114; R: 32; B/P: 122/64. Urine output 45cc/hr.
Basic Metabolic Profile, CBC, UA, ABG and BNP ordered:
Labs and Diagnostics:
Na 134 meq/L K 3.5 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 66 mg/dL Cr 3.0 mg/dL
eGFR 36 cc/min WBC 16.8 x 103/mm3 Hb 11.6 g/dl / Hct 37% Glucose 180 mg/dL
Clear, dark yellow urine; Microscopy was negative for cells, casts, pigments, and crystals
SG 1.032 (-) bacteria (+) glucose (-) protein (-) Nitrate (-) RBC (-) WBC
Urine sodium 8 mEq/L. FeNa <1%
BNP 975 pg/ml Troponin I High Sens. 15 pg/ml
ABG: pH= 7.30; PaCo2=12; PaO2= 88; HCO3: 18 BE: 1
Answer the following questions based on the information above:
10) The patient is noted to have acute kidney injury (AKI) and nephrology is consulted. Based on the patient’s diagnosis of CHF, physical findings and labs, is the patient exhibiting pre-renal, intra-renal or post renal failure? (1point). Explain your decision (3 points)
11) Oliguria occurs in AKI whether the cause is pre-renal or intrarenal. What are three mechanisms which account for the decrease in urine output? ( 3 points)
12) Describe the key differences in the pathophysiology between pre-renal and intrarenal failure.(4 points) As the nurse, what would you look for on your assessment of the patient who is in pre-renal failure? (2 points)
13) Comorbidities such as hypertension and diabetes can affect kidney function over and above this patient’s diagnosis of CHF. List five teaching points and expected outcomes on her diagnoses at discharge to prevent a reoccurrence and readmission ? (5 points)
APA 1 point Scholarly Work 1 point Total points 20
Urinary Tract Infection Glomerular Disease
Urinary Tract Infection
A urinary tract infection (UTI) is an inflammation of the urinary epithelium usually caused by bacteria from gut flora.
A UTI can occur anywhere along the urinary tract
Acute cystitis is an inflammation of the bladder and is the most common site of UTI.
The morphologic appearance of the bladder through cystoscopy describes different types of cystitis:
Mild inflammation- the mucosa is hyperemic (red)
Hemorrhagic cystitis- diffuse hemorrhage
Suppurative cystitis- pus formation, or suppurative exudates on the epithelial surface of the bladder
Ulcerative cystitis- prolonged infection, sloughing of the bladder mucosa with ulcer formation
Gangrenous cystitis- necrosis of the bladder wall
The most common infecting microorganisms are uropathic strains of Escherichia coli and the second most common is Staphylococcus saprophyticus.
Less common microorganisms include Klebsiella, Proteus, Pseudomonas, fungi, viruses, parasites, or tubercular bacilli.
Schistosomiasis is the most common cause of parasitic invasion -strong association with bladder cancer.35
Bacterial contamination is by retrograde movement of gram-negative bacteria
These bacteria resist flushing by normal micturition
Hematogenous causes are uncommon and usually occur in septicemia
Clinical Manifestations of cystitis
Related to the inflammatory response
Usually include frequency, urgency, dysuria (painful urination), and suprapubic and low back pain
10% of individuals with bacteriuria have no symptoms
30% of individuals with symptoms are abacteriuric
Clinical Manifestations of cystitis
Elderly persons with cystitis may be asymptomatic
May demonstrate confusion or vague abdominal discomfort.
The elderly with recurrent UTIs and other concurrent illness have a higher risk of mortality.
Evaluation and treatment
Urine dipstick testing that is positive for leukocyte esterase or nitrite reductase can be used for the diagnosis of uncomplicated UTI without a culture
Individuals are diagnosed by urine culture of specific microorganisms with counts of 10,000/ml or more from freshly voided midstream urine.
Microorganism-specific antibiotics used
3-7 days uncomplicated; 7-14 days complicated
An infection of one or both upper urinary tracts
Urinary obstruction and reflux of urine from the bladder are the most common underlying risk factors
One or both kidneys may be involved
Most cases occur in women
- coli, Proteus, or Pseudomonas most common organisms
Urethral instrumentation or urinary tract surgery are commonly associated
Infection is usually ascending pathogens up the ureters
May be spread through the blood stream
Inflammation affects pelvis, calyces and medulla
Result is renal inflammation, renal edema,
and purulent urine
Severe infection may result in abscess formation and extend to the cortex
Rarely causes renal failure
Uncomplicated acute pyelonephritis responds well to 2 to 3 weeks of microorganism-specific antibiotic therapy.
Complicated pyelonephritis requires blood cultures and urinary tract imaging
Follow-up urine cultures are obtained at 1 and 4 weeks after treatment if symptoms recur.
Disorders affecting the glomerulus
Rapidly progressing glomerulonephritis
Inflammation of the glomerulus from:
Immunologic abnormalities –think post streptococcal!
Drugs or toxins
Most common of the glomerular diseases
Mechanism of injury
Deposition of circulating soluble antigen-antibody complexes, often with complement fragments
Antibodies to the glomerular basement membrane are formed
Causes an increase in glomerular capillary permeability and loss of negative ionic charge barrier
This results in gaping holes in the basement membrane, allowing large plasma proteins and RBCs to escape into the urine
The loss of plasma proteins causes a drop in albumin and subsequent leakage of fluid into the interstitial spaces edema
Encompasses many glomerular diseases
Associated with hypercholesterolemia and proteinuria
Diabetes and Lupus are secondary causes
Inflammation and damage again caused by damage to the glomerular basement membrane
Rapidly Progressive GN
Develops over days to weeks
Usually affects adults in 50’s and 60’s
Hematuria is a common sx along with proteinuria
Goodpasture’s Syndrome is a form of RPGN and involves both the basement membrane of the lung and the glomerulous
Excretion of more than 3.5 grams of protein in a 24 hour period in glomerular injury
Manifested by hypoalbuminemia, edema, hyperlipidemia and lipiduria
Assessment in Glomerular Diseases
Usually periorbital and extremity edema
Can develop anasarca (generalized edema) if albumin gets too low to hold fluid in the vascular space
Albumin and total protein always low
Proteinuria measured on a 24 hour urine. Can be in excess of 5 grams!!!
BUN and Creatinine not affected because filtering is still taking place
Biopsy gives definitive diagnosis