Apollo Bramwell Nursing SchoolMoca, Mauritius

Medical Underwriter

Kidney Disorders: Underwriter Focus

Disorders Risk Factors Diagnostics Treatment of Choice Complications PrognosisKIDNEY STONES

1. Gender and Age: Male: 2X more

common, inc at 40-70 y/o

Female: risk peaks @ 50 y/o

2. Family Hx 2X the risk3. Obesity and weight

gain: Higher BMI and weight

increases the risk4. Lifestyle: Low H2O intake High protein and

calcium athletes5. Pre-Existing medical

Conditions Gout- uric acid stone HPN- 3X the risk UTI- struvite stone Hyperparathyroidism

Imaging Technique:1. CT scan- the best method in diagnosing

renal stone Plain- No special prep Contrast- fasting 4 hours before

2. X-ray- standard x-ray for kidney, ureters and bladder. Can detect stones but usually limited

in relation to the size No special prep, can be done on OPD

bases3. Ultrasound- not effective in detecting

small stones. Fasting is necessary with full bladder

4. Intravenous Pyelography- a dye is injected and the technician takes and x-ray as it passes in the kidney. Fasting, risk for allergy Can be done either inpatient or out-

patientOthers:1. Urine analysis- use to determine specific

chemical and biological factor. pH- Norm- 7.0

high- calcium phosphate, struviteLow- uric acid and cystine stone

Hematuria (blood)- blood in the urine2. Blood test for stone factors

Creatinine, Calcium, Phosphate, uric acid- elevates usually in the blood

Note: the size, the location, and the number of stones.1. Increase fluid intake

If the stone is less than 5 mm- they pass through normal urination

Alpha blockers- relax the muscles in the urinary tract allowing stone to pass.

2. Surgical Interventions: a. Extracorporeal Shockwave

lithotripsy- a sound wave is used to break the stone and allow it to pass with the urine/stent can be placed.-Has 50-90% success rate-Can be done on outpatient bases

-Does not work for stone greater then 3 cm

-Common complications: Blood in the urine Bruising on the area Rarely: kidney damage

b. Ureteroscopy- used for stone in the lower and middle ureter. A fiber optic instrument called ureteroscope is passed through the urethra, bladder and ureter and removed the stone by laser or with basket.

Obstruction and infection

Chronic Kidney disease- stones increases the risk of CKD and heart attack

Kidney failure- rarely develop

Great chance of recurrence: 40% during the

first 5 years after the initial attack

75% within 20 years

Renal Failure Acute or

chronic

Acute Renal failure- decrease in GFR generally occurring within hours, days or weeks that is associated with accumulation of waste products including urea and creatinine.Risk Factors:Pre-renalo Dehydration, bleeding,

hypoalbuminuria, decrease cardiac output, MI, Heart failure

Intrarenalo Acute tubular necrosis

due to nephrotoxins, ischemia, sepsis

Post-renalo BPH, calculi, tumor

Blood Study:1. BUN and Creatinine- less sensitive to

changes in GFRTest Normal ResultBUN 7-20 mg/dl IncreaseCreatinine 0.7-1.2 mg/dl increase

2. Urine analysis- useful to identify the cause of the acute renal failure.o Ultrasound- identify obstruction/no

special preparationo CT- identifies obstruction, lesions and

vascular abnormalities.

Medications:

1.Dopamine and Diuretics2.Insulin therapy

Renal Replacement therapy:Dialysis: Indications:a.Volume overloadb.Elevated serum K and Mgc. Metabolic acidosisd.BUN greater than 120 mg/dle.Significant changes in mental

status1.HEMODIALYSIS- the method

of choice when rapid changes are required in a short period of time- A temporary vascular access

is required.- During the procedure,

substance from the blood move from the blood through a semi-permeable membrane and into a dialysis solution

- Usually done in in-patient.- Complications:o Hypotensiono Blood infectiono Loss of blood

Chronic kidney disease

Metabolic acidosis

Fluid accumulation

Electrolyte imbalances

40-50% mortality

Chronic Renal Failure- is the progressive irreversible loss of kidney function.- There is decrease in GFR

by < 60 ml/min for > 3 months.

- and inc. urinary albumin excretion.

Risk factors: Diabetes- 2/3 of the

Investigations:1. Serum GFR- is preferred to determine

kidney function.o <60 ml/min and persistent (present

for less than 3 months) indicates substantial reduction in renal function.

2. Urine analysiso Persistent WBC or RBC in the absence

of instrumentationso Presence of cellular cast

Control of risk factors:1. Control of diabetes with

insulin or oral hypoglycemic agent

2. Control of hypertension with anti-hypertensive medications.

3. Nutritional therapy: Protein restriction Water restriction

Complications:1.Anemia- low Hb

count2.Hypertention3.Cardiovascular

disease (10-30 X mortality)

4.Dyslipidemia- risk increases with CKD

No cure for CKD.Untreated will lead to end-stage-renal diseaseIt requires long term treatment.

cases Hypertension- 1/3 of the

cases ObesityStages of CKD

Stages GFR ml/min

Stage 1 >90-90Stage 2 60-89Stage 3 30-59Stage 4 15-29Stage 5 <15 RRT

o Albumin/creatinine ratioNormal: <30 mg/g

depending on the stage Sodium and potassium

restriction Phosphate restriction

For GFR >15 ml/minRenal Replacement Therapy1. Hemodialysis

Requires fistula or graft for long term use

Fistula is the anastomosis between artery and vein

2. Renal transplant

5.Metabolic acidosis6.Hyperkalemia

Urinary Tract Infections- Is a bacterial

infection affecting the urinary tract

- Commonly due to E-coli

1.Women – 8X higher than in men

2.Pregnancy3.Menopause 4.Hospitalization-

nosocomial in nature.5.With indwelling catheter6.Co-morbidities:

a. DM, co-existing kidney disorders

1. Urine culture and sensitivity- to identify the specific bacteria and the appropriate antibiotic.

- The most accurate diagnostic test- No special preparation- It takes time before the result is

available2. Routine urine test

- Presence of WBC, pus, change in color of urine (cloudy)

3. CT scan and Intravenous pyelography- Can only be done if obstruction of

urinary tract system is suspected of causing the UTI.

1. Antibiotic therapya. Broad spectrum

antibiotics2. Non-pharmacologic

management:a. Increase fluid intakeb. Dietary modification

1.Pyelonephritis2.Bacteremia

Recurrent infection

http://umm.edu/health/medical/reports/articles/kidney-stones