Apollo Bramwell Nursing School

Moca, Mauritius

Medical Underwriter

Kidney Disorders: Underwriter Focus

Disorders Risk Factors Diagnostics Treatment of Choice Complications Prognosis
KIDNEY
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 risk
3. Obesity and weight
gain:
Higher BMI and weight
increases the risk
4. Lifestyle:
Low H2O intake
High protein and
calcium
athletes
5. 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
bases
3. 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-
patient
Others:
1. Urine analysis- use to determine specific
chemical and biological factor.
pH- Norm- 7.0
high- calcium phosphate, struvite
Low- uric acid and cystine stone
Hematuria (blood)- blood in the urine
2. 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-renal
o Dehydration, bleeding,
hypoalbuminuria,
decrease cardiac
output, MI, Heart
failure
Intrarenal
o Acute tubular necrosis
due to nephrotoxins,
ischemia, sepsis
Post-renal
o BPH, calculi, tumor

Blood Study:
1. BUN and Creatinine- less sensitive to
changes in GFR
Test Normal Result
BUN 7-20 mg/dl Increase
Creatinine 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 preparation
o CT- identifies obstruction, lesions and
vascular abnormalities.
Medications:

1. Dopamine and Diuretics
2. Insulin therapy

Renal Replacement therapy:
Dialysis: Indications:
a. Volume overload
b. Elevated serum K and Mg
c. Metabolic acidosis
d. BUN greater than 120 mg/dl
e. Significant changes in mental
status
1. 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 Hypotension
o Blood infection
o 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
cases
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 analysis
o Persistent WBC or RBC in the absence
of instrumentations
o Presence of cellular cast
o Albumin/creatinine ratio
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
depending on the stage
Complications:
1. Anemia- low Hb
count
2. Hypertention
3. Cardiovascular
disease (10-30 X
mortality)
4. Dyslipidemia- risk
increases with
CKD
5. Metabolic acidosis
No cure for CKD.
Untreated will lead
to end-stage-renal
disease
It requires long
term treatment.

Hypertension- 1/3 of
the cases
Obesity
Stages of CKD
Stages GFR
ml/min
Stage 1 >90-90
Stage 2 60-89
Stage 3 30-59
Stage 4 15-29
Stage 5 <15 RRT





Normal: <30 mg/g Sodium and potassium
restriction
Phosphate restriction
For GFR >15 ml/min
Renal Replacement Therapy
1. Hemodialysis
Requires fistula or graft
for long term use
Fistula is the
anastomosis between
artery and vein
2. Renal transplant
6. 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. Pregnancy
3. Menopause
4. Hospitalization-
nosocomial in nature.
5. With indwelling catheter
6. 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
available
2. 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 therapy
a. Broad spectrum
antibiotics
2. Non-pharmacologic
management:
a. Increase fluid intake
b. Dietary modification

1. Pyelonephritis
2. Bacteremia


Recurrent infection



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