Renal Component Assessment in ITU - Essay Example

? School: RENAL COMPONENT ASSESSMENT IN ITU Lecturer: RENAL COMPONENT ASSESSMENT IN ITU Introduction One of the most crucial processes that should make up normal life for every other healthy person is the periodic filtering of waste products from the blood. This is a very important system function due to the fact that we continue to consume food products, which produce a lot of filtrate waste after the necessary transfusion into the blood stream of needed nutrients (John, Webb & Young, 2004, p. 827). As part of the anatomy of the human being, the kidneys are expected to perform this all important function described above. This notwithstanding, some people develop a medical condition where the kidneys are almost incapacitated or fail to adequately perform this role of filtration of waste products from the bloodstream. Once this situation is diagnosed, the person is said to be suffering from renal dysfunction, kidney failure, or renal insufficiency. The situation described above is only the end result of the health problem as it involves several complex component aspects that bring about this medical condition. This paper therefore aims to critically assesses and analyse renal dysfunction from a medical point of view, where emphasis is placed on renal anatomy and physiology, effect of renal system on cardiovascular and respiratory systems, clinical plans for renal dysfunction, and the treatment of various components of renal dysfunctional situations such as hyperkalaemia. Case Study Analysis This is a case of 90 year old Mrs. X (name withdrawn for ethical purposes of anonymity). Mrs. X has medical history that includes hypertension, cataracts and previous rectal prolapse. Three days before her admission to the ITU, she had been presented to the Accident and Emergency Unit with abdominal pain. She was then treated for urinary tract infection using Trimethoprim and then sent home. On the day of admission to the ITU, which was three days after she left the Accident and Emergency Unit, Mrs. X was found with nausea, distended abdomen and suffering anuria for 3 days. Through an Electrocardiography, Mrs. X was identified to be showing ventricular ectopic beats with the following readings: blood creatinine 984, urea 54:8, potassium 8.7, CK 227, and CRP (c-reactive protein) 177. Indeed this case gives a multi-variant indication of possible complications that Mrs. X may be suffering from. But more significantly, it would be noted that most of the situational conditions of the patient are highly related, and for that matter, related to the functioning of her renal systems (UK Renal Association, 2012, p. 86). According to UK Renal Association (2012, p. 87), there are three major groups of renal failure, with each of these having their own causes based on their location within the renal system. These types are prerenal renal failure, postrenal renal failure and intrinsic renal failure. For patients with prerenal renal failure, they are diagnosed to have perfusion of the kidney, which signals that there is lack of proper cleaning in the blood (Web MD, 2010). This may be caused by dehydration, continual blood loss or heart failure. Postrenal renal failure on the other hand involves an inhibited flow of urine out of the two kidneys, leading to amassed pressure in the renal nephrons (Watts, Harri and Shaw, 2010, p. 98). This is often caused by factors including bladder stone, kidney stones, and neurogenic bladder. Intrinsic renal failure is however a damage to both kidneys and is not associated or caused by either prerenal or postrenal renal failures. Intrinsic renal failure is however caused by vascular diseases, diseases of tubules, and acute tubular necrosis. By comparison, it will be noted that Mrs. X is currently suffering from a postrenla renal failure as she shows symptoms directly related to her renal nephron functioning. Quite apart from these renal related issues, her experience with cataracts and hypertension could be said to be highly isolated for her current symptoms, which has become necessary for her to be admitted to ITU. Multi-variant Assessment approach to Renal Dysfunction There are various techniques that are used in the diagnosis of renal dysfunction. Shibihi & Melton (2007, p. 394), however note that the most traditional forms of these techniques include the use of blood test and urine sampling, where plasma creatinine and creatinine clearance are always on the lookout for decision making. For renal dysfunction to be ascertained by this method, symptoms including anuria, distended abdomen, nocturnal urination, nausea, muscle paralysis, and abnormal heart rhythm may be on the lookout. This method or technique has however been criticised for most of its weaknesses, including the fact that most significant change in creatinine levels are not detectable in these situations until 60% function loss has taken place in patients (Smellie, 2007, p. 693). What is more, using this technique is most likely not to reveal an explicit kidney location, be it the left or the right kidney as a cause of the renal dysfunction (Stengel 2003, p. 24). Given these weaknesses with what may be referred to as the most traditional form of diagnosis, a more advanced system that involves the use of renal anatomical and physiological analysis is required. This has led to the call for dynamic imaging of the kidneys to be used. One of the commonest forms dynamic imagining of the kidneys that can be used is the electrocardiography (ECG) that was used in the case of Mrs. X. In accordance with findings of a recent study by Fonarow (2009, p. 116), it has been said that renal dysfunction will be assessed in a patient who records certain levels of blood creatinine, urea, potassium and c-reactive protein that are considered to be higher. In such situations, where plasma potassium is found to be in excess of 5.5 mmol/L, hyperkalaemia, which is an indication of renal dysfunction, could be suspected. For creatinine levels, adult males are not expected to record levels exceeding 0.6 to 1.2mg per decilitre (dL) and 0.5 to 1.1 mg of dL in female adults (Smellie, 2007, p.695). Normal adults are expected to record 6 to 20 mg of urea nitrogen per every 100 ml of blood. For CRP, the following interpretations are expected Source: Web MD (2010) In the case of Mrs. X, both the traditional and dynamic imagining of the kidneys shows signs, readings and symptoms that are indicative of the fact that she is suffering from renal dysfunction. Renal anatomy and physiology Having settled on the conclusion that Mrs. X has renal dysfunction through a multi-variant assessment approaches, it is important to have a direct understanding of the renal anatomy and physiology in order to suggest further interventions and treatments. The kidney is part of the larger urinary system, made up of other organs including ureters, urinary bladder, and urethra (Gennari and Segal 2012, p. 5). Independently, kidneys may be described as a retroperitoneal organ, which means that they have peritoneum on their anterior side only. All normal people have two kidneys, one on the left and the other on the right, with the left kidney found slightly higher in position than the right kidney (Guidelines and Audit Implementation Network, 2008, p. 694). The bean-shaped organs have a normal size of 11 to 15 cm in adults. The kidney is responsible for several functions in the body, including execratory function, homeostatic function, endocrine secretion function, endocrine metabolic function. The table below outlines the four major functions that the kidney plays. Table 1: Physiology of the Kidney Execratory Function Homeostatic Function Endocrine Secretion Function Endocrine Metabolic Function 1. Metabolism 2. Drugs 3. Toxins 1. Maintenance of water balance 2. Maintenance of electrolyte balance 3. Maintenance of acid-base balance 1. Rennin 2. Erythroprotein hormone 3. Prostaglandins 1. Conversion of vitamin D3 to active 1,25 dihydroxycholecalciferol Adapted from Gawad (2012) The pictorial representation of the kidney is given below. Fig 1: Anatomy of the Kidney Source: Gawad (2012) Effects of the renal dysfunction on other body systems From table 1, it would be noted that the renal system is highly important in regulating a number of functions in the body. Two of these systems are the cardiovascular and respiratory systems. As far as the cardiovascular system is concerned, it has been found that the renal system is so much connected with this that heart diseases have actually been identified as the leading cause of death in end-stage renal disease (Coetzee 2011). Indeed, there are several specific effects that bring about this end point consequence. First and foremost, the renal system is responsible for fluid and potassium overload, by which function the kidney is expected to regulate fluid balance in the body (Watts, Harris & Shaw 2010, p. 26). Once this function is hampered, there is a build up of fluid in the lungs, heart, brain and other tissues connected to the cardiovascular system (Coetzee 2011). This in effect increases the workload to be performed by the heart, leading to possible cases of heart failure. Secondly, because there is loss of kidney cells, which produces erythropoietin in renal dysfunction situations, anaemia sets in for patients with renal dysfunction. Meanwhile, anaemia makes the heart demand higher rates of oxygen and thereby increasing the heart rate and output, which could also be a potential cause of heart failure (Stengel 2003, p. 34). Lastly, uremia, which is high levels of urea or urine in the blood, and which is associated with renal dysfunction because the kidney refuses to collect waste leading to dietary protein breaking down into urea, has also been found to be dangerous to the heart (Coetzee 2011). Once there is urine in the blood, toxic conditions develop, leading to inflammation of the outer layer of the heart, which is the pericardium (Walker & Edwards 2009, p. 32) Like the cardiovascular system, renal dysfunctions affect the respiratory system in a number of ways. For the respiratory system, there are two major forms of effects that renal dysfunction poses to its. The first has to do with swellings and its attendant problems. Shibihi & Melton (2007, p. 76) notes that when there are swellings on most visible parts of the body such as the arms, legs, face, and feet, it is a direct indication that other internal organs that are directly related to the respiratory system have also become swollen. Meanwhile, in renal dysfunction when the kidney fails to plays its role of removing excessive water and keeping only useful substance of protein in the blood, the excessive water remains in the body, causing edema, which swelling to parts of the body such as arms, face and feet (Isnard et al 2009, p. 6). The state of these swellings become aggravated when protein leaks into the urine and causes proteinuria, leading to blood flowing into the tissues from blood (Kidney Service China, 2013). Indeed, such aggravated swelling that signal that respiratory organs have swollen results in shortness of breath, anhelation and pleural effusion (Gennari & Segal 2012, p. 53). The other effect of renal dysfunction on the respiratory system has to do with toxins deposition. As outlined as part of the physiology of the renal system, the kidney plays an important role in removing toxins from the blood. Once the functioning of the kidney will become hampered, this will lead to toxins being deposited in the blood, bringing about symptoms including alveolar capillary permeability and pulmonary congestion, which are all directly related to the respiratory system (Kidney Service China 2013). Relationship between SIRS/sepsis/MODS and renal system According to Isnard et al (2009, p. 53), the most effective forms of clinical plans that can be taken towards the management and care of renal dysfunction are those that take into consideration the need for a holistic approach to tackling the situation rather than an approach that only tackles specific aspects of the problem. In line with this, the need to have an understanding of how other factors and health situations are connected to the renal system is very crucial and critical. In light of this, the relationship between SIRS, sepsis, and MODS and renal system is investigated. Watts, Harris & Shaw (2010, p. 693) notes that the major relationship that exists between these Sepsis, systemic inflammatory response syndrome (SIRS) and Multiple organ dysfunction syndrome (MODS) is that they all deal with holistic systemic dysfunction in one way or the other. For example, MODS represents an “alteration in organ function can vary widely from a mild degree of organ dysfunction to completely irreversible organ failure” (Al-Khafaji 2013). On the other hand, SIRS and sepsis represent a fatal whole-body inflammation that arises due to an infection. In terms of relationship therefore, MODS brings about an alternation in the renal system in the state of renal dysfunction, which subsequently complicates 50% of cases of septic shock as the normal functioning of the kidney in maintaining renal blood flow and glomerular filtration through auto-regulation is hampered in renal dysfunction (Webster and Paterson 2010, p.385). Meanwhile, this auto-regulation is dependent on the level of afferent and efferent arterioles, which becomes disturbed in sepsis (Webster and Paterson 2010). Therapeutic interventional Treatment of hyperkalaemia for Mrs X The filtration technique in the treatment of hyperkalaemia will be advised for Mrs. X in this situation. By this therapeutic interventional treatment, there are a number of objectives that will be aimed to be achieved for the patient. These objectives include (1) to stop further accumulation of potassium, (2) to protect the cardiac membrane, (3) to shift potassium into the cells, and (4) to remove potassium from the body, which is the major basis of the filtration process. All these objectives will be achieved through a number of procedural steps as enlisted below. Treatment Objective Major Interventions To stop on-going accumulation of potassium 1. Withdraw from administering any potassium supplements or medications that conserve potassium (Guidelines and Audit Implementation Network 2008). 2. Due to the effect of digoxin and beta-blocks in preventing the buffering of intracellular potassium and reduce the effectiveness of insulin-glucose, it is recommended that their administration be stopped (Rull 2013). 3. The intake of diet high in potassium must be reduced. To protect cardiac membrane: 1. To achieve transient effect of improved ECG over a period of 30 to 60 minutes, the administration of 10 ml 10% calcium gluconate is recommended (UK Renal Association 2012, p.80). 2. The process must be repeated with 10 ml every 10 minutes until ECG normalises if there is no improvement achieved after the first process. To shift potassium into the cells 1. Rull (2013) recommends the infusion of 10 units of solution of Actrapid® and 50 ml of glucose 50% over 30 minutes intervals. 2. The level of glucose in the capillary blood must be checked at all stages of the intervention, namely pre, intervention, and post intervention stages. 3. The above process will lead to the reduction of potassium by 0.6-1.0 mmol/L after 15 minutes and this is expected to last for 60 minutes (Fonarow 2009). 4. There is the need to recheck for potassium after 30 minute and U&E after 1-2 hours. 5. To achieve further reduction of potassium by 0.5-1.0 mmol/L, the administration of 10-20 mg nebulised salbutamol is recommended in 15-30 minutes for a continouous 2 hour period (Walker & Edwards 2009). To remove potassium from the body 1. Injection of Calcium polystyrene sulfonate resin such as Calcium Resonium®) with regular lactulose will lead to the removal of potassium through the gastrointestinal tract (Rull 2013). 2. Undertaking Haemodialysis will lead to the removal of potassium from the body (John et al 2004, p. 835) Adapted from Rull (2013) Once the patient is set on recovery from renal failure, there are a number of phases that the kidney goes through. It must first be noted that the recovery phase is a gradual process that may last for several months. As part of the recovery, there will be a reduction in the edema with the renal tubules beginning to function properly (WEB MD, 2010). Due to the control of the renal tubules on fluid movement, there is the restoration of fluid and electrolyte balance in the kidney (Watts, Harri and Shaw, 2010, p. 65). This is however not always the case, especially for patients who experience very significant damage to their renal tubules. The final phase sees the glomerular filtration rate (GFR) returning to up to 80% normalcy. Conclusion From the case analysis above, Mrs. X is suffering from renal dysfunction, which is a very complex situation that requires immediate treatment to ensure that the situation is not worsened. Through the discussion, it has been noted that further harm could result in very fatal effects and consequences on other systems, particularly the cardiovascular and respiratory systems. Meanwhile, Mrs. X has a history of hypertension and so such consequence will be highly detrimental for her. As an intervention, four major clinical objectives must be set for her, with the aim of treating symptoms and cases of hyperkalaemia. References Al-Khafaji (2013). Multiple Organ Dysfunction Syndrome in Sepsis. [Online] Available at [Accessed: 27th December, 2013] Coetzee K (2011). Renal failure and its effect on the cardiovascular system. [Online] Available at [Accessed: 29th December, 2013] Fonarow G. C (2009). Managing the patient with diabetes mellitus and heart failure: issues and considerations. Am J Med. 8(23), pp. 116 Gawad M. A (2012). Renal Physiology I - Kidney Function & Physiological Anatomy. [Online] Available at http://www.slideshare.net/MohammedGawad/renal-physiology-i-kidney-function-physiological-anatomy-14636745 [Accessed: 29th December, 2013] Gennari F. J. & Segal A. S. (2012). Hyperkalemia: An adaptive response in chronic renal insufficiency. Kidney Int; 6(21), pp.1-9. Guidelines and Audit Implementation Network (2008). Guidelines for the treatment of hyperkalaemia in adults. BMJ. 3(1), pp.693-5. Isnard B. C, Deray G, Baumelou A, et al; (2009). Herbs and the kidney.; Am J Kidney Dis; 44(1):1-11. John, R., Webb. M. & Young, A. (2004). Unreformed chronic kidney disease: a longitudinal study. Am J Kidney Dis 43(5), pp. 825–35. Kidney Service China (2013). Chronic Renal Failure Effects on Respiratory System. [Online] Available at [Accessed 26th December, 2013] Rull G. (2013). Hyperkalaemia. [Online] Available at [Accessed: 29th December, 2013] Shibihi, H. & Melton, K. G. (2007). Human biology and health. New Jersey: Prentice Hall. Smellie W.S. (2007). Spurious hyperkalaemia. BMJ. 31(3), pp. 693-5. Stengel, B. (2003). Lifestyle factors, obesity and the risk of chronic kidney disease epidemiology. London: Century Business. UK Renal Association (2012). Clinical Practice Guidelines: Treatment of Acute Hyperkalaemia in Adults. Am J Med. 8(11), pp. 77-88. Walker, R. & Edwards, C. (2009). Clinical pharmacy and therapeutics. Edinburgh: Churchill Livingstone. Watts, G. F., Harris. R. & Shaw, K. M. (2010). The determinants of early nephropathy in insulin- dependent diabetes mellitus: a prospective study based on the urinary excretion of albumin. Sydney: Allen and Unwin. Web MD (2010). Information and Resources: C-Reactive Protein CRP. [Online] Available at [Accessed: 28th December, 2013] Read More