Nephrolithiasis

Instructions for Discussion Replies to 6 DQS

DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.

1- Each reply should be at least 200 words.

2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)

3- APA 7th edition style needs to be followed.

4- Each response should have reference at the end of each reply

5- Reference should be within last 4 years

 

 

Q-1

Nephrolithiasis is crystalized stones that obstruct the urinary tract that is classified by chemical components, such as calcium, uric acid, magnesium, and phosphate. The pathophysiology includes a high concentration of stone-forming salts within the urine, presence of chemical or physical stimuli promoting stone formation, lack of urine compounds that inhibit the formation of stones and increase intake of calcium, vitamin C, magnesium, and protein which increases the prevalence of calculi (Cunningham et al., 2016). The pH of the urine can also increase the risk of stone formation as alkaline urine increases calcium phosphate calculi whereas acidic urine increases uric acid stones. Nonmodifiable risk factors include age, gender (men>women), and genetics. Modifiable risk factors include diet such as an increase in animal protein and decrease fluid intake, thiazide diuretic use for gout, sedentary lifestyle, and renal, endocrine, and metabolic disorders, including metabolic syndrome and type 2 diabetes mellitus (Cunningham et al., 2016). Patients will report sudden onset of back and flank pain that may radiate to the groin, testicles, and suprapubic area. Physical assessments include costovertebral angle tenderness, hematuria, dysuria, and urinary frequency. If an infection is present secondary to obstruction, the patient would present with chills, fever, tachycardia, tachypnea, and diaphoresis. For diagnosis, a CT is the gold standard as it identifies stone size and location for treatment planning, but due to costs, ultrasonography may be useful, especially for pregnant patients (Shafi et al., 2017). A KUB x-ray is not ideal as will not identify uric acid stones or small stones. Lab testing should include a BMP to assess kidney function, CBC for suspected infections, and a urinalysis should be done as the urine pH helps identify the stone composition. To rid renal stones depends on the size and type of stone. If needed, the pH of the urine can be adjusted by pharmacologic management, as well as, pain management. For example, potassium citrate administration can decrease the acidity of the urine for the treatment of uric acid stones, or the use of Tamsulosin has been proven to be effective for expulsion (Cunningham et al., 2016). Smaller stones may require increase fluid intake to promote stone passage. Larger stones that are greater than >6 mm will require surgery, including ureteroscopy, percutaneous nephrolithotomy, laser lithotripsy, or extracorporeal shock wave lithotripsy (Shafi et al., 2017). Nonpharmacological management includes adequate fluid intake to maintain urinary output at 2-3L/day, avoid soft drinks, and dietary considerations, such as limiting sodium, decrease animal fat and increase fiber. To prevent calcium stones entails restriction of protein, dairy products, and calcium-rich foods with a calcium restriction of 1,000 to 1,200 mg/day (Cunningham et al., 2016).

References

Cunningham, P., Noble, H., Al-Modhefer, A.-K., & Walsh, I. (2016). Kidney stones: Pathophysiology, diagnosis and management. British Journal of Nursing, 25(20), 1112–1116. https://doi.org/10.12968/bjon.2016.25.20.1112

Shafi, S. T., Anjum, R., & Shafi, T. (2017). Clinical predictors of an abnormal ultrasound in patients presenting with suspected nephrolithiasis. Pakistan Journal of Medical Sciences, 33(3), 545–548.

 

 

 

 

Q-2

Patients with severe acute kidney injury or chronic kidney disease (CKD) need renal replacement therapy (RRT) to remove solutes and toxins as most of these patients have multiple organ dysfunction, hemodynamic instability, and/or sepsis. Various options for RRT include intermittent hemodialysis (IHD), peritoneal dialysis (PD), and continuous RRT (CRRT). Therapy depends on the nephrologist, the patient’s signs and symptoms and overall assessment, and the patient‘s treatment of choice (Jaryal & Vikrant, 2017).

IHD is the standard RRT modality for hemodynamically stable patients, which would require an AV fistula and, in some cases, an external catheter for access. The advantage of IHD includes rapid solute and volume removal resulting in rapid correction of electrolyte disturbances, such as hyperkalemia, and rapid removal of drugs or other substances in fatal intoxications (Mineshima, 2018). Therefore, there’s a risk of systemic hypotension caused by rapid fluid and electrolyte removal. However, IDH may not be beneficial for patients with acute brain injury or other causes of increased intracranial pressure as it may worsen cerebral edema (Mineshima, 2018).

PD is cheap, easy, and simple as it lacks the need for anticoagulation or vascular access and typically for patients with hemodynamic stability. It requires a hollow tube into the lower abdomen where dialysate is instilled into the peritoneal cavity, which absorbs the waste products and toxins through the two special membrane layers, the peritoneum (Jaryal & Vikrant, 2017). The fluid is then drained, measured, and discarded. PD is contraindicated in patients with recent abdominal surgery, slow solute clearance, and technical failure of the procedure. Additionally, may compromise the respiratory status due to increased abdominal pressure, lead to hyperglycemia, and provide insufficient solute clearance in hypercatabolic patients (Jaryal & Vikrant, 2017).

CRRT is the preferred method for unstable patients due to its slow and continuous therapy via vascular access. The rates of fluid and solute removal are slower; therefore, it is more beneficial for patients who require large-volume fluid administration including TPN and IV medications (Jaryal & Vikrant, 2017). Disadvantages include anticoagulation, vascular access, high cost, and is labor-intensive.

References

Jaryal, A., & Vikrant, S. (2017). A study of continuous renal replacement therapy and acute peritoneal dialysis in hemodynamic unstable patients. Indian Journal Critical Care Medicine, 21(6), 346-349. https://doi.org/10.4103/ijccm.IJCCM_143_17

Mineshima, M. (2018). 2016 update Japanese Society for Dialysis Therapy Standard of fluids for hemodialysis and related therapies. Renal Replacement Therapy, 4(1), 1. https://doi.org/10.1186/s41100-018-0155-x

 

 

 

 

 

 

 

Q-3