Ms. S, a 78-year-old black female, is brought to the emergency room by her son who reports that she has been vomiting violently for the past 24 hours. Her mucous membranes are dry and cracked. Her skin is warm and dry with tenting. Her temperature and heart rate are elevated, and her blood pressure is low.

1. What do these findings most likely indicate?
Upon further questioning Ms. S reports that she has had a urinary tract infection (UTI) that just will not go away because she is allergic to so many antibiotics.
2. What additional assessments and diagnostic testing would be pertinent at this time?
Ms. S is unable to void, so the nurse inserts a catheter with a return of less than 50 mL of amber, malodorous urine. The nurse receives the following results, which are significant from her lab work:
Urinalysis = + Protein; + RBCs; +WBCs, nitrates
BUN = 35
Creatinine = 3.5
GFR = 65
Na+ = 150
WBC = 12,000
3. How would the nurse explain these findings?
4. Describe the three types of renal dysfunction (prerenal, intrarenal, postrenal) .
5. Which dysfuction(s) does the nurse suspect with Ms. S? Is Ms. S at risk for acute kidney injury (AKI) as a result of Acute Tubular Necrosis, why or why not?
As the nurse is completing Ms. S’s health history, Ms. S mentions that she takes a pill for her "high blood," and when she has a headache, she will take two because she knows her "pressure" is up. When her son brings in her medication bottle, the nurse notes that she is taking lisinopril.
6. What concerns does the nurse have based on the above information?
Ms. S received antiemetics, and her vomiting subsided. She was rehydrated with IV fluids, and the UTI was being adequately treated. As she was being discharged from her 3-day hospitalization, she said, "I was so afraid I was going to have to go on that machine that cleans the blood for the rest of my life like my cousin who has chronic kidney disease (CKD)."
7. What is CKD?

1. Severe dehydration

2. Investigations required will include serum urea, electrolytes and creatinine (U/E/Cr), full blood count and differentials, urinalysis, urine microscopy, culture and sensitivity, renal ultrasound, random blood glucose.

3. Deranged U/E/Cr that is urea, creatinine and sodium are elevated which indicate kidney injury. There is proteinuria, haematuria, positive nitrate and leucouria points towards UTI. The WBC is high which indicate infection.

5. She is likely to have prerenal AKI

6. The concern is that she is not regular on her antihypertensive medication, and hypertension can cause renal impairment ( hypertensive nephropathy). There is need for dialysis if there is markedly elevated E/U/Cr or renal impairment was very severe.

Explanation:

Acute kidney injury is when there is sudden and often reversible loss of renal function which develops over days or weeks and is usually accompanied by a reduction in urine output.

There are many causes of AKI, which are classified as prerenal, renal and post renal. In prerenal AKI, the kidneys gets damaged as a result of hypoperfusion leading to acute tubular necrsosis. Common examples are severe dehydration( like in this patient from vomiting), cardiac failure, sepsis, blood loss etc. Renal AKI is usually cause by direct insult to the kidneys which can result from drugs, toxins, inflammatory conditions etc. Post renal AKI occurs when there is obstruction to urine flow at any point from the tubule to the urethra e.g in BPH, stones, strictures etc.

In Prerenal AKI, it leads to acute tubular necrosis. Histologically, the kidney show inflammatory changes, focal breaks in the tubular basement membrane and interstitial oedema.

Chronic kidney disease(CKD) refers to an irreversible deterioration in renal function which develops over a period of years.initially, it is manifestation only as biochemical abnormality but eventually, loss of the excretory, metabolic and endocrine functions of the kidneys leads to clinical symptoms and signs of renal failure.

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