Urinary and Reproductive

Discussion Post 4-Urinary and Reproductive
Case Study 1
Acute kidney injury (AKI) is an abrupt onset of renal dysfunction affecting kidney structure and function, which results in the minor loss of function of the kidneys. Approximately two-thirds of all acute kidney injury cases occur before hospitalization characterizing it as a community-acquired condition. It is associated with acute illness, chronic diseases, aging, and medications (Vicary et al., 2020). Other causes of AKI include volume deficits, sepsis, and nephrotoxic drugs (Dlugasch & Story, p. 322, 2020).
Types of acute kidney injury and clinical manifestations
There are three types of AKI: prerenal, intrarenal, and postrenal. The most common cause of AKI is prerenal disorders and acute tubular necrosis. The mortality rate of AKI is 10-60% determinate of the underlying etiology (Dlugasch & Story, p. 323, 2020). Prerenal AKI occurs because of inadequate renal perfusion associated with volume depletion. Diarrheal illnesses, insufficient fluid intake, heart failure, and decompensated liver disease contribute to volume depletion (Gaut & Liapis, 2020). It is generally reversible, not causing permanent damage unless the depleted profusion is prolonged and severe, as this can cause urine output of less than 500mL per day (Malkina, 2022). Manifestations in Mr. J.R.’s case associated with prerenal AKI include continued frequent diarrhea, vomiting, fever, and intolerance of solid foods and liquids.
Intrarenal AKI may be caused by a number of different diseases, some of which are vascular, glomerular, and tubulointerstitial, causing intrinsic kidney disease or damage. The most common causes included acute tubular necrosis, glomerulonephritis, and nephrotoxins (Malkina, 2022). Postrenal AKI occurs when there is urinary flow obstruction that is either unilateral or bilateral such as hydronephrosis, calculi, or kidney inflammation, also known as pyelonephritis (Gaut & Liapis, 2020). The most common cause of urinary flow obstruction is bladder outlet obstruction due to an enlarged prostate (Malkina, 2022).
Risk factors
In the case study of Mr. J.R., he is likely experiencing prerenal acute kidney injury related to the acute illness and volume depletion caused by the vomiting and diarrhea in the last forty-eight hours. Possible risk factors include ischemia, volume depletion, sepsis, hypotension, absence of enteric oxalate-degrading bacteria (Oxalobacter formigenes), and aspergillosis and drugs such as Orlistat and Praxilene (Gaut & Liapis, 2020). Risk factors associated with Mr. J.R. include vomiting, nausea, diarrhea, and fever as it creates fluid and electrolyte depletion from the gastrointestinal system. Dehydration and low blood pressure may occur due to the loss of fluids experienced. Chronic kidney disease (CKD) occurs gradually and is the irreversible loss of kidney function. As renal function declines, associated complications worsen.
Complications on the hematologic system & pathophysiology
Some complications that may occur are problems with coagulopathy, where there is a prolonged bleeding time related to abnormal aggregation and platelet dysfunction. Decreased platelet counts are seen in patients with CKD. There is an increased risk of thrombosis, and petechiae may be present (Dlugasch & Story, p. 326, 2020). Iron deficiency anemia is common in CKD patients with bone marrow suppression and red blood cell destruction.
Intravenous treatment for iron deficiency is best as oral iron absorption is hindered (Dlugasch & Story, p. 326, 2020). In CKD, the patient is experiencing intraglomerular pressure inside the kidney, which destroys the nephrons inside the kidney. Thus, resulting in progressive damage and reduced function of the kidneys. CKD can progress to ESRD (end-stage renal disease), which is fatal without dialysis or a kidney transplant (Akchurin, 2019).
Case Study 2- probable diagnosis, microorganism, & why
The most probable diagnosis for Ms. P.C. is gonorrhea with associated pelvic inflammatory disease (PID). Gonorrhea is caused by an aerobic bacterium called Neisseria gonorrhoeae and is gram-negative. It is the second most prevalent bacterial sexually transmitted infection (STI), with eighty-seven million new gonorrhea infections globally (Oree et al., 2021). Approximately ten to twenty percent of women with gonorrhea have PID, with Neisseria gonorrhoeae being the causative organism in 40% of PID cases (Goje, 2021). Although gonorrhea is often asymptomatic, symptoms may appear within 2-10 days after exposure to the infection. These symptoms can vary by gender and the anatomical site of infection (Alturki et al., 2020).
Some symptoms may include vaginal discharge, abdominal/pelvic pain, cervicitis, and heavy intermenstrual bleeding. It is important to note that the absence of symptoms does not necessarily mean there is no infection; however, it could mean the presence of a constant infection (Alturki et al., 2020). Ms. P.C.’s possible exposure was eight days ago, with symptoms present the last two days. She complains of foul smelly, purulent, greenish-yellow vaginal discharge that is heavy, lower abdominal pain, nausea, and vomiting. Given the onset of symptoms and patient complaints, it is supportive of a diagnosis of gonorrhea and PID.
If gonococci are seen on a microscopic examination using gram stain, culture, or a nucleic acid-based test, then a diagnosis of gonorrhea is made. The exam consists of evaluating genital fluids, blood, or joint fluids. Nucleic acid amplification tests (NAATs) are the gold standard for testing and can be used for each anatomical site with the ability to detect gonorrhea and chlamydia. This is important because many cases are usually positive for both (Morris, 2020). The recommended treatment of uncomplicated gonorrhea in the United States is a single dose of ceftriaxone 500mg intramuscular (IM) and doxycycline 100 mg orally two times a day for seven days for chlamydial infections that have not been excluded (CDC, 2021).
Hospitalization criteria
Hospitalization is indicated for complicated gonorrhea, which is identified by the presence of disseminated gonococcal infection (DGI) or gonococcal arthritis (CDC, 2021). DGI is confirmed with the aspiration and testing of joint fluid for synovial fluid testing is more accurate than blood cultures. Risk factors for DGI are female sex, pregnancy, menstruation, and terminal complement deficiency. Initial treatment should include hospitalization and consultation with an infectious disease specialist, especially for those who may not adhere to treatment, have an uncertain diagnosis, or have purulent synovial effusions or other complications. A clinical examination for endocarditis and meningitis should be carried out (CDC, 2021).
The recommended treatment is ceftriaxone 1 gram IM or intravenously (IV) every twenty-four hours, ceftizoxime 1 gram IV every eight hours, or cefotaxime 1 g IV every 8 hours (Morris, 2020). This treatment is to be continued for 24-48 hours until symptoms begin to resolve, then oral therapy should be initiated for a minimum of seven days. The oral antibiotic given will be based on the results of antimicrobial susceptibility testing (Morris, 2020). All gonorrhea cases, uncomplicated and complicated, should be complemented with treatment for a chlamydial infection if it has not been ruled out. Treat chlamydia with doxycycline 100 mg orally two times a day for seven days (CDC, 2021). Abstaining from sexual activity until treatment is complete to avoid transmission to partners or reinfection.
References
Akchurin, O. M. (2019). Chronic kidney disease and dietary measures to improve outcomes. Pediatric Clinics of North America, 66(1), 247–267. https://doi.org/10.1016/j.pcl.2018.09.007
Alturki, Y. D., Albalawi, S. M. S., Alyami, B. A., Alahmari, S. A. M., Al Hashim, A. A., Jokhaideb Alalyani, N. S., Alqahtani, D. S. F., Saeedi, S. S., Aljehani, S. M., & Ali Hakami, K. A. (2020). An overview on gonorrhea diagnosis and management in primary health care centre. International Journal of Pharmaceutical Research & Allied Sciences, 9(4), 77–80.
CDC. (2021). Gonococcal infections among adolescents and adults – STI treatment guidelines. Centers for Disease Control and Prevention. Retrieved January 30, 2022, from https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm
Dlugasch, L., & Story, L. (2020). Applied pathophysiology for the advanced practice nurse (1st ed.). Jones & Bartlett Learning.
Gaut, J. P., & Liapis, H. (2020). Acute kidney injury pathology and pathophysiology: A retrospective review. Clinical Kidney Journal, 14(2), 526–536. https://doi.org/10.1093/ckj/sfaa142
Goje, O. (2021, April). Pelvic inflammatory disease (PID). Merck Manuals Professional Edition. Retrieved January 30, 2022, from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/vaginitis,-cervicitis,-and-pelvic-inflammatory-disease-pid/pelvic-inflammatory-disease-pid
Malkina, A. (2022, January). Acute kidney injury (AKI). Merck Manuals Professional Edition. Retrieved January 30, 2022, from https://www.merckmanuals.com/professional/genitourinary-disorders/acute-kidney-injury/acute-kidney-injury-aki
Morris, S. R. (2020, December). Gonorrhea. Merck Manuals Professional Edition. Retrieved January 30, 2022, from https://www.merckmanuals.com/professional/infectious-diseases/sexually-transmitted-diseases-stds/gonorrhea
Oree, G., Naicker, M., Maise, H. C., Tinarwo, P., & Abbai, N. S. (2021). Antimicrobial susceptibility patterns in neisseria gonorrhoeae isolated from south African pregnant women. Infectious Diseases in Obstetrics and Gynecology, 2021, 1–6. https://doi.org/10.1155/2021/6684680
Vicary, D., Hutchison, C., & Aspden, T. (2020). Avoiding acute kidney injury in primary care: attitudes and behaviours of general practitioners and community pharmacists in Hawke’s Bay. Journal of Primary Health Care, 12(3), 244. https://doi.org/10.1071/hc19106

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