UTI and CKD

This article discusses the case study of a patient with UTI and CKD, including medications prescribed, vital sign assessment, and potential adverse effects. It also explores the interconnection between heart failure and chronic kidney disease.

Running Head: UTI AND CKD
0
Nursing
student
7/10/2019

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Table of Contents
Case study...................................................................................................................................................2
Q 1 (Answer)...........................................................................................................................................2
Q 2 (answer)............................................................................................................................................3
Q 3 (answer)............................................................................................................................................4
Q4 (answer).............................................................................................................................................5
Q 5 (answer)............................................................................................................................................7
References...................................................................................................................................................9

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Case study
Q 1 (Answer)
As discussed in the case study Naomi has been diagnosed with myocardial infraction
fifteen years ago and now has heart failure. Her vital sign assessment showed that her blood
pressure is 135/85 (which is considered high) and GFR is 50 ml/minute which is mildly to
moderately low. She also has micro-albuminuria and Chronic kidney disease.
Heart failure occasionally called as congestive heart failure, happen when the muscle of
the heart does not pump the blood appropriately. Certain health conditions like narrowed arteries
in the heart or high blood pressure causes heart too weak or pumps improperly. This may affect
other organ or system the body. Naomi’s heart failure and chronic kidney diseases are interlinked
to each other (Ziaeian & Fonarow, 2016). As Naomi has been facing heart related issues for a
long time, and developed kidney issues, these might be connected. It has been identified by
different researches that when an individual have heart disorder, their heart may not works in
right way. The heart might become overfilled with blood. This leads to the pressure build in the
blood veins that are connected to the kidneys, which results in blockage and a decreased
transportation of the blood rich in o2 to the patient’s kidneys. This may source different kidney
diseases (Unger et al., 2016). This happened in Naomi’s case as she had myocardial infraction,
and recently diagnosed with heart failure, which resulted in micro-albuminuria, and urinary tract
infection. Micro-albuminuria is the health condition in which the levels of urine albumin is
elevated, this happens when patient’s kidneys secrets albumin in the urine. According to Nayor
et al., (2017), both chronic kidney disease and micro-albuminuria issues are linked to the
elevated risk of heart failure. Naomi’s GFR was 50ml/minute which indicated that her kidney

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were not functioning the filtration process appropriately. Kidneys filtering lee than 60 per cent of
usual is stage 3 chronic kidney diseases. On the other hand kidney related issues may also cause
heart disease. When the patient’s kidneys are note functioning well, the hormone system
responsible for regulating blood pressure, forced to work harder to enhance the blood
transportation to the patient’s kidney. This might force heart to pump the blood more hardly,
which ultimately case heart disease. Therefore Naomi’s heart issues and impaired excretory
system were interlinked (Unger et al., 2016).
Q 2 (answer)
Naomi has been prescribed with certain medications such as aspirin, atorvastatin,
irbesartan, frusemide, and fluoxetine. Atorvastatin is given along with the favourable diet to
assist the patient to decrease the levels of bad cholesterol and fat and raises the levels of healthy
cholesterol in the blood. This reduces the risk of heart disorders and assists in preventing the
strokes or heart attacks (Kowalski, 2016). In case of Naomi this drug might be helpful to reduce
the risk of developing heart attack related problems as she has heart failure. It will help in
clearing the veins that usually blocked due to increased levels of cholesterol and forces heart to
pump the blood more hardly. Some of the most common side effects associated with this drug
and might be caused in case of Naomi include, headache, hoarseness, lower back pain, and side
pain, pain or tenderness nearby the eyes and cheekbones, painful or difficulty in urination, and
stuffy or runny nose (Zhang et al., 2018). Aspirin is also provided to Naomi, which is the acetyl-
salicylic acid commonly used medicines to treat the pain and fever occurs due to many causes. It
has both antipyretic and anti-inflammatory effects. This particular drug is also prevents the
platelet aggregation and inhibits the blood clot stroke, and the myocardial infarction. Different
researches conducted on this drug also identified that the long term usage of this drug may

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reduce the risk of developing many cancers like colorectal, oesophageal breast, skin, lung, and
prostate cancer. This particular drug can be effective in Naomi’s case in reducing the severe
acute pain she has been experiencing due to the urinary tract infection (Sharma, & Yadav, 2017).
She may also develop blood clot issues due to the obstructive veins, this particular drug address
these issues and keep her safe from blood clotting. Some of the side effects can occur after the
use of aspirin are upset stomach, heartburn, dyspepsia, epigastric discomfort, and nausea. Both
the drugs have specific role in managing her heart and kidney related problems, although the
patient must be assessed for side effects of these drugs, regularly (Kowalski, 2016).
Q 3 (answer)
Naomi’s vital sign assessment identified that her glomerular function rate was 50 ml per
minute, which is considered low and third stage of chronic kidney disease. At the stage 3 of
chronic kidney diseases the patient’s kidney are not able to filter completely and only complete
50 per cent filtration, Which indicate that the metabolism of the drugs might also be affected
(Garcia-Garcia, Agodoa & Norris, 2017). As discussed in the case study Naomi’s brother died
because of lung cancer, due to this she has developed depression related issues. To address the
Naomi’s depression problem she has been provided with fluoxetine drug. It has been identified
that Renal and hepatic illnesses have a substantial influence on the plasma concentration profiles
and the dose necessities for nearly all drugs. Fluoxetine undertake first-pass metabolism that
might occur through the patient’s liver and/or lungs. This particular drug appears to be
comprehensively metabolized, to be expected in the liver, to norfluoxetine and other metabolites.
Norfluoxetine, the principal active metabolite, is formed via N-demethylation of fluoxetine. The
Norfluoxetine seems to be similar pharmacologic strength as fluoxetine. Fluoxetine and the
norfluoxetine both undertake phase II glucuronidation responses in the patient’s liver. It is

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similarly supposed that fluoxetine and the norfluoxetine undertake O-dealkylation to produce p-
trifluoromethylphenol, which is formerly afterward metabolized to the hippuric acid (Ponticelli,
Sala & Glassock, 2015). The main route of removal seems to be the hepatic metabolism to the
sedentary metabolites emitted by the kidney. In case of renal impairment like Naomi, the
metabolism of these drugs is altered. Chronic kidney disease may disturb antidepressant like
fluoxetine pharmacokinetics randomly for more than a few reasons. Diminished kidney function
reduces drug elimination; however might also results in reduced intestinal obtainability by
slowed gastric discharging. Drug build-up may result from the changed absorption or the hepatic
metabolism and binding of the protein might differ rendering to the drug acidity. Lastly, dialysis
provided in kidney diseases might eliminate a drug to such degree that the substitution dose is
required to reserve the desired result (Nagler, Webster, Vanholder & Zoccali, 2012). According
to Miners, Yang, Knights, & Zhang (2017), In addition to the impacts on renal drug removal,
collecting evidence specifies that chronic kidney disease and ESRD may reduce the non-renal
clearances of the drugs removed by enzymes and transporters responsible for drug‐metabolism.
CKD changes some of the processes that undertake inside the body such as absorption,
distribution, and removal not only of medicines cleared by the patient’s kidney, but also of those
that are cleared non-renally. The associated Mechanisms include the hindrance of the hepatic and
intestinal transport of the drug by intermediaries of continuing inflammation for example
cytokines, PTH, and uremic toxins through transcriptional, the translational and the post-
translational modifications (Dreisbach & Flessner, 2015).
Q4 (answer)
Metabolized to the nor-fluoxetine, fluoxetine medicine is a SSRI (selective serotonin-
reuptake inhibitor); it stops the re-uptake of the serotonin at the serotonin re-uptake pump of a

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neuronal membrane, increasing the activities of serotonin on the 5HT auto-receptors. The SSRIs
attaches with considerably less similarity to histamine, the acetylcholine, and norepinephrine
receptors compared to the tricyclic antidepressant medications. Fluoxetine is absorbed in the GI
tract, and its oral bioavailability is expected to be minimum 60 to 80 per cent. the drug is then
undergo first pass metabolism and phase 2 glucuronidation via the liver and/or lungs. The route
of elimination of this drug is appears to be the hepatic metabolism and inactive metabolites are
eliminated through the kidney (drugbank, 2019a). As reported by Naomi, she has been
experiencing Nausea, it needs instant response form the healthcare providers. Nausea is a
common medication-related side effect with many potential causes. Nausea can have a
significant impact on a patient's physical and psychological health. It can also affect the
metabolism and absorption of the other drugs as well. Proper counselling on prevention and
treatment of nausea due to medication use can help patients better understand how to take their
medications for optimum benefit with minimal side effects. Some of the coping strategies can be
used by healthcare provider after nausea incidences, Naomi should be educated to take her
medicine with the food unless the physician recommend to take otherwise, the drug should be
taken at bedtime, and she should consume smaller, and more common mean. Whenever the
patient feels nauseous, she should be asked to such sugar free hard candies. In nauseous
condition sipping ginger tea or small amount of flattened ginger ale can also work, although her
renal issues must also be considered while providing these liquids. It is known that after taking
antidepressants like fluoxetine, the patient feel nauseous, but the dosage must be lowered if the
patient is frequently experiencing nausea. In case if the non-pharmaceutical strategies do not
work as expected, some pharmaceuticals can also be used. For example Dopamine antagonists,
for instance promethazine and the prochlorperazine, are particularly efficacious for opioid-

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prompted nausea, however can be helpful for nausea produced by other drugs like fluoxetine as
well (Palmer, et al., 2016).
Q 5 (answer)
Whilst patients on opioids should be monitored for adverse effects, particular
opioids are likely to cause toxicity in renal patients. These include morphine, diamorphine
and codeine derivatives which produce toxic metabolites which accumulate in renal failure.
Studies report profound respiratory depression and narcosis when renal patients are given
these Opioids.
Naomi is also diagnosed with urinary tract infection, which might affect her health
condition, therefore to must be dealt with proper treatment. I have been asked by the physician to
administer morphine this health condition. Morphine and the metabolites of this drug act as the
agonists of opioid receptors such as mu and the kappa which originate later into the analgesia.
The opioid receptor mu is an important part of the morphine effect in the area of ventral
tegmental which strengthens the morphine effects. The absorption of this drug completed in the
alkaline conditions in the upper intestine in the addition to rectal mucosa. It represent first pass
metabolism. It shows comparatively low transfer between the plasma and an effect area. It also
represents a low protein binding (nearly 35 percent). Nearly 90 percent of this drug is then
glucuronidated as well as sulfated in the position three and six in the liver. The excretion of this
drug and its metabolites occurs by the urine. From the 3 target receptors of this drug, the mu
receptor is linked with the adverse effects of the morphine (drugbank, 2019b) for example
modifications in the Naomi’s respiratory system and dependence

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However in case of Naomi the main adverse reaction may occur due to the morphine
administration is respiration depression. As the patient is already suffering from CKD where the
kidney are not able to function properly, respiratory depression in this situation can additionally
affect her condition. Respiratory depression indicates that the individuals’ rate and depth of the
respiration are reduced or lower than usual (Zadina et al., 2016). This leads to the low levels of
oxygen and increased levels of carbon dioxides in the blood. In case of Naomi the specific
condition can leads to the build-up in the body and results in respiratory acidosis which is the life
threatening situation linked with the failure of organs. It is basically the failure of the lungs to
function the exchange process of CO2 and O2 (Hill et al, 2016).
Oxygen therapy is the common therapy which can be provided. In case of Naomi as the
adverse reaction might occur due to the toxicity of the drug medicine are commonly used that act
against the impacts of morphine, for example naloxone, methadone, and the suboxone. She can
also be provided with the fluid therapy which is administered intravenously and orally.
Mechanical ventilation can also be effective to reduce the adverse effects (respiratory
depression) of this drug (Algera et al, 2019)

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References
Algera, M.H., Kamp, J., van der Schrier, R., van Velzen, M., Niesters, M., Aarts, L., Dahan, A.
and Olofsen, E., (2019). Opioid-induced respiratory depression in humans:
pharmacokinetic–pharmacodynamic modelling of reversal. British journal of anaesthesia.
Dreisbach, A. W., & Flessner, M. F. (2015). Drug metabolism and chronic kidney disease.
In Chronic renal disease (pp. 674-681). Academic Press.
Drugbank, (2019a). Fluoxetine [online]. Retrieved from:
https://www.drugbank.ca/drugs/DB00472
Drugbank, (2019b). Morphine [online]. Available from:
https://www.drugbank.ca/drugs/DB00295
Garcia-Garcia, G., Agodoa, L., & Norris, K. C. (Eds.). (2017). Chronic Kidney Disease in
Disadvantaged Populations. Academic Press.
Hill, R., Lyndon, A., Withey, S., Roberts, J., Kershaw, Y., MacLachlan, J., Lingford-Hughes, A.,
Kelly, E., Bailey, C., Hickman, M. and Henderson, G., (2016). Ethanol reversal of
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Kowalski, M. (2016). Atorvastatin/topiramate/valproate. Reactions, 1592, 39-12.
Menda, F., Temur, S., Bilgen, S., Yencilek, F., Koyuncu, H., Sancar, N., & Koner, O. (2013).
Effect of morphine on lower urinary tract discomfort after transurethral resection of

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prostate under general anesthesia: a randomised clinical study. Journal of
anesthesia, 27(5), 720-724.
Miners, J. O., Yang, X., Knights, K. M., & Zhang, L. (2017). The role of the kidney in drug
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Nagler, E. V., Webster, A. C., Vanholder, R., & Zoccali, C. (2012). Antidepressants for
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