What is the next step in managing a 45-year-old woman with moderate bilateral hydronephrosis due to lymphoma, who has impaired renal function, after placement of ureteral stents?

From the Guidelines

The next step in managing this patient is to provide free access to oral fluids, as there is no strong evidence to support aggressive fluid resuscitation in this scenario, and the patient's urine output and vital signs are stable 1. The patient's moderate bilateral hydronephrosis due to lymphoma has been addressed with the placement of ureteral stents, and her urine output has increased to 180 mL/hour.

• Her serum creatinine is elevated at 7.5 mg/dL, indicating impaired renal function.
• Her vital signs are stable, with a pulse of 69 bpm and a sitting blood pressure of 128/80 mmHg. Given the patient's stable condition and the absence of signs of hypovolemia or acute kidney injury, there is no need for aggressive fluid resuscitation.
• The use of 0.9% NaCl or 0.45% NaCl infusion is not supported by the evidence in this scenario, as the patient's fluid status is not compromised 1.
• The patient's renal function should be closely monitored, and her fluid intake should be adjusted based on her individual needs. The evidence from the World Journal of Emergency Surgery suggests that ureteral stenting is a suitable treatment for partial ureteral injuries or obstruction, and that fluid management should be tailored to the individual patient's needs 1. In this case, free access to oral fluids is the most appropriate next step, as it allows the patient to regulate her own fluid intake and avoids the potential risks associated with aggressive fluid resuscitation.

From the Research

Patient Management

The patient has moderate bilateral hydronephrosis due to lymphoma, with impaired renal function, as indicated by a serum creatinine of 7.5 mg/dL. After placement of ureteral stents, her urine output is 180 mL/hour for the next three hours.

Fluid Management

• The patient's urine output is 180 mL/hour, which is an important factor in determining the type and amount of fluid therapy.
• According to the study 2, intravenous fluid therapy is a crucial component of care for prevention and treatment of acute kidney injury (AKI).
• The study 3 explains the principles and aims of intravenous fluid therapy, including the importance of maintaining a balance between fluid intake and excretion.
• The study 4 highlights the effects of intravenous fluid administration on kidney function and renal outcome measures.

Treatment Options

• Option A: free access to oral fluids may not be sufficient to maintain adequate fluid balance, especially in a patient with impaired renal function.
• Option B, C, D, and E: infusion of intravenous fluids, such as 0.9% NaCl or 0.45% NaCl, at different rates (90 mL/hour or 180 mL/hour) may be considered to maintain fluid balance and support renal function.
• The study 5 compared half-saline versus combined normal saline and 1/3-2/3 intravenous fluid therapy in kidney transplantation, and found that either solution can be safely used as fluid replacement therapy.

Next Step

• Based on the patient's urine output and serum creatinine level, the next step would be to provide fluid therapy that matches the patient's urine output, which is 180 mL/hour.
• Infusion of 0.9% NaCl at 180 mL/hour (Option C) would be a reasonable choice to maintain fluid balance and support renal function, as it matches the patient's urine output and provides adequate hydration.