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Dr Ayyad's Kidney Contest -Stick Please


Dr Ayyad's Kidney Contest -Stick Please

HEY
Do u have any question regarding the kidney just post it here
please note this post is for benefit not challenge so anyone who wants to ask for the mere goal of challenging me plz post ur question in a different thread
hope it is gonna be useful

by
بعد التخرج


THanks 4 this offer
we (5th year student) will take kidney medicine in our college this semister
i think many of us will have many questions
so........ i also ask the ADMIN to stick this thread

Ghufran's picture
Ghufran
بعد التخرج


Really u r so helpful Dr_Ayyad
ur propasals always carry the benefits to all the members
God grant you the success you wish
With our debt of gratitude

rawia's picture
rawia


thank u very much dr Ayyad..and to tell the truth I do not know any thing about renal disease ..we have not studied them yet...but we will do this semester..so I do not have question now ..
but can we ask u during the semester ?

gardeania's picture
gardeania
بعد التخرج

gardeania wrote:
thank u very much dr Ayyad..and to tell the truth I do not know any thing about renal disease ..we have not studied them yet...but we will do this semester..so I do not have question now ..
but can we ask u during the semester ?

of course
anytime u r always welcome

Dr_Ayyad
بعد التخرج


Hi dr-Ayyad
sorry for asking this silly question
i didnt start clinical study years yet,but can you please explain about Hemolytic uremic syndrome
the causes? is it really affects mostly children under 10 y/o?

Dania's picture
Dania
السنة الرابعة

Dania wrote:
Hi dr-Ayyad
sorry for asking this silly question
i didnt start clinical study years yet,but can you please explain about Hemolytic uremic syndrome
the causes? is it really affects mostly children under 10 y/o?

Hemolytic Uremic Syndrome HUS is a multisystem disease characetrized manily by the triad of
Hemolysis,thrombocytopenia and renal failure
the disease occurs probably as aresult of exposure to toxins cuzing endothelail damage and fibrin deposition ,platelet activation and clearance
the most imporatnt among these toxins is The VEROTOXIN or SHIGA-LIKE toxin produced by ENTERO HEMMORAGIC E.COLI SEROTYPE O157:H7
HUS occurs maily in children
A similar,but distinct,clinical entity is seen in adults and is reffered to as TTP=thrombocytopenic thrombocytiopenia pupura in which renal failure is uncommona nd neurological signs usually predominate-the opposite of HUS

Dr_Ayyad
بعد التخرج


i don't know what to say, i read things in the book but i see something different.
there was a patient in the hospital, she was 56, unconscious , Choronic renal failure.

her tests :

creatinin was 6.5
uria 200
i can't remember the exact number for the electrolytes, but i remember very well the NA was in the lowest limites, and K was in the topest limites, she had spent 7 days in the ICU sufferring Pulmonary oedema when i saw her for the first time , i asked her doctor, when was the last time of dialysis??? she said: i still didn't request a dialysis!!!!! i am still putting her on IV duiritics!!!!

i am confused!!!! what was she waiting for to request a dial????

dr.tabban's picture
dr.tabban

hazemhazem wrote:

i don't know what to say, i read things in the book but i see something different.
there was a patient in the hospital, she was 56, unconscious , Choronic renal failure.

her tests :

creatinin was 6.5
uria 200
i can't remember the exact number for the electrolytes, but i remember very well the NA was in the lowest limites, and K was in the topest limites, she had spent 7 days in the ICU sufferring Pulmonary oedema when i saw her for the first time , i asked her doctor, when was the last time of dialysis??? she said: i still didn't request a dialysis!!!!! i am still putting her on IV duiritics!!!!

i am confused!!!! what could be worse till you request a dial????

starting dyalisis is not an arbitary decision,ther should be at least one on the following indications
1-specific numbers
Cr clearance less than 10 ml/min (less than 15 in case of diabetes)
serum creatinine higher than 8 mg\dl (higher than 6 mg\dl in case of diabetes)

other indications
metabloic acidocis refractory to medical therapy
hyperkalemia refractory to medical therapy
pulmonary edema not responsive to medical therapy
neurological manifestations
uremic pericarditis
uremic encephalopathy

so I think in this patient ,dialysis should be started soon,cuz she has more than one indication

Dr_Ayyad
بعد التخرج


yes. yes that's what i thought, and had an argument with her doctor coz she was refusing the dial, the patient died this morning.

dr.tabban's picture
dr.tabban


Below is the most current recommendation for initiation of dialysis in both acute and chornic renal insuficiency;

You have to notice that many of the indication are common between both of these two entities but there are few differences.
As exmaple, even if the patient has no symptoms, you place him on Dialysis when crcl<15, while if somebody with acute failure who is otherwise stable, but reached during the acute episode crcl of 15, wouldn't require dialysis

Also remember that you need to prepare your chronic renal failure patient for dialysis when his crcl becomes less than 25. Thus, you may send him to vascular surgery to establish AV fistula that takes 3-6 months to start working after creating it.
If you have an urgent need for dialysis like a patient with acute renal failure with one the indication mentiond below, or if you have a chronic renal failure that presented to you with indication to start dialaysis and he he has no access (no av fistula), then you get temporary access
The temporary access can be established with Dialysis cath access (Called Quinton cath: similar to a central line but a little big larger) if there is an emergent need.
If the need is urgent but not emergent, you can get what is called tunneled cath which is placed by Vascular surgery or Interventional radiology. The main difference between these two catheters( the quinton and the tunnel cath) is the length you can leave the catheter in. As example, you may not leave the quinton one more than few days while you can leave the tunneled one for few months. The main reason behind that is the infecton rate since it is too high in the superficial line like quinton.

The other indication tunnel cath is when you have a chronic renal failure patient that reached the need for dialysis and he doesn't have A-V fistula. Remember that for the A-V fistula to start working it takes 3-6 months. During this months, you can use tunnel cath

Acute renal failure:

INDICATIONS FOR DIALYSIS — It has been suggested that patient outcome can be improved by early or more intensive dialysis to keep the BUN under 80 to 100 mg/dL (29 to 36 mmol/L). Some studies, however, have not been able to document significant benefit of prophylactic or very early dialysis; by comparison, others have reported a possible benefit.

No consensus exists concerning the optimal timing for the initiation of dialysis in patients with acute renal failure. Indications include the following]:

Refractory fluid overload
Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels
Metabolic acidosis (pH less than 7.1)
Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36 mmol/L])
Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
Severe dysnatremias (sodium concentration greater than 155 meq/L or less than 120 meq/L)
Hyperthermia
Overdose with a dialyzable drug/toxin
In an attempt to minimize morbidity, dialysis should generally be started prior to the onset of such complications due to renal failure

Some also initiate renal replacement therapy in patients in whom excessive volume resuscitation is required (such as hepatic failure), even in the absence of significant azotemia. This is particularly relevant in patients demonstrating hemodynamic instability, a setting in which volume removal must be performed slowly. Such a strategy of early, gentle intervention may protect damaged or recovering kidneys from hypotensive insults.

Chronic renal failure:

There are a number of absolute clinical indications to initiate maintenance dialysis.
These include:

Pericarditis
Fluid overload or pulmonary edema refractory to diuretics
Accelerated hypertension poorly responsive to antihypertensive medications
Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe, cases, seizures
A clinically significant bleeding diathesis attributable to uremia
Persistent nausea and vomiting
Plasma creatinine concentration above 12 mg/dL (1060 µmol/L) or blood urea nitrogen (BUN) greater than 100 mg/dL (36 mmol/L)
However, these indications are potentially life-threatening and the patient is generally known to have advanced chronic renal failure. As a result, most nephrologists agree that delaying initiation of dialysis until one or more of these complications is present may put the patient at unnecessary jeopardy. Patients with chronic renal failure or disease should therefore be closely followed and the GFR estimated. (See "Overview of the management of chronic kidney disease in adults" and see "Assessment of renal function: Plasma creatinine; BUN; and GFR", for a discussion of these issues)

The following are the author of this article guidelines:

Dialysis should be initiated whenever indices of malnutrition develop in a patient with chronic renal failure").
We strongly consider initiation of dialysis when the approximate GFR is below 15 to 20 mL/min, especially in elderly patients and diabetics.
Dialysis should be initiated when the plasma creatinine concentration is above 10 mg/dL (884 µmol/L) and the BUN is above 100 mg/dL (36 mmol/L).

To be honest, in real life even here in the states, you may not be too compliant with these recommendation
As exmaple, we had a patient with acute renal failure (cr of 6) and hyponatremia Na 113
This is according to the guidelines is indication of dialysis
The nephrologist who is 70 y/o refused to dialyse him since he was asymptomatic and treated him conservatively

burhan

burhan wrote:
Below is the most current recommendation for initiation of dialysis in both acute and chornic renal insuficiency;

You have to notice that many of the indication are common between both of these two entities but there are few differences.
As exmaple, even if the patient has no symptoms, you place him on Dialysis when crcl<15, while if somebody with acute failure who is otherwise stable, but reached during the acute episode crcl of 15, wouldn't require dialysis

Also remember that you need to prepare your chronic renal failure patient for dialysis when his crcl becomes less than 25. Thus, you may send him to vascular surgery to establish AV fistula that takes 3-6 months to start working after creating it.
If you have an urgent need for dialysis like a patient with acute renal failure with one the indication mentiond below, or if you have a chronic renal failure that presented to you with indication to start dialaysis and he he has no access (no av fistula), then you get temporary access
The temporary access can be established with Dialysis cath access (Called Quinton cath: similar to a central line but a little big larger) if there is an emergent need.
If the need is urgent but not emergent, you can get what is called tunneled cath which is placed by Vascular surgery or Interventional radiology. The main difference between these two catheters( the quinton and the tunnel cath) is the length you can leave the catheter in. As example, you may not leave the quinton one more than few days while you can leave the tunneled one for few months. The main reason behind that is the infecton rate since it is too high in the superficial line like quinton.

The other indication tunnel cath is when you have a chronic renal failure patient that reached the need for dialysis and he doesn't have A-V fistula. Remember that for the A-V fistula to start working it takes 3-6 months. During this months, you can use tunnel cath

Acute renal failure:

INDICATIONS FOR DIALYSIS — It has been suggested that patient outcome can be improved by early or more intensive dialysis to keep the BUN under 80 to 100 mg/dL (29 to 36 mmol/L). Some studies, however, have not been able to document significant benefit of prophylactic or very early dialysis; by comparison, others have reported a possible benefit.

No consensus exists concerning the optimal timing for the initiation of dialysis in patients with acute renal failure. Indications include the following]:

Refractory fluid overload
Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels
Metabolic acidosis (pH less than 7.1)
Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36 mmol/L])
Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
Severe dysnatremias (sodium concentration greater than 155 meq/L or less than 120 meq/L)
Hyperthermia
Overdose with a dialyzable drug/toxin
In an attempt to minimize morbidity, dialysis should generally be started prior to the onset of such complications due to renal failure

Some also initiate renal replacement therapy in patients in whom excessive volume resuscitation is required (such as hepatic failure), even in the absence of significant azotemia. This is particularly relevant in patients demonstrating hemodynamic instability, a setting in which volume removal must be performed slowly. Such a strategy of early, gentle intervention may protect damaged or recovering kidneys from hypotensive insults.

Chronic renal failure:

There are a number of absolute clinical indications to initiate maintenance dialysis.
These include:

Pericarditis
Fluid overload or pulmonary edema refractory to diuretics
Accelerated hypertension poorly responsive to antihypertensive medications
Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe, cases, seizures
A clinically significant bleeding diathesis attributable to uremia
Persistent nausea and vomiting
Plasma creatinine concentration above 12 mg/dL (1060 µmol/L) or blood urea nitrogen (BUN) greater than 100 mg/dL (36 mmol/L)
However, these indications are potentially life-threatening and the patient is generally known to have advanced chronic renal failure. As a result, most nephrologists agree that delaying initiation of dialysis until one or more of these complications is present may put the patient at unnecessary jeopardy. Patients with chronic renal failure or disease should therefore be closely followed and the GFR estimated. (See "Overview of the management of chronic kidney disease in adults" and see "Assessment of renal function: Plasma creatinine; BUN; and GFR", for a discussion of these issues)

The following are the author of this article guidelines:

Dialysis should be initiated whenever indices of malnutrition develop in a patient with chronic renal failure").
We strongly consider initiation of dialysis when the approximate GFR is below 15 to 20 mL/min, especially in elderly patients and diabetics.
Dialysis should be initiated when the plasma creatinine concentration is above 10 mg/dL (884 µmol/L) and the BUN is above 100 mg/dL (36 mmol/L).

To be honest, in real life even here in the states, you may not be too compliant with these recommendation
As exmaple, we had a patient with acute renal failure (cr of 6) and hyponatremia Na 113
This is according to the guidelines is indication of dialysis
The nephrologist who is 70 y/o refused to dialyse him since he was asymptomatic and treated him conservatively

thanks
I was just about to post those

Dr_Ayyad
بعد التخرج

Quote:
As exmaple, we had a patient with acute renal failure (cr of 6) and hyponatremia Na 113
This is according to the guidelines is indication of dialysis
The nephrologist who is 70 y/o refused to dialyse him since he was asymptomatic and treated him conservatively
_________________

doesn't this case put the patient in danger???ok i understand that with acute failure the patient should be symptomatic , while in choronic the patient lives his normal life untill both of his kidneies become totally useless but even if the patient is not symptomatic , would it be a wrong approach to put him on dialysis ?? especially with cr 6 and na 113 and god knows what else?? i am lost between books and reality.

dr.tabban's picture
dr.tabban


Dear Hazem,
Take it easy and make it simple
In your patient if her pulmonary edema didn't respond to diuretics rapidly, then it is obvious she need emergent dialysis, otherwise, she would die
Any way, with Cr of 6, I expect her GFR to be close to the range of dialysis if she has chronic renal failure
I am not sure if your patient had acute or chronic renal failure
Let us suppose it is acute, then treat the symptoms conservatively (unless she's got one of the absolute indication for dialysis) and if not improving, go to dialysis. Some will recommend dialysis when she reaches BUN of 100 but I rarely saw that in real life
If she has chronic renal failure, then it is like what I mentioned earlier. Prepare for dialysis if Crcl is less than 25 and start when it is less than 15 and faster if she has one of the absolute indication for dialysis (uncontrolled fluid overload, pericarditis, encephalopathy...etc)

burhan


ok got it thanks.

dr.tabban's picture
dr.tabban


ok got it thanks.

dr.tabban's picture
dr.tabban


I have one question please.
Is ACEI the drug of choice in treating renovascular hypertension (renal artery stenosis)? or not?
and is there a difference between unilateral and bilateral renal artery stenosis regarding the treatment with ACEI????

Thanks so much in advance.

amsy
السنة السادسة

amsy wrote:
I have one question please.
Is ACEI the drug of choice in treating renovascular hypertension (renal artery stenosis)? or not?
and is there a difference between unilateral and bilateral renal artery stenosis regarding the treatment with ACEI????

Thanks so much in advance.

ACEI should be use cautiosly in bilaterla renal atretry stenosis
but i think they are good for unilateral dis though the ttt of choice is surgical

Dr_Ayyad
بعد التخرج


هاي
انا ماخد رمضان عطلة
سو بليز خلو الأسئلة لبعد العيد
ثانكيو ان ادفانس

Dr_Ayyad
بعد التخرج

question please, do i have to know what are the cells responsible of secreting erithropioetin, renin, endothilin, activ vitD?? i beleive all of them are in the cortex but dont know what cells...Embarrased

could you please tell us.

dr.tabban's picture
dr.tabban

dr.tabban wrote:
question please, do i have to know
what are the cells responsible of secreting erithropioetin, renin, endothilin, activ vitD?? i beleive all of them are in the cortex but dont know what cells...Embarrased

could you please tell us.

Mesangial cells are responsible for secreting erythropoeitin.
The cell or the prox convulated tubule have 1alph hydroxylase enzyme so they convert vitD to its active form.
Juxtaglumerulor apparatus in the afferent arteriole is responsible for secreting renin.Eye-wink Eye-wink Eye-wink Eye-wink
Hot sauce's picture
Hot sauce
طبيب مقيم

Hot sauce wrote:
dr.tabban wrote:
question please, do i have to know
what are the cells responsible of secreting erithropioetin, renin, endothilin, activ vitD?? i beleive all of them are in the cortex but dont know what cells...Embarrased

could you please tell us.

Mesangial cells are responsible for secreting erythropoeitin.
The cell or the prox convulated tubule have 1alph hydroxylase enzyme so they convert vitD to its active form.
Juxtaglumerulor apparatus in the afferent arteriole is responsible for secreting renin.Eye-wink Eye-wink Eye-wink Eye-wink

thank you dr although the answer was a little bit late but thanks.

dr.tabban's picture
dr.tabban
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