Q.581. What is the effect of uremia on homocysteine levels?
HEMODIALYSIS
Q.581. What is the effect of uremia on homocysteine
levels?
A. Hyperhomocystenemia is
universal in ESRD. It’s independent risk f. in a. & v.
thrombosis & CVS deaths. It can cause ➤ endothelial dysfunction through N.O. inact-iveation. ttt: No
beneficial evidence of vit. B6,12, folic a.- despite improvement in endothelial
function é Folc a., independent effect from
decrease in homocysteine level.
Q.582. How to do thromboprophylaxis in uremic patients? ☂
A. Most hospitalized ptn. hv
additional f. for VTE(old age, obesity, immobility). One 1/4th:
deep veins ➤ P.E..
So, LMWH⮜ Safely used
in R.I. ptn, but not in ch. base. If heparin C.I., deterrent stocking
cn be used unless PVD is present .
Q.583. What are the suggested investigations for a
suspected case of VTE?
A. Clinical
probability of VTE should be estimated 1st, then diagnostic
tests cn employed safely & cost-effectively. Scoring system- esp. Wells
Score- can be employed. D Dimers (fibrin breakdown products)➤ highly sensitive
to Ac. thrombus formation. So,
ptn. é low probability score, a –ve
D Dimers cn EXCLUDE Ac. thrombosis. However their accumulation in R.F.,
make them less helpful tht imaging 👉 (Doppler) would be
mandatory.
Q.584. What are the recommendations for
anticoagulant use in renal impairment?
A. All ptn commencing
anticoagulant thpy shd hv their kid. function evaluated:
I. Heparin: If Kid. func. is N., LMWH is preferred for
VTE ttt. (long ½
life & once /d.). In R.I.,
dose reduction is needed due to drug accumulation & other f. Xa.
inhibitors(e.g.
Fondaparinux)➤Risk of bleeding.
Still unfractionated heparin (UFH)
remains the preferred anticoagulant despite risk of bleeding. 5 % of UFH ptn., esp. bovine
heparin dev. severe immune mediated reaction ➤
increase plt., endothelial activation & fatal thrombosis. HIT ➤ 0-12%. Clotting in extracorporeal
system or site of vascular access, skin necrosis, cutaneous
allergy or Ac systemic reactions. Thrombocytopenia occur é 5-10 % of cases due to “immune
mediated” etiology, with rapid onset occur é previous exposure (last 3 m.) to heparin. Dgx
can be made by: [Clinical probability score,
serology or functional (serotonin
release, gold std. but not practical)
assay]. Unfractionated heparin conventionally used in
HDX. There’s now evidence of safety & efficacy of LMWH, given as single👆 bolus in arterial line☜ at beginning of DX. Advantage:{ Less: bleeding, HIT, Osteoporosis & better uremic
dyslipidemia}.
II. Warfarin: metabolized é liver & doesn’t accumulate in
renal dis.. It’s associated é 🠉 risk of bleeding in HDX. To
monitor INR,
take care of heparin contamination.
- The anti-Xa level of: 0.4 iu/mL at 3 h. post DX,
appear to be Optimal.
Q.585. What
are the recommendations for antiplatelet use in renal
impairment?
A. (1) Asprin: hs the
foll. effects: ✋
1)
Anticoagulant.
2)
Aniinflammatory.
3)
🠉 Fibrinolysis.
4)
Cyclo-oxygenase–independent
Plt. inhibition.
5)
Cyclo-oxygenase
modification ➤ irreversible
defect in Thromboxane synthesis ➤ Plt. dysfunction.
- As CVS risk is high in ESRD, Aspirin
benefit is undoubted, keeping the risk of uremic bleeding under control by
suitable measure like keeping Hct to be steady at 👉 30 %. Aspirin can
improve graft function & survival ,
as the pathogenesis of allograft Rj has common features with atherosclerosis.
(2) Clopidogrel: blocks
ADP pathway➤🠟its amplifying effect on Plt. activation (Permanent). Using Aspirin+Clopidogrel,
to keep access patency ➤Risky
bleeding.
(3) Glycoprotein IIb/IIIa
inhibitors (GPIs):
block binding of fibrinogen to active-ted Plt. GP receptors ➤ prevent Plt. thrombi
formation. They’re adjunctive thpy for
non-ST rise Ac. coronary synd. & essential in PTCA: 🠟peri-inerventional thrombotic comp., but é ➤
risk of bleeding, wch’s highest in CKD. PT, aPTT, Hct, HB, all shd be
monitored. As GPIs cleared by Kidnet➤🠟dose é R.I. Tirofiban should🠟50% é GFR
<30 ml/min. Avoid👆 eptifibatide é GFR < 30 ml/min. No
dose reduction é abciximab,
alth. It’s C.I. in DX or severe R.I..
Q.586. What
are the major psychological aspects in
treatment of renal failure?
(1) Dgx. of R.F.➤ Shock, Anger, 👉 Denial, acceptance 😐😐 Explain, communicate, acknowledge, consult
psychotherapist.
(2) Loss
of privacy & independence,
confusion ☁ &
disorientation ➤
explain & social support.
(3) Lack of information, highly dependent to others ➤ explain & social support.
(4) Depression: see next Q..
(5) Anxiety: tense,
sweaty, palpitation, hyperventilation, dizzy, faint, drr., inability to ease
or relax, panic:➤
identify, cognitive skills, relaxation & breathing technique,
exposure-based therapy. — ¯¯
(6) Needle phobia: 😓😓 anxiety, avoidance, fear of
pain ➤ relaxation, cognitive
behavioral technique.
(7) Body image😵: fistula
, P.D. catheter, abdominal appearance:➤
explain & acknowledgement, psychological consultation.
(8) Sexual dysfunction:
[erectile dysfunction, loss of libido, ejaculation dysfunc-tion, dyspareunia,
fear about pregnancy & fertility in females]➤ Psychosexual consultation, involve the
partner.
(9) Trauma/post trauma stress
disorder:➤
nightmares, distressing dreams, hyperalertness, irritability & anger➤CBT( cognitive
behavioral therapy).
(10) Nonconcordance:➤ see next Q.
(11) Sleep disorder:➤ delayed sleep onset, insomnia. ‚
(12) Eating disorder:➤ anorexia , bolimia.
Q.587. How
to evaluate depression in ESRD patients?
A. Depression is
frequently seen in R. ptn. either é Dgx.
or ttt. it’s often reactive & transient in nature. Depression
& anxiety are twice as common in medical ptn. as
in general population. C.F.: incl.:
1)
Low
mood & persistent sadness. 😔😔
2)
Loss
of interest or pleasure. 😐😐
3)
Fatigue
or low energy.
4)
Decreased Libido.
5)
Low
self-confidence. €
6)
Suicidal
thoughts or acts.
7)
Guilt
or self-blame.
8)
Agitation
or slow movement.
9)
Poor
concentration or indecisiveness.
10) Sleep disturbance. [insomnia
& hypersomnia].
11) Appetite disturbance[🠉 or 🠟 appetite].
NIMHE(National Institute of Mental
Health in England) provides the foll. advice for
evaluation of severity of depression/suicide risk:
1)
Level of hopelessness.
2)
Thoughts of
ending life.
3)
Thoughts about specific
available method of suicide.
4)
Ever acted on such
thoughts in the past.
5)
Feel able to resist them
or make them disappear.
6)
Circumstances that
make things worse
7)
Willing to turn for help
if
crises occur
Q.588. How to treat?
b)
Referral for further specialist
intervention.
c)
CBT:
recent guidelines recommend Cognitive Behavioral Therpy
as effective method.
d)
Combination of CBT
+ antidepressants for severe & resistant cases.
e)
key component of CBT
incl.:
Learning new
coping skills:
activity scheduling, problem solving & goal-setting. Identifying,
monitoring &
altering –ve thinking pattern, beliefs & interpreting
target Sn & Sm.
Q.589. How
to evaluate nonconcordance in renal & ESRD patients? How to manage?
A. Reported medications non-concordance rate: 50% or more, main areas incl.:
1.
Fluid restriction.
2.
Medications.
3.
Dietary advice.
4.
Continuing/withdrawal of
ttt.
** Management:
1)
Agree in treatment
goals. 👆👀
2)
Ensure understanding of
ttt regimen.
3)
Identify potential barrier
to concordance.
4)
Ensure good
communication & ptn. involvement.
5)
Refer to further
specialist if needed.
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