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Q.581. What is the effect of uremia on homocysteine levels?



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 patencyRisky 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 & angerCBT( 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?

hemodialysis complications hemodialysis meaning hemodialysis machine hemodialysis procedure hemodialysis and peritoneal dialysis

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?

a)   Recognize tht depression can be a normal response to Dgx & ttt.

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.