#192 Dialysis for the Internist with Joel Topf MD

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He's a clinical nephrologist at St. John's Ascension in Detroit, the co-creator of Nef Journal Club, Neff Madness, and the Freely Filtered Podcast, and he's a recipient of the Robert Narrens Award from the ASN. My co-hosts for this episode are Matt Watto and Paul Williams, and we have a fantastic conversation with our guest, Dr. Toff, who teaches us about how to counsel patients who are approaching dialysis, what we should and shouldn't do when we're co-managing a patient on dialysis.

and his approach to med management for these patients. So without further ado, let's get to it.

And let's really focus on education. And so it's a very educational focused, uh, really intense, uh, social media oriented uh nephrology conference. It's just uh three days. They've got uh a CRT school on Thursday. Thursday night, there's a um, there's a cooking class where they're bringing in uh the cooking doc who's on Twitter. He's a nephrologist that teaches people how to cook. food that is good for a renal diet that is also tasty.

And then after that, we're going bowling with the Nephology Social Media Collective. So it's a Thursday's a super fun day. Then on Friday there's an acute a series of acute kidney injury lectures. And then Friday night there's a a jeopardy for the trainer tr the trainees. There's a keynote lecture, a dinner, and then everybody goes out to the bar after that. And then Saturday There's uh workshops, and you can do a kidney biopsy workshop, you can do uh POCUS workshop.

They have uh a women in medicine workshop. There's all kinds of different things that you sign up, you do two of them, one in the morning, one in the afternoon. And then Saturday night, everybody that goes to the conference goes to the organizer's house. And he makes martinis and meatballs for everybody.

So grotesque and then there's Ian McKellen and then Judy Dench is there and then she eventually breaks the fourth wall and stares right down the lens of the camera and it is horrifying. Like I felt my soul leave my body. It is just I I cannot recommend it highly enough. It is it's not good, but it is an experience that I think everyone should go through at least one time, like jumping out of an airplane.

She hasn't seen her nephrologist in a while and she's asking us if she thinks sh she might need to start dialysis soon and what she might need to do to prepare. So is she a candidate for dialysis and kind of at what point should we be referring her?

Without a lot of data, it it looks like this is diabetic nephropathy with that microbial minoria. Uh we need to know more of the history to get a better sense of that, but that's what it's looking like. Um and that's certainly uh the Most common cause of uh end-stage kidney disease in the United States, something around 45% of the patients that are on dialysis are due to diabetes.

And we actually have enough information to kind of calculate her, what they call the tangri renal failure risk formula. And so you take the um the age of the patient, uh, the gender, the GFR, and the microalbuminuria, and you plug that in. Um, this is a uh formula that was published in JAMA a few years ago. And when you do that, she comes out to she has a uh she has a 37% chance of being on dialysis in the next two years.

Most of the time when I talk to people and I show them this data, uh patients are horrified, right? Because all of a sudden it becomes very real when you put a percentage on it. But doctors are actually kind of they go the other way. They think a patient with the GFR of eighteen is knocking on the door of dialysis.

When you say that they only have a one in three chance of being on dialysis in the next two years, their eyes kind of pop out of their skull. They're like, Well, I I thought it was much more certain than that. And that ends up becoming uh really useful because uh, you know, is it is it does this woman have a real chance of going on dialysis? Absolutely. In my mind, anything over twenty percent risk of dialysis in the next two years.

Is data that I'm gonna act on. I'm gonna start to do dialysis education, start to talking about access, and start talking about transplant. Now her age is sixty-seven. She's getting to be pretty old for transplant, but not too old. Right. She's rubbing up against the top of that age, but she's not there yet. And at a GFR of eighteen, that's one of the priorities is getting her to transplant orientation and trying to get her listed for a transplant. If you know, again.

With you know, once you've talked to her about the realities that her kidneys may fail in the future and that the best option if she wanted to live longer would be a transplant. In terms of would she be a transplant, uh dialysis candidate, well she would be a she's a candidate for dialysis, but it's gonna take, you know, yeah, is this something that she wants to do? Generally, you know, someone at age sixty seven, she's over this line, this kind of imaginary line in the sand of sixty five.

that makes her you know an elderly person on dialysis. And patient elderly patients on dialysis don't do great. Their numbers are definitely significantly worse than younger people. And that's something that you would want to talk with her about. Um But uh yeah, absolutely a uh a candidate for dialysis. Um, and especially because she's a possible transplant patient. You know, uh to me, the most compelling argument for doing dialysis is as a bridge to a definitive therapy like transplant.

where it gets stickier is the patient that's 70. Or a patient who's got an act of malignancy. or uh patient with severe heart failure. And those patients, they're not gonna get a transplant. They're never gonna oh almost certainly aren't going to get a kidney transplant. And then now you're on a you're not on a bridge to transplant, you're on a bridge to nowhere and dialysis. It's a more difficult question. You know, certainly uh these fragile patients, they don't do great on dialysis.

And there's a pretty high uh mortality in that first year. And it may be a situation where you're actually shortening their life. by uh selecting dialysis, especially It's probably the most compelling data looks at um uh patients in nursing homes. So they there's uh a study in the New England Journal of Medicine from a a number of years ago that looked at um What was the functional status of patients uh one year after starting dialysis?

And the unfortunate truth of me was just it was a bloodbath. I mean, half the over half the patients were dead within one year and uh only I think uh it was certainly less than twenty percent, I think it was twelve or fourteen percent of them were able to maintain their functional status. The rest of them were either dead or had lost m functional status. And this really kind of goes against like this

vision for what dialysis can offer. Like, oh, we ought we see we patient, we see patients that are debilitated and have uh advanced kidney disease. And we say, oh, well, if we clear out the uremia, that patient's going to be much more functional. And that this is the dream, but the reality, especially in patients that are nursing home patients, is just the opposite.

Is that you actually have a patient that's much more stable and much more functional the day before they start dialysis than they ever will be again once you start a monologue?

Protectively because something seemed bad and imminent and those patients were not doing well at their baseline. Do you know do you want do you understand what I'm asking?

after age 70. Now certainly there's plenty of patients that are under 70 that have a lot of comorbidities and a lot of medical problems and they won't be able to get a kidney transplant. But generally the scrutiny goes up at age seven. And then, you know, why do these patients do so bad on dialysis? I kind of think, you know, some some some of these patients that are uh in nursing homes with a lot of comorbidities, I kind of think of them as a as a kind of a tall Jenga tower.

And everything is stable until you put'em on dialysis and it's like shaking the table and everything falls apart. Right. It's just it is a very traumatic. It is a pretty rough treatment. to add on to that. Plus, I mean, we're asking a lot of these patients, uh, we're asking them to get into a van to be transported to a dialysis center three days a week, and then we're gonna hook them up to a machine and we're gonna run

uh their blood flow and a typical blood flow on dialysis is four hundred C C's a minute. Most of these people have a cardiac output probably close to four liters a minute. So you're talking about ten percent of their blood flow. uh cardiac output being diverted to this dialysis machine to have this blood being uh clean cleansed.

Um, we're gonna remove usually around four pounds of excess water during that dialysis treatment. And this this is this can be a shock to their system. And I think that if they're fragile, uh they can't tolerate. In terms of what patients uh die of when they're on dialysis, the biggest cause of death is uh cardiovascular disease. Uh it doesn't tend to be uh Q-wave MIs, it's a lot of sudden cardiac death.

There's a belief that it may be a lot of um uh arrhythmias, though there was a landmark trial published this year. that looked at putting um I C Ds into dialysis patients. If we think this is the cause of death, maybe we can uh prevent it with I C D's and it was a negative trial. Did not help. So it's complicated.

a little bit more tricky if someone just has already baseline like cognitive impairment. So can you talk a little bit about like what are the symptoms or what are the situations where people commonly get started on dialysis? Like I remember learning the AEIO. Um but it seemed like it's it's very subjective in some ways as to when to start.

And um what they found is uh they didn't very few patients got down to the lower limit to start, the late start patients. Almost all of them ended up being started for cause that they developed. some symptom of uremia. So ultimately what the trial ended up being was we're going to start at a GFR 12 or we're going to start because someone needed dialysis because they had a symptom of uremia.

That's under what ended up being the trial because they didn't get to that lower limit of GFR. And what they found is there was no advantage to starting dialysis early. And this was uh an absolute uh it sh it kind of really, I think it really changed the conversation and the way we perceived.

that the important that I and again I I emphasize this to patients all the time because every time my patients with advanced CKD come to clinic, they're like, what's my GFR? What's my creatine? Where am I now? And I'm like, hey, that doesn't matter because I'm not going to start you on dialysis based on that creatine.

Right. I'm looking to see, are you eating? Are you losing weight? Are you having nausea? Are you having itching? How's your blood pressure control? Do you have any electrolyte abnormalities? These are the things that I focus on. Right. And um w you know, uh I'm thinking of two patients in particular that I started on dialysis in the last month and one of them had uh weight loss and couldn't

Yeah, that was his uremic symptom. Okay, we'll start you on dialysis. And he really felt pretty sick and he was asking to start on dialysis, which I think is That's kind of the best way to start on dialysis. Not to be told by your doctor, but to say, Hey, I'm really feeling sick and I really want this to

And so I think that that accelerated hypertension, you know, hypertension that you can't reasonably control with meds, that fluid overload that you're losing control with the diuretics are not being effective.

I had a couple of patients that I remember and they, you know, they they they sought me out after another nephrologist had recommended they start dialysis. So the first day I saw them, they already had a recommendation to start dialysis. And they just told me I don't want to do it. And I was like, Okay, well let's find alternative therapies and we just kinda worked through all the different things that we could do, uh, to keep them off of dialysis and

i they went over a year, right? I mean it was really it was really remarkable and the idea that you'll be dead in two weeks if you don't start dialysis at this X GFR. It's we're not as good as we think we are at predicting that. Again, these are patients that didn't have that nausea and vomiting, right? They didn't get the fluid overload and the hypertension. Like that we were able to manage those with medications and they did and they did w great for a long period of time.

Um and then transplant is absolutely the best therapy, right? They get the they get the longest life and they get the best quality of life. So it's not only more life, but it's better life. And so you want to get as many patients transplanted as soon as possible. And then the last the last ones are the two forms of dialysis. And so in the United States, 85 plus percent of patients get hemodialysis.

It kind of is the standard, but that's not the case all around the world. So uh Hong Kong, uh, the numbers are reversed. It's about eighty-five percent peritoneal dialysis. Mexico, over fifty percent of people patients get peritoneal dialysis. And there's a lot of advantages to peritoneal dialysis. And um

And you know, one of the the biggest advantages is the day that you start dialysis, your GFR is usually not zero, right? Almost always they're not aneuric. They got a GFR of four CCs a minute, three CCs a minute. We call that residual renal function. And it is an incredibly powerful survival.

Having that residual renal function just makes a huge difference. And when you start on hemodialysis, that residual renal function goes to zero within months. It's very unusual for people to have that long-term preserved residual renal function on hemodialysis. But I'm paired Neil Dile.

they can continue it for a long period of time. And you can see that the the survival advantage that peritnual dialysis has on hemodialysis is almost entirely predicated on that residual renal function. And you go out two or three years. And that residual residual real function finally goes away and they finally get to zero. Peritoneal dialysis survival benefit evaporates and kind of flips over and becomes worse than hemodialysis.

So early on, there's a bit of a survival advantage for peritoneal dialysis, largely predicated on residual renal function, but over time that advantage disappears as the residual renal function goes away. But it's important to be cognizant of that, right? Because you're gonna be seeing these patients in the hospital. And should you be giving them an NSAID? Probably not, right?

Can you give them a diuretic? Yeah, we do that a lot. We use a lot of diuretics in perineal dialysis patients just to continue getting any kind of urine flow that we can makes a huge difference in how well they do on that motor. But the big advantage of perineal dialysis is huge patient independence, right? They control their therapy. They're able to do the dialysis on their schedule rather than racing into a dialysis unit, waiting in the waiting room until they're called back.

sitting in the chair waiting for someone to put the needles in, sitting there for three and a half hours, four hours, and then having to recover and go home. They get to do this on their schedule. A lot of people are able to just do um Uh an automated dialysis, a cycler system overnight.

And they'll run the cycler overnight, they'll finish the dialysis, go and they'll drain their belly completely, have no fluid in them during the belly and be able to during the day and live their life normally during the day and then hook themselves up back. Not everybody, right? Some people need more clearance and they'll need to do carry a duel in the middle of the day or even do an exchange in the middle of the day. But a lot of flexibility with that makes travel very easy.

And you know, it's a it's a it's a it's a great solution for patients that wanna do

Once a day, very small amount. Is that just um I think bladder sweat is maybe a term that's thrown around? Um, but like at what level do you just decide like, okay, they don't have enough renal function, I'm just gonna go to town. If I need to, I'll give'em NSADs. I'll give'em I'll send'em for contrast.

I I guess two questions. Is there's geographic variation within the country in terms of how much it's utilized? And then I guess the bigger question is is this the pattern everywhere and why is that the case that there are these benefits to peritoneal over human dialysis, at least early on?

And two, nephrologists have less experience with peritoneal dialysis. When you have 85% of your patients on Hemodialysis and you get these kind of concentrations where that 15% is not equally distributed. You know it's going to be in hot spots areas. There'll be some doctors that have very, very little peritoneal dialysis. And you ask those phoneologists, what are they more comfortable with?

Almost all of them are going to say hemodialysis. And I'm sure we give, you know, signals to our patients that this is what we want them to do. I'm sure that and you know and when I say I'm sure. I'm pretending like I don't know the data. Like that's absolutely happened. It's definitely happening. The doctors are are at fault. But then there's infrastructure issues also. So we have patients that are in the hospital, their perineal dialysis, but they're gonna have to go to a rehab facility.

There's six rehab facilities. Only one of them offers PD. Oh, and they're nurses on vacation. And now you can't do PD there. And it's it's a real problem. And so, you know, trying to move that number up, it's a systems issue. But uh so there's patient issues, there's doctors issues, um And there's been efforts from the federal government to move patients to home and this is one of the things that was uh recently implemented by President Trump.

um the to increase the number of people going home. And uh we'll s we'll see if these uh these measures make a difference. But they're gonna really be Um, encouraging uh doctors financially to get their patients to go home, both stick and carrot.

small volumes and observe. We don't send them go home. We had do it in in the unit. But uh that allow so we even if you need to start dialysis right away, you can still choose peritoneal. Hemodialysis, there are uh the key here is getting blood out of the body, run it through the dialysis machine, the artificial kidney, and return it to the body. And things I always emphasize to patients, your blood doesn't mix with anybody else's, right? There's no transfusions involved.

We're used to seeing these uh to IV lines, right? An IV line goes a hundred CCs a minute, a hundred CCs an hour, right? Uh maybe a hundred and fifty or two hundred if you really got it rolling. Uh a dialysis access runs 400 cc's a minute. Right. It is such a it may you know, that that that tunneled catheter may look like just a big IV, but it really is a completely different technology in terms of the volume of blood that runs through.

It really it's it's huge. And um And so you can't use a little peripheral vent, it has to be in a big central vein, um and that, you know, so the the a tunneled catheter usually enters through the internal jugular, but it's the the ends of those tips, they go into the uh they go into the right atrium. But that's where you can get enough blood to draw that much in and out. So tunneled catheters are great because we can put them in quickly and use them immediately. Продолжение следует...

The big downside of them is infection, right? You've got a plastic tube that's hanging out of it. It's handing right into the central vein. We get a lot of infections with those. Keep them in long enough, you're guaranteed to get an infection. And these can be serious. And we see a lot of endocarditis in our patients, unfortunately.

The other alternative is to use um uh an A V access, usually uh using the brachial arteries and veins in the uh upper extremity, sometimes in the radial, to get that type of blood flow.

We need to we need to go from a pretty significantly sized artery directly into a vein without breaking down into the capillaries first. We create these fistulas connection between the artery and the vein. Um and Once you've created that connection between the artery and the vein, you give it some time and that vein essentially arterializes, it thickens up.

And it allows it to have uh uh and you want to see about uh uh 1.2 liters of flow going through that fistula so you can pull off four hundred cc's a minute. And so again, that's a pretty significant fistula, right? If your heart only pumps five liters a minute with a good cardiac index, we're gonna take twenty percent of that. and run it through a fish to you know, not oxygenating anything, totally useless circulation.

Interesting, that's the same amount of blood flow that normally goes to the kidneys, one liter a minute. And now we were just dedicating it to the uh to the fistula.

There's no foreign tissue in there that can be get thin get infected. So they're resistant to infection and they are resistant to failure. They work really well. They're difficult to set up. You need to have pretty healthy veins, pretty good size veins to do that. But once you have one that's working, it'll work for a long period of time. Graft, unfortunately, we get a lot of uh obstruction and we they can get they can they can get uh obstructed and they can get infected.

And uh so it's uh it's less good. So the best that you can have is a fistula, the second best is a graft, and third place is a tunneled cap.

And so we tell people to go on a low phosphorus diet. We want them to be about eight hundred milligrams of phosphorus a day. Difficult to do, but even if you do that, you're still gonna have excess phosphorus left. And then we add um phosphorus binders. And these are just medications that bind up the phosphorus in the diet so it doesn't get absorbed by the body. And so you poop it.

And uh the most common phosphorus binders is calcium acetate or calcium carbonate, otherwise known as tums, and the calcium binds the phosphorus, and it's not it's not able to be absorbed. There are then uh all uh non-calcium-based binomines. There's um Sivelomere.

Which is uh uh again, binds up the phosphorus so it can't be absorbed. There's lanthium carbonate or phosrenol, which is a big chewable pill, like a big ROLAIDS, that binds up the phosphorus. And then there's um Iron citrine, I believe it is.

is uh is the last one's called auryxia. It's the newest with the newest binder and it uses iron to bind up to phosphorus. And with the side effect of actually raising their iron, actually it's better for their anemia. It's a pretty cool drug. And I found it to be pretty effective at lowering the phosphorus.

completely unbelievable study in Italy that had a tremendous powerful effect that is I I do not believe it, right? Like nobody dies if you give them civelomere and everybody dies if you give them calcium, right? The effect size is just unbelievable. If you ignore that, then there's no compelling evidence that non-comp calcium-based binders are better than calcium-based binders.

Okay. Now you can look at second order effects like, oh, but I got a high calcium. Well, probably if you have a high calcium, giving them additional calcium doesn't make a lot of sense. That's fair enough. Um, but then the next question is, well, why are we giving them the phosphorus binders? What what advantage do patients get from the phosphorus binders? And that fundamental question hasn't been answered.

Right. There's a lot of soft stuff. Oh, their itching will be better. Oh, they can get uh very high uh PTH and that can cause uh bone pain and they might need to get a parathyroidectomy if you don't take care of it. Um, but those end up being relatively rare in the exceptions. And we put all these patients on phosphorus binders trying to get that phosphorus down with pretty thin evidence that there's any advantage to patients to doing.

Um, and I believe in Canada they are now doing a randomized controlled trial looking at phosphorus control, kind of having a relaxed phosphorus control fra versus tight phosphorus control. I'm super interested in that trial. It is really uh overdue.

for ionized for i uh uh intact pth. Um but again everything i said about phosphorus goes doubly for pth We have no compelling evidence that controlling PTH provides patients any benefit. The there was a well-done randomized controlled drug uh trial of a drug called Sinicalcet, which is a calcium emetic. It's a very effective drug for lowering the PTH. They were looking at improvements in cardiovascular disease. So it was powered for mortality and they found no difference in mortality.

And they were randomizing patients to calcium medic or not, but there was at least a twenty percent spread in the PTH between the patients on the drug and the patients on placebo. And there was no benefit to patients. Big drop in their PTHs, no benefit. Um no difference in fractures, no difference in bone pain, right? All the other things, all the other effects that you would want to see, they couldn't find with this, with this protocol. And so I am

I am not a stickler for getting patients' PTH right on the bun, uh right on the money. I think it's a lot of effort with and a lot of pills and a lot of cost and a lot of side effects without known benefit for patients. It makes me very concerned.

None of the patients on dialysis. And so uh and there's been some trials looking at correcting vitamin D and dialysis patients, and it seems to be a totally meaningless thing to do. Okay. Right. Doesn't it doesn't affect anything to look at nutritional 25 OH vitamin D. We use active vitamin D like uh calcitriol and some semi synthetic versions like pericalcitol and um doxer calciferol.

And these are used to lower the PTH. And the semi synthetic ones promise that they'll get less hyperphosphatemia and less hypercalcemia. compared to the natural calcitrial, it's unclear whether they really do that.

And bone mineral bone mineral metabolism being one of them. But what what other things are sort of really squarely in the domain of nephrology that we should maybe stay out of the way for or at least make sure that we're actively collaborating with uh when we're managing an end stage renal disease patient?

they they are not gonna be too upset about the patient coming in at one sixty and leaving at one forty. And that's probably not ideal for those patients, but it's making the dialysis unit's life easier because they're not worrying about the patient bottoming out. And so I think uh and and then There's the other additional problem is When you look at blood pressure, the pre-dialysis blood pressure is not a good predictor of mortality like the off-dialysis day blood pressure.

That's probably the best way to measure the blood pressure doing home readings, just like we always talk about with regular outpatient blood pressures. Home readings are best. And so that's an opportunity where the primary care doctor gets information that the nephrologist doesn't. But I don't get I don't see my patients on non dialysis days. You see them by definition only on non dialysis days.

And they're and they're just gonna have a bad outcome. And um and so that's that's definitely a warning sign. That's a patient you should pay attention to. That's a sick person and you don't wanna make any mistakes on that patient because they're gonna have trouble. Yeah, you need to pay attention to those people and

And so uh you will see more hyperkalemia when you use these drugs. But most patients on dialysis, not all, but most of them, don't have a problem with potassium even with speronolectone and they get away with it just fine. And it's a good and these are good medications, especially the ACE inhibitors, still good for the heart. And so we use'em all the time. They're good blood pressure medications, good for the heart, good for patients. Okay.

But the thing to think about with hypertension and dialysis patients is it's almost always volume. These patients are highly volume dependent. They all live with a, you know, in in volume overload. And so When you get a patient who's hypertensive You know, this is something that's best controlled by adjusting their dry weight in the dialysis.

Um, there is a trial undergoing right now. I think it's called Stop Ace that's looking at that very question, should we stop them or keep it going? But that said, a lot of people stop these drugs in CKD stage four. And this is one of the things that's routinely resumed. once they get on dialysis, because they're good for the heart.

And so we see a lot of iron deficiency in CKD long before dialysis. And then that's just made worse once they're on dialysis. They start losing a little bit of blood in uh in the dialysis machine or in the filters. They lose uh they have a um muc loss of mucosal blood in their GI tract. They have a little bit of uremic bleeding, uh, and their hepside levels are even high.

And so there's a lot of iron deficiency and we use IV iron um pretty aggressively in the dialysis units, run their ferritins up into the high and close to a thousand eight hundred, oftentimes we'll see uh before we'll stop with that uh with that iron'cause they get a good ref good response. There was a trial last year called the Pivotal Trial that looked at uh iron versus more iron. And more iron was more better.

What you have is you have patients that have marginal nutrition that are being told, Hey, don't eat for twenty four hours. We're gonna do a colonoscopy. We're gonna take this prep and, you know, they're fragile already and we're gonna disrupt all their fluids going across their colon. I mean It it's it's a big ask for patients and the likelihood that you're gonna improve anything is nearly nil. Yeah, nearly nail. Uh so the recommendation is no colon no screening colonoscopies, no mammograms.

Um uh no CT scans of chest, low-dose CT scans of chest, like none of that stuff should be done in your dialysis patients unless. You have a particularly young dialysis patient that fits that still fits the criteria that they should bet they would benefit from these things, but in most patients, don't stop doing all that screening stuff. No PSAs.

But nephrologists, while they're good at the things we just talked about, hypertension, anemia, managing the mineral bone disease, they're not as great at the normal primary care stuff. So you're telling us not to do cancer screening, but things like making sure they've had their vaccinations and if they're if they have diabetes doing their their foot care and things like that, I think we should think of ourselves almost as now we're the consultant for primary care to the nephrologist.

And I th I thought that was a great way to to think about this.

Are if you are on a statin when you start dialysis, you continue on the statin. If you are not on the statin and you get on dialysis, you do not initiate the statin. That's the guideline now.

Right. And it says right on the damn box of the Fleet Zenoa, you know, don't use if you have kidney problems. So don't use fleet enemas, right? You can use a soap sud enema, you can use a tap water enema. Uh you can use uh uh uh uh pe uh polyethylene glycol. You cannot use uh sodium.

uh in dialysis patients can imitate a stroke. Uh, big problem with that drug, avoid completely. I've never seen as I mean it's w I've seen patients get toxic on backlyvin after a single dose. It's a wild, how toxic it can be.

Or it was not a good and I I just you know, I saw the patient, he gave me the complaint, I said looked at his med list, I was like, Here's your problem, stop this and I saw him a week later and he was so happy. It was all you know, stopped the drug and he got better. He was delighted. Another drug that's uh questionable is the NSAIDs, right? So when they have CKD, we tell people never to use them. They cause a lot of high blood pressure, they cause fluid retention, they cause a drop in the GFR.

And most of those issues go away as problems once they're on dialysis, but I just I caution just because um Uh these patients are already prone to GI bleeds and so I always want to make sure patients don't have any history of peptic ulcer disease or gastritis before I get throw a net on and I always worry about cardiovascular disease also because that's a there's a real signal with those drugs also.

And try to minimize the amount of phosphorus in the diet. I don't know if it helps anything. Patients complain about it regularly. I am a I'm a softy. I

And there's been a number of retrospective studies that have looked at this and some have said you need to anticoagulate and others have said you can't ag you you shouldn't anticoagulate. And so I don't I don't know what to do. And there's actually there's not even a study on the horizon that's going to answer this question. Really we're need a placebo-controlled trial of anticoagulation versus no anticoagulation.

The next question is if you're going to choose to anticoagulate, should you use a doac or should you use uh warfarin? And um The big concern with warfarin is it can cause this calcifellaxis, which is oftentimes a lethal complication. It's a skin lesion, it's ischemic lesions on the skin. It's absolutely horrible. It's profoundly disfiguring. It's very painful. Um

It's it's, you know, one of the horrible complications of end stage renal disease. And it's clear uh right down to a m they've worked out the entire mechanism that warfarin is a major promoter of this condition. Uh

And I think uh the jury spit is it's a it's a bit uncertain. And so I don't have a great answer for you for this, unfortunately.

And so don't check the labs. We don't need you don't need to verify the dialysis works. It does. And if you do, you will find that the potassium is low and then you will there's that there's that uh Reflex that every intern develops. I see a low potassium. I give them 40 millikolbins of potassium. Don't do that. You will get in trouble. Uh the next is uh is um pick lines.

Uh every patient that is gonna be going to rehab or out and be leaving the hospital that needs to continue their IV therapy, they wanna put a PIC line in. These are not good for hemodialysis patients and That is oftentimes extrapolated to patients with advanced C K D. I'm not sure if it's right or wrong. Ac well, the data shows that it's right. You should not do it in patients with advanced C K D.

And uh so these pick lines definitely decrease the likelihood that they will be able to get a functioning fistula in the future. So avoid PIC lines in these patients.

And the decision is, you know, you're going to use a 2K bath or a 3K bath. And you can usually look at the last the last blood draw that you've done. I try to avoid daily labs on these patients, try to minimize blood draws, just do it when they're on the machine.

Uh next is there's a lot of different choices when it comes to dialysis. You want to get the patient a transplant if they can get to a tr get a transplant. If they're gonna need dialysis and this is something they want. Peritoneal dialysis is a great option. You kind of got to put it.

Swim a little bit against the current. There's gonna be a lot of things that are gonna be pushing patients towards hemodialysis. But don't be one of those people that's pushing them that direction. Be a cheerleader for peritoneal dialysis. Be a cheerleader for your patient to be more independent. to be able to have uh greater control over their over their health care and uh patients will appreciate that. Um

And at the same time, you can't do peritoneal dialysis forever. Peritoneal membranes wear out and eventually hemodialysis becomes a better option. And patients need to be able to adjust towards that. Uh when they're on uh hemodialysis.

Be real careful about your gabapentin, your narcotics, your um, and uh avoid uh fleets animals. Be careful with the NSAIDs, avoid GI bleed. I'm not sure what what other things do you think I should have touch on as take up points.

Until next time oh and I should thank Stuart for the theme music, thanks to Claire at Notterly for our audio editing, and until next time, I've been Dr. Matthew Frank Wado.