How I Manage Advanced

Renal Failure

Dr Andrew Mooney

GIM Trainees Day

York

February 2019

Learning objectives

1. How to be a good physician

Learning objectives

1. How to be a good physician

– Being a good enough mother is to be a good

mother, whereas the attempt to be the best

will guarantee that you won’t be (indeed, you

may be a highly damaging mother). Similarly,

you should aim to be a good enough medical

student and doctor (Smith R. Thoughts for new medical students at a

new medical school. BMJ. 2003;327(7429):1430–3)

Learning objectives

1. How to be a good physician

– Being a good enough mother is to be a good

mother, whereas the attempt to be the best

will guarantee that you won’t be (indeed, you

may be a highly damaging mother). Similarly,

you should aim to be a good enough medical

student and doctor(Smith R. Thoughts for new medical students at a new

medical school. BMJ. 2003;327(7429):1430–3)

2. How to be a great physician?

A Recent Case

A Recent Case

Mr HT

Born Autumn 1931

Admitted to Renal Unit in Leeds for further

management

– 27 August 2016

Mr HT

Presented to local DGH 23 August 2016

Presenting Complaint– Gradual deterioration over last 1 week

– Not been eating/drinking; some diarrhoea

– Breathless

History of Presenting Complaint– Worsening over last 1-2 weeks; maybe some

haemoptysis

– Wife concerned – brought to A&E

Mr HT

Previous Medical History

– NIDDM

– AF

– Myasthenia Gravis (2013)

Mr HT

Drug history

– Prednisolone (alendronate)

– Furosemide

– Simvastatin

– Apixaban

– Omeprazole

– Metformin

– Lisagliptin

– Gliclazide

– Cyanocobalamin

Mr HT

Social History

– Lives alone with wife in ground floor flat

– Walks short distances with stick

– Previous comedian/entertainer till 4-5 yrs ago

Family History

– 2 healthy adult sons aged ~55

– Parents died aged 70-80ish of uncertain

cause

Systems Review

– Possible haemoptysis (pink-staining sputum)

– No epistaxis, joint pains, rash, conjunctivitis

Mr HT

On examination

– Pulse 106 SR; BP112/65; Resp rate 23;

apyrexial; O2 Saturation 99%; GCS 15

– JVP ; Dry oral mucosa; reduced skin turgor

– HS 1+2+0; Bipedal oedema to mid-thigh

– Crackles left base

– Soft non-tender abdomen

– Catheterised 100mls clear urine

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

– Partially compensated

metabolic acidosis

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

– Partially compensated

metabolic acidosis

What is the anion gap?

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

– Partially compensated

metabolic acidosis

What is the anion gap?

– (Na + K) – (Cl + Bic) =

– (128 + 6) – (100 + 9) =

– 25 ie elevated

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

– Partially compensated

metabolic acidosis

What is the anion gap?

– (Na + K) – (Cl + Bic) =

– (128 + 6) – (100 + 9) =

– 25 ie elevated

What is the differential?

Mr HT

Blood Gases

– pH 7.33

– pCO2 2.9

– pO2 10.2

– Bicarbonate 9

– Na 128

– K 6.4

– Cl 100

– Lac 3.1

– BE -12.6

– Blood glucose 9.0

What is the acid base

disturbance?

– Partially compensated

metabolic acidosis

What is the anion gap?

– (Na + K) – (Cl + Bic) =

– (128 + 6) – (100 + 9) =

– 25 ie elevated

What is the differential?

– Multiple mnemonics

Poisonings, DKA, Lactic

acidosis, Renal failure

Mr HT

Baseline investigations

Date Na K Urea Creat eGFR AKI Bil ALT AlkPh Alb CRPAdj

Ca

24-Aug-2016 131 6.5 47.4 404 12 24 1904 313 26 106 2.07

Date Hb WCC Neut Plat MCV Lymph

24-Aug-2016 106 9.45 8.62 211 104 0.45

Mr HT

How would you proceed?

Mr HT

Chest X-ray

Mr HT

Ultrasound scan urinary tract

– “Normal size unobstructed kidneys;

catheterised bladder and ureters appear

normal; bladder indented by mildly enlarged

prostate”

Renal Screen

– Baseline assessment

Creatinine/eGFR/AKI score (plus historical results)

Urinalysis

BP

Nephrotoxins

Systemic symptoms

– ANCA

– ANA

– Complement

– Immunoglobulins and SEP (and BJP)

– Anti-GBM

How to be a good doctor

Very important to distinguish acute from

chronic renal failure

– Acute – try to reverse ASAP

– Chronic – prepare patient for long term RRT

Previous serum biochemistry

Ultrasound scan

– Renal size

Normal (10-12cm) – likely AKI (exceptions

amyloid, diabetes)

Small (up to 8cm) – likely CKD

Anything missing?

Mr HT

Progress and initial management

– Admitted

– Emergency K treatment

– Slow IVI

Contacted Critical Care Outreach and

Leeds Renal Unit

Mr HT

Progress

– No change in serum biochemistry

– Worsening respiratory distress pO2 5.4 (pO2

10.2 on admission; treated with oxygen)

Transferred Leeds Renal Unit

Mr HT

Arrived in Leeds 27 August 2016 (3-4 days

post admission)

Saturday of August Bank Holiday

Weekend

No additional tests available

Mr HTWhat should be done now?

– Observe until test results known?

– High Dose Prednisolone?

– Additional Cytotoxics/Biologics/Plasma

Exchange?

– Other care pathway?

Mr HT

At Leeds

Mr HT

At Leeds

Discovered

– DNACPR order in place

– ITU outreach had declined respiratory support

but had considered admission for CVVHF

Mr HT

At Leeds

Discovered

– DNACPR order in place

– ITU outreach had declined respiratory support

but had considered admission for CVVHF

– Echo had shown severe LVSD

Mr HT

At Leeds

Attempted dialysis

– Line inserted and attached to dialysis

machine

– Dropped BP and required saline resuscitation

– Whenever machine programmed to remove

fluid – same scenario

– After 2 hours dialysis ~ 100ml filtered

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

– Not left house for ~4-6 months

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

– Not left house for ~4-6 months

– Needed help dressing & using bathroom for

same length of time

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

– Not left house for ~4-6 months

– Needed help dressing & using bathroom for

same length of time

– 2-3 falls in house last few weeks

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

– Not left house for ~4-6 months

– Needed help dressing & using bathroom for

same length of time

– 2-3 falls in house last few weeks

– Admission precipitated by wife unable to cope

and generally worried about him

Mr HT

At Leeds

Further history now known to us

Further history taken (profoundly deaf)

– Not left house for ~4-6 months

– Needed help dressing & using bathroom for

same length of time

– 2-3 falls in house last few weeks

– Admission precipitated by wife unable to cope

and generally worried about him

– eGFR 52, 39, 22 on GP bloods last 12 months

prior to presentation

Mr HT

At Leeds

No further dialysis attempted

Palliated and died in hospital 30 August

2016 (3 days later)

Mr HT

At Leeds

During discussions discovered

– Preferred place of care/death was home/local

hospice

– Wife unable to visit Leeds unaided, whereas

could attend local DGH or hospice within 15

minutes under own steam

Mr HT

Cause of death was Heart Failure

Probably every intervention following

hospital admission hastened his demise

and worsened his situation

How to be a good doctor

Anything missing?

Anything missing?

How to be a great doctor?

How to be a great doctor?

– …some new data!!

Dialysis and ITU

Dialysis and ITU

Unclear whether this was a case of

advanced CKD or AKI

For simplicity, let’s imagine AKI = ITU

admission and advanced CKD = chronic

dialysis programme

Dialysis and ITU

ICNAR data – courtesy of Prof M Bellamy,

2016

Dialysis and ITU

Dialysis and ITU

“Not for full ITU, but consideration of

CVVHF”

Dialysis and ITU

“Not for full ITU, but consideration of

CVVHF”

ITU is a bridging treatment; so is CVVHF

Dialysis and ITU

“Not for full ITU, but consideration of

CVVHF”

ITU is a bridging treatment; so is CVVHF

Something needs to improve for the

patient to move on to the next stage of

their treatment

Dialysis and ITU

What’s new in Renal Medicine?

Dialysis and ITU

What’s new in Renal Medicine?

Dialysis and ITU

What’s new in Renal Medicine?

Dialysis and ITU

Dialysis and ITU

Dialysis and ITU

Dialysis and ITU

Assessing physical capacity to

withstand interventionsJust shown that choosing dialysis does not

necessarily provide increased survival if…

– Age>80

– Highly co-morbid (Charlson score ≥ 9)

– Dependent on others for ADL’s (WHO ≥ 3)

New data…!

New data…!

Frailty scores readily available by

calculation of number of deficits (maximum

36) calculated from >2000 GP read codes

New data…!

Survival curves in community dwelling 65-

95 year olds

New data…!

New data…!

Frailty Score

Increase functional capacity

Tamura et al NEJM

2009

Opportunity costs…

Summary

Summary

AKI or Advanced CKD in young otherwise

completely healthy patients is generally

well recognised and well managed

Summary

AKI or Advanced CKD in young otherwise

completely healthy patients is generally

well recognised and well managed

AKI or advanced CKD in such

circumstances is rare…

Summary

Summary

AKI or advanced CKD is usually managed

in the setting of elderly, co-morbid, frail

patients of poor functional status

Summary

AKI or advanced CKD is usually managed

in the setting of elderly, co-morbid, frail

patients of poor functional status

Initiation of CVVHF, intensive care or

admission to the Chronic Dialysis

Programme should involve holistic

assessment of the patient

Summary

Intensive care support frequently fails to

lead to hospital discharge

Even if discharged, it can take over 3

years to acquire 1 QALY

Summary

Intensive care support frequently fails to

lead to hospital discharge

Even if discharged, it can take over 3

years to acquire 1 QALY

It is unclear that dialysis enhances survival

if age>80, significant co-morbidity or

needing help with ADL’s (dressing,

cooking, going to the toilet, etc)

Learning points

Learning points

Mr HT was dying, but there were still

opportunities to make things better for him

Learning points

Mr HT was dying, but there were still

opportunities to make things better for him

All of us can put current results in context

and look up previous letters, test results

etc

Learning points

Mr HT was dying, but there were still

opportunities to make things better for him

All of us can put current results in context

and look up previous letters, test results

etc

All of us can ask whether patients can

dress/feed/toilet themselves

Learning points

This is not new

Learning points

William Osler FRCP (1849-1919)

– The good physician treats the disease – the

great physician treats the patient who has the

disease

Learning points

Maimonides (1135-1204)

– The physician should not treat the disease,

but the person suffering from it

Learning points

Hippocrates (~460-377 BC)

– It is more important to know what sort of

person has a disease than what sort of

disease a person has