Managing renal patients

Please note that the advice mentioned here varies from trust to trust therefore always ask your seniors if in doubt and follow you local guidelines. You should seek advice from your seniors before sending any fancy (an expensive) tests. 
I am just sharing my experience. This is only for educational purposes 

Renal patients are well looked after by the renal consultants - as they know them for years. From the day they developed an AKI, to getting a renal biopsy, to progressing CKD, end stage renal disease and then requiring dialysis- the relatively young ones get a transplant and are seen in clinic regularly..

They are followed up in all sorts of clinics (depending on what stage of their kidney disease they are at):
1. Low clearance clinic
2. Dialysis clinic
3. Transplant clinic

We, as junior doctors are expected to look after their patients and ensure that the relevant tests and investigations are requested when they are admitted to hospital.

This blog will very briefly explain what is expected from us.

ACUTE KIDNEY INJURY 
Acute kidney injury is defined as worsening of renal function by a certain degree as explained here:
https://cks.nice.org.uk/acute-kidney-injury#!scenario

We see a lot of patients with AKI on the acute take. This may be due to:
1. Nephrotoxics - such as furosemide, ramipril, NSAIDS.
2. Dehydration - secondary to reduced oral intake or over-diuresis
3. Sepsis - pnuemonia, UTIs, abdominal infections can cause renal shut down.
4. Other interesting pathologies - like autoimmune diseases.
5. Rhabomyolysis - secondary to long lie, McArdles syndrome

How to manage patients with AKI.
Take a full history.
Check old letters - whether they have been under renal follow up.
Examine the patient in detail

Do investigations :
Monitor U and E's
- This is very important. Daily monitoring is necessary to ensure that the patient is responding to the aforementioned treatment.
FBC - Renal anemia is common especially in CKD. WCC will tell you if there is an active infection.
CRP - To check if there is an active infection/inflammatory process.
Calcium and phosphate - In kidney dysfunction, these levels can be abnormal. The pathophysiology is explained here:
https://www.kidney.org.uk/help-and-info/medical-information-from-the-nkf-/medical-info-calcium-phosphate-index/
Therefore it is important to check these and to prescribe the right treatment ( which is usually done by renal consultants).
Vitamin D levels
If the calcium and phosphate are abnormal, do a PTH level.
Bladder scan ( to ensure they are not in retention). A pre and post void scan can be helpful.
Ultrasound KUB - to r/o hydronephrosis and to assess the renal size.
VBG/ABG - this is an excellent test. It takes 5 minutes to get a result, you get the pH, bicarbonate, potassium, lactate levels and can decide about treatment without waiting for the other lab results.
ECG - in case the patient has had a MI, has hyperkalemic changes
CXR - to r/o pnuemonia, fluid overload.
Clotting profile - in case they need further investigations like a renal biopsy or need a central line put in for dialysis.
Urine dip - this is very important. It tells if the patient has proteinuria, blood and can help make a diagnosis.
Urine Protein creatinine ratio - This can reliably assess how much protein a patient is peeing out.
If the creatinine is very high, do a viral serology in case the patient needs dialysis. This includes: HbsAg (Hepatitis B surface antigens), anti HCV antibodies and HIV screen ( These tests may vary from trust to trust). There are specific machine for HBV/HCV/HIV positive patients.
Bence Jones proteins - to rule out myeloma
Sometimes, no cause is identified and you need to think about a vasculitic cause. Therefore a vasculitic screen needs to be sent which includes:
ANA , ENA, anti- GBM, complements ( C3 and C4) , electrophoresis and if you are thinking about lupus nephritis ( secondary to SLE), send a dsDNA as well.
Creatine Kinase if the patient has had a long lie.


Be careful on what you request though. If a patient was on 80 mg of furosemide and has come to hopsital with dehydration, it is unlikely to be a vasculitic picture hence there is no need to send the vasculitic screen.
Similarly if a patients creatinine has increased from 80 to 120, it is unlikely that he will need dialysis therefore there is no need to send a virology screen.

Treatment
Try to find out the cause in the first instance, stop nephrotoxics and if they are clinically dry and dehydrated, give fluid. Remember to avoid nephrotoxic medications ( do not prescribe dalteparin - instead prescribe enoxaprin, do not prescribe morphine, instead prescribe oxycodone).
Once you have identifies the cause, treat it ( ie stop meds, hydrate).
Catheterize the patient to monitor urine input and output.
Treat any underlying electrolyte abnormality.

MANAGEMENT OF RENAL VASCULITIS 
Patients may be transferred to the renal unit from small district hospitals with acute deterioration of renal function on the background of newly diagnosed vasculitis. They should receive steroids immediately and it is best to talk to the renal consultants who are admitting them for further management. The basic things expected from junior doctors are:
1. Clerking them in detail
2. Doing a septic screen ( in case this has triggered the acute deterioration)
3. Starting them on streroids ( Give the patient a leaflet on steroids as they will require these for a long period and it is good that they know the side effects)
4. Giving PPI and bone protection ( steroids can cause gastritis and bone destruction)
5. Discussion with renal consultants if there is anything you are concerned about  6. Monitoring their blood sugar levels ( steroids cause high BMs)
7. Not treating a high WCC count (remember steroids can raise the neutrophil count).

RENAL TRANSPLANT PATIENTS
These patients need to be managed very carefully. They are already on immuno-suppressant medications (to avoid rejection) which include:
Prednisolone
Tacrolimus
Mycophenolate Mofetil
They usually present with infections and it is very important to review their immuno-suppressants AFTER contacting the renal team ( usually the renal consultants may advise holding the mycophonolate if the patient has severe sepsis).
Tacrolimus comes in 2 forms - adoport or prograff. Both have different bioavailabilities so make sure you know which one the patient is on (usually patients know their medications).
Tacrolimus is usually continued in infections however it is important to check tacrolimus levels as sepsis can worsen renal function which in turn can cause increased levels of tacrolimus in the blood stream causing increased toxicity. These levels are checked by holding the tacrolimus in the monring and doing a venous sample for tacrolimus levels. REMEMBER TO ASK THE PATIENT TO TAKE HIS/HER TACROLIMUS AFTER YOU HAVE DONE THE BLOOD TEST - Do not wait for the results. The tacrolimus dose can be adjusted once the levels are back ( which may take a day or 2).
You should also be aware of side effects of these medications. The most common being:
Sepsis for all patients - A mild bacterial infection can become a nasty septic shock really quickly.
Mycophenolate - GI upset, loose stools.
Tacrolimus - Tremors, skin tumors (take any skin lesions in such patients seriously- get a dermatology opinion if you are not sure). 

Do not stop any immunosuppresants yourself unless a renal consultant advises you to do so. 
Complications in renal transplant patients:
Other than the side effects mentioned above ( plus others which you can read about in reference books), post transplant lymphoprofilerative disorder is something else you should be aware of. This is a malignancy seen in post transplant patients and patients may present as weight loss, generalized aches and pains, fatigue, loss of appetite. It is very important to examine their lymph nodes carefully to check for lymphadenopathy secondary to malignancy and talk to the renal consultants about doing a CT neck, thorax, abdomen and pelvis ( This requires contrast therefore the renal team may want pre and post contrast hydration or talk to the radiologist to give minimal contrast - wait for the renal consultants decision on this).
CMV, BK and EBV infections - send a sample for BK virus, CMV PCR and EBV PCR in patients who have a renal transplant with deteriorating renal function ( if no other cause of this is found).

RENAL BIOPSIES
Sometimes when a cause of deteriorating renal function is not found/ a patient has significant poteinuria , a renal biopsy needs to be done. Usually, the renal consultants who have advised them to get a biopsy done have given them an information leaflet on this ( Even if they have, it is important you go through the whole process with them again).
If the patients are on anticoagulants/ anti platelets, they will be advised to stop them by the renal consultant. However make sure when they stopped these and if they have been taking any bridging medications ( ie if they were on warfarin for a metallic heart valve - they would be advised to stop this 5 days prior to the procedure and start on low molecular weight heparin injections till 24 hours before the procedure - this varies from consultant to consultant and from trust to trust)

This involves the following steps:
1. The patient is admitted to a medical day unit/ renal ward
2. Bloods are done which include FBC ( monitor platelets, WCC), CRP ( to rule out infection), U and Es, LFTs( to ensure albumin is normal- a low albumin level seen in nephrotic syndrome is a high risk for clots like DVTs and PEs) , clotting (it must be within normal range), Bone profile, group and save (in case the patient needs a transfusion).
3. Urine dip - UTI is a contraindication for renal biopsies.
4. A doctor comes and sees the patient - This is usually one of the juniors in renal team.
5. We do a basic clerking which involves -
Taking a history of any infections ( pneumonia, UTI, abdominal infection, cellulitis, etc)
Asking if they feel short of breath, orthopnea ( This is important as the patients have to lie supine for 4 hours), pedal oedema.
Ask about allergies
Examine the patient
6. Consent the patient
Inform them about the procedure ( the details of which vary from trust to trust):
They will be wheeled to the radiology dept. / renal unit where a specialist radiologist/renal consultant will be doing the procedure.
They will be asked to lie on their tummy ( if it is a native kidney biopsy or on their back if it is a renal transplant biopsy- renal transplants are in the iliac fossae).
They will do a jelly scan (ultrasound scan) to find what the best point of insertion of the biopsy needle is and mark that area.
They will then inject some local anesthetic in that area (again, ask for any allergies/reactions to local anesthetic they may have had the past- eg at dentists, etc ) to numb it. This may sting a bit initially when they are injecting the local anesthetic medication.
They will then insert the biopsy needle which is a long but thin needle ( as thin as the needle we use to take blood tests).
Once they have managed to take a piece of the kidney, they will send the sample to a specialist lab.
The patient will then be sent back to the ward and advised to lie supine ( the timing varies from trust to trust) - 2 hours on their tummy and 4 hours on their back (for native kidney biopsies).
They will be monitored for a certain period and then be allowed to go home at night or kept in till the following morning ( this depends on their renal function and co-morbidities).
Inform them about the risks and benefits:
Benefits - To find out why their kidneys are not functions as they should be.
Risks-
Pain ( this will be minimized by ensuring they get adequate analgesia: PRN paracetamol and PRN codeine ( oxycodone if they have significant renal impairment)
Bleeding. This can be of varying degrees:
Visible blood in the urine : 1 in 20 ( these stats vary from trust to trust)
Requiring a transfusion ( ask if they have any issues with transfusion. Remember that renal transplant patients/candidates may need irradiated blood )- 1 in 50 to 1 in 100- (these stats vary from trust to trust)
Requiring a further X ray procedure to find out any particular vessel which may be bleeding and trying to stop it. 1 in 200 ( these stats vary from trust to trust)
Loss of the kidney completely due to blood loss.
Death.
Damage to surrounding structures ( liver, spleen, bowel)
Despite the patient going through all of this and scaring them about the risks, we sometimes do not get sufficient samples or the piece of kidney we have obtained may be completely normal.

All of this should already be documented in the consent form. Some trusts have a pre-filled consent form for renal biopsies making it easier for doctors. Sign it and then ask the patient to read through it and once they are satisfied, ask them to sign it.
Remember - all of this varies from trust to trust so it is best that you observe someone consenting these patients first before you do it. This is what I did:
I observed my reg consent a patient.
Then my reg observed me consent a patient - gave me feedback.
Then I was able to consent patients independently.
It is advisable to observe these procedures yourself as well before you consent so you know exactly what happens during this.
Write up/type up their prescription charts.

Do not prescribe dalteparin/enoxaparin as the kidneys are highly vascular and they have a potential of bleeding. Prescribe TEDS if they have a low albumin but do not have any leg ulcers/swelling.

Prepare their discharge paperwork as soon as you see the patient and add in the minor details later on post -procedure as you will just have to spend 1 or 2 minutes on this saving a lot of time.

Sometimes, patients who were on anticoagulation may need to stay in longer as they will need restarting on anticoagulants ( in some trusts this is bridged with IV heparin infusions) and monitored for longer. 

PERITONEAL DIALYSIS PERITONITIS. 
Peritonitis is a common complication of peritoneal dialysis and this must be investigated and treated immediately. Usually, the peritoneal dialysis specialist nurses know these patients well and immediately take fluid from the PD catheter and send it to the lab (urgently) and if the WCC is high, they are started on antibiotics according to the hospital protocol. Once the culture sensitivities are back, the antibiotics may be changed. 
The patients usually have antibiotics ( vancomycin) via their PD catheter and it is the doctors responsibility to assess these patients ( do a formal clerking ), request investigations, do cultures, bloods, cannulate , request a sepsis screen ( CXR, urine dip, MSU as well as an abdominal X ray) and prescribe the appropriate antibiotics according to the trust guidelines.
Some antibiotics (like vancomycin and gentamicin) need regular levels - so be aware of this. 
Patients respond well to antibiotics in a first day or 2, however if they are not improving they may need further imaging ( like a CT abdomen) which may require contrast therefore it is important to get a seniors opinion on this ( especially if the renal function is deteriorating).

PATIENTS WHO ARE DUE TO GO ON DIALYSIS/ NEED DIALYSIS URGENTLY 
When patients have end stage renal failure but are asymptomatic , they are seen in the renal clinic on a regular basis and are counselled and prepared for dialysis which involves:
- AV fistula, these are done under the vascular surgeons. 
- Regular counselling about the fact that they will be dependent on a machine 3 to 4 times a week for 4 hours ( for each session).
Unfortunately, such patients may become symptomatic before they are "prepared" ( ie they do not have a fistula, they have a fistula but it has not "matured"- it takes 4 to 6 weeks for a fistula to start functioning well. This depends on what the renal and vascular consultants think though and the timing may be different). 
Such cases need urgent dialysis. Therefore, they need some sort of access for this.
Usually they have a special line inserted.
There are different types of lines:
Central venous catheter - This can be inserted by the ITU team as well as the renal team for immediate dialysis. This cannot stay in for long. 
Tessio line - this is a special line which can stay in for long periods and is inserted by the renal registrars and consultants.
Tessio lines have special cuffs which help anchor them in the vessels (by fibrosis) therefore removal of Tessio lines is also done by renal registrars or consultants ( who may need to dissect the cuffs and remove the fibrosis). 
Patients can be discharged safely with Tessio lines ( if they know about how to manage these lines, risks and red flag signs).
A chest X ray is always done after line insertion and should be reviewed by the doctor who inserted the line to ensure there is no pneumothorax, heamothorax and if it is Tessio line, the cuffs are in the right place.


AV FISTULA FOR DIALYSIS 
Patients who are on dialysis for a long period have a fistula. We, as doctors have to very careful that the arm where the active fistula is should not be used for cannulation, taking bloods or using it for blood pressure measurement as there is a high risk of bleeding or thrombosing the site.
Some patients may have had a failed fistula which is no longer active in the other arm/wrist - always ask which fistula is active and which is not plus using your clinical acumen. Ie, an active fistula will have marks of recent "needling"(scabs), will have a palpable thrill and audible bruit.
There is a renal vascular access nurse ( all nurses in the dialysis unit are trained as well) to take bloods from the fistula if you are unable to bleed the patient from any other part.
Some renal consultants are happy for junior doctors to cannulate the wrist of the same side as the fistula site ( if the fistula is located in the anti cubital fossa) so always ask your consultant and document that s(he) is happy for you take bloods/cannulate the same side. 



LINE INFECTIONS
Sometimes, dialysis lines (like Tessio lines) can get infected. This warrants urgent investigations ( the whole septic screen) and then line removal ( by the renal reg or consultant). The tip is sent for culture and sensitivity and the patient is started on appropriate antibiotics ( As soon as he lands in hospital - This should not be delayed).
The antibiotics depend on local guidance and previous positive cultures. It is advisable to discuss this with the microbiologist on call. 

DIALYSIS UNIT
This unit deals with all sorts of patients:
1. Patients who come to the unit, set up the machines and equipment themselves or with the help of a family member and start their regular dialysis session. A nurse is around to help them.
2. Patients who need full assistance with this - they sit on the couches and the nurses do the whole process.
3. Peritoneal dialysis patients - Usually patients do this at home and have a specialist nurse who visits them and helps them
There are peritoneal dialysis nurses who do this for inpatients as well.

The renal doctors may be called to see patients who become unwell on the dialysis unit. Common issues are:
1. Low blood pressure - when too much fluid is removed from patients. The renal reg or consultants may be called as the nurses know that junior doctors may not be aware of what to do. Stopping dialysis and giving fluid is usually advisable.
2. Chest pain - Dialysis puts a lot of extra pressure on the heart therefore chest pain should always be taken seriously. Take a full history and examine the patient.
Do an ECG, check the potassium ( may be high prior to starting dialysis or too low post dialysis, Which is why every dialysis patient has a venous gas done ), FBC ( symptomatic anemia). Doing a trop may not be very helpful as it will be high anyway (due to kidney dysfunction) so talk to the consultant about this (if it seems high risk a repeat trop after 3 hours may be advised).
Do a CRP, U and E's, CXR as well.
Ruling out gastritis is important and a PPI ( like ranitidine) may be helpful.
3. Falls - These need to be taken seriously. Due to the imbalance of calcium and phosphate in renal patients, they are prone to fractures. So if the patient has pain, tenderness, swelling then get a X ray.
4. Other symptoms like cough, rash, low mood.
5. Sometimes, it may be more complicated than this like a newly diagnosed metastatic cancer and the oncology team have advised that the patient is for palliation and they have asked the patient to discuss whether dialysis should be continued or not with their renal doctor. This is best dealt by the renal consultants but if the consultant wants you, as a junior doctor to discuss this and if you are confident enough to discuss this, you can do it. It is best to then dictate a letter and ask the consultant to verify it so that your conversation with the patient is on the system and not lost if you have documented it on a piece of paper.
In all of the above, always inform the renal consultants on call so that they are aware of what is going on and may suggest something different.

RENAL CLINICS 
Junior doctors ,especially SHOs may be asked to do renal clinics. This is an excellent way to learn about dealing with patients and taking a full detailed history and doing a full examination. Some consultants allow their junior doctors to dictate letters and then verify these. This is an excellent way to learn and you get yourselves assessed formally by sending them tickets, ACATS, CBDs, etc. 

MEDICAL DAY UNIT
Some patients come to the medical day unit for infusions. Some common cases are:
1. Renal vasculitis
2. SLE
3. Other conditions involving immunosuppression.

You may be asked by the nurses to see these patients. It is important you see them ASAP as they can be started on the infusion once they have been seen and can go home.

Some common infusions include:
1. Cyclophosphamide
2. Rutuximab
3. Ponticelli Regimen
4. Blood transfusions
5. Iron infusions
For all of the above, the basic tests would already been done - ie routine bloods, urine dip, weight, documentation of any allergies. The doctors are expected to take a very quick history ( ask about any infections, allergies, reaction to this infusion before), examine and then prescribe the infusion according to the trust protocol. 

IN PATIENT REFERRALS
In patient referrals are usually seen by the renal registrars or consultants. These  may involve something very basic like - AKI secondary to dehydration due to over diuresis in a 90 year old dementia patient or something which can be treated immediately like an AKI with metabolic acidosis, hyperkalemia, fluid over load and oliguria requiring urgent dialysis. So inform your seniors immediately if  you have been asked by your colleagues on advice about a patient. 

GENERAL MEDICAL PATIENTS 
Renal physicians not only look after renal patients but also do on calls, have general medicine patients admitted to the renal wards and may need to see general medical patients in other wards. Every hospital has its own policy. 
Therefore the junior doctors working in renal medicine get to see all sorts of patients. 


Overall, I love seeing renal patients. I get to see the stable patients, see the sick ones, get to manage all sorts of complications and I am very well supported by my registrars and consultants.

The renal consultants are available 24/7 and if I am in any doubt, I ring them ( or ask my registrar to ring them if it is 4 AM).

Local trusts policies - found on the intranet. 


PS: Please note that all of the above varies from trust to trust therefore always ask your seniors if in doubt and follow you local guidelines. You should seek advice from your seniors before sending any fancy (an expensive) tests.
I am just sharing my experience.

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