End Stage Renal Disease Patients, Doctors and Trust

End Stage Renal Disease (ESRD) patients require different level of attention and different level of trust between doctor and patient. For several reasons. They can weaken quickly. Imagine they walk to dialysis room and soon after they get getting to dialysis they get sleepy and tired. They feel drained. They feel no energy is left. They walk in with smile and they leave with a tired face. Doc has to understand it. We should brief for them what happened during their dialysis while they were sleeping through it. It helps them to feel and become part of this treatment. If they look too tired after dialysis and they do not want to talk as much, that does not mean that they are moody patients. It may mean that they just got very drained.

They have pain in their body. All over the body. It is real. We need to believe that. Hyperparathyroidism, osteomalacia (while phosphorus is high), microfractures, adynamic bone disease, muscle spasms, muscle necrosis and atrophy, being irritable, constant puncturing of the veins and vascular accesses, chronic pain syndrome, neuropathy, side effects of medications, chronic nausea due to medications and the disease, depression, lack of sleep at the right time, restless leg syndrome, falls, and several other reasons induces either chronic pain or low threshold to pain in these patients. These are real. We need to understand it, believe it, and be with them when they need us to help them with their condition.

Blood flow and volume removal adjustments. It really matters. It matters on one side to get the best KT/V and fluid adjustment. And on the other side most of patients symptoms during dialysis is just because of different rates of blood flow and volume removal. A smart dialysis patient senses changes in the body and associates it with changes in blood flow and fluid removal rate. They learn that different filter may have different fluid removal and dialysis profile. We better respect their opinion. They always have a point. Slow down the speed of your round doc, and listen to your patient. You may know the formula but remember you are applying it to their body. Be patient and understand they have the right to know what is going on. Do not get mad easily and do not tell you are the doctor because you are the doctor for the patient and patient needs to know what the deal is.

Trust and confidence is specially very critical issue at the time we need to decide about initiation of dialysis. Try to earn it. Very critical time. Remember we are telling a patient that your life is going to completely change. Completely. You will have several hours a week that does not belong to you anymore. It belongs to dialysis. You will have no urine after a while. You will be dependent on this machine in order to survive. We know our hands and legs belong to ourselves. And we know we have some organs in the body. Now we are telling the patient you have another organ which is not in you. It is next to you. Which you do not control it, the medical group controls it. And in order to get a good result you need to follow the advice of medical group. Trust me, these are major life changes. Give the patient some time to get through this major challenge of signing in for a dependency. They only do it because there is no other option at that time. As medical professionals we need to know that we should put a patient in this dependency only if it is vital. On the other hand we should not delay till they get harmed.

Understand that major certain elements of a normal person’s life is seriously damaged in a patient with ESRD. Daily activities, jobs, sex, relationship, endurance, persistency, independency, and many things are all poorly functioning or totally disabled in these patients. These patient are still so strong that they can smile. Remember this when you see them being nice to you. They are trying to be hero. They are trying to be successful in dealing with these new challenges while their resources are getting very limited. They should look at you as resource. Again try to earn it. We have to have respect for these heroes.

Our new lives as doctors and medical professionals with limitations of bundling and so on. As much as possible choose the best for your patient. If you can share with them the options in a realistic way. It does not help the patient if we tell them the only thing that can help them is for example drug A and we cannot write it due to limitations of bundling. If drug A is that important do your homework first. Talk to the dialysis company or patient’s social worker and insurance. See if you can arrange it. There might be a way to get it available. Do not put all the burden on the patient. They are already looking at life through a very small hole in the door. Do not close up that hole.

Alireza Atef, MD, Dallas, Texas

Ask Dr. Atef about Urine Testing

What is the use of 24 hour urine protein in patients with swelling in their legs or with generalized body swelling? 24 hour urine test in patients with swelling in their legs or with generalized body swelling. What is the use of 24 hour urine protein in patients with swelling in their legs or with generalized body swelling? In certain diseases of kidneys, large amount of protein can pass the kidney filter and find their way to urine. In this setting, the amount of protein in the vessels decreases and this can lead to retention of fluid and swelling in body. A clue that should make a person suspicious of passing large amount of protein in the urine – having “persistent” foamy urine may be a clue toward passing large amount of protein in urine. Foamy urine is shown in the following pictures:

Foamy urine in toilet

Foamy urine in toilet (source: buzzle)

Foamy urine specimen

Foamy urine specimen (source: kidneyfailureweb)

Why the doctor asked for 24 hour Creatinine as well? Each person passes a fixed amount of Creatinine in urine in 24 hours. In all 24 hour urine tests we also ask for 24 hour urine Creatinine. By doing so we can verify if the urine was collected properly or not.

Please read more about Creatinine on my site by clicking here.

Ask Dr. Atef about Swelling

I have noticed swelling in my ankles. The swelling has been there for a few weeks. I am concerned about it. Do you have any advise? Swelling in feet, ankles and lower part of legs is due to leakage of fluid from the vasculature in the soft tissues around the vessels. Fluid makes about %60 of our body weight. It is important to know that this fluid is all placed in different compartments. Two third of this fluid in placed in the cells. The rest of this fluid is outside the cells. These two fluids have different constituents. From the one third which is outside the cell, one fourth of it is in blood vessels and the rest (three fourth of the fluid which is outside the cells) is distributed between the different tissues of the body (the fluid between the cells).

Just for the sake of better understanding imagine if somebody is 160 pounds (lbs). This person will have about 96 lbs of fluid in the body. From this 96 lbs, about 64.3 is inside the cells, 21.2 lbs are between the cells and 10.5 lbs are in the vessels.

Under different conditions the amount of fluid which resides in the area between the cells (interstitial fluid) increases. This excessive amount of fluid in the areas between the cells is called edema.

Edema moves with gravity. This is why if somebody develops edema, this fluid tends to accumulate in the lower part of the body (ankles and legs). And if the person lies flat, this fluid tends to move away from the legs.

This is a simplified way of understanding edematous state.

Now in our example person, when he or she develops edema his or her weight increases. In this case the person’s weight can increase to about 175 lbs or more.

This excessive fluid will show itself mostly in interstitial area and is called edema.

Edematous status requires further work up.

This information is important for patients who have edema (such as in patients with heart failure, kidney failure or liver disease) and take water pills (diuretic).

I will post more info on that on my near future blog posts.

Dr. Atef (Dallas)

Ask Dr. Atef about Creatinine

I was told my serum creatinine level was high. What does that mean and why should I see a kidney doctor about it? First of all “serum creatinine” is a blood test. In order to this test a sample of blood is drawn from a vein. This test is mostly done in the labs (not in the office). The test for serum creatinine measures a compound which is called creatinine. Creatinine is a byproduct of energy metabolism expenditure by muscles. The more muscle a person has the more creatinine will gets released to the blood and this is why his or her serum creatinine will be on the higher end of normal. But more than muscle mass serum creatinine is determined by the filtering function of kidneys. We use this test (serum creatinine) not as indicator of muscle mass but as an indicator of kidney function.

How these two (serum creatinine and kidney function) relate? As you know as blood passes through kidneys some of chemicals in blood gets filtered out into urine. One of these chemicals is creatinine. If kidney function deteriorates (such as in kidney disease) the filtration function of kidneys deteriorates as well. In this case creatinine does not get filtered in urine in normal amount and its concentration in blood increases.

If you look at the blood test you will see this test written and reported as: “Cr”, “Creat” or “Creatinine”.

If you have any further question please contact Dr. Atef, kidney specialist in Dallas.