Dialysis Unplugged: When Good is Not Good Enough

When DaVita in a press release boasts that it's shown “a nearly 20 percent reduction in gross mortality rates since 2001” that is good, but not good enough. And, when DaVita says that it “outperformed the industry with 75 percent of the company's clinics ranking in the top clinical performance tier”, that again is good, but not good enough.

Am I being feint with my praise? I don’t think so.

The following statement worries me: “"DaVita and the industry are working with CMS to improve quality for our patients in several aspects," said DaVita Group Vice President LeAnne Zumwalt. "We look forward to partnering with CMS on the development and implementation of the expanded QIP in 2014 and beyond." QIP takes two clinical areas into account. The first is anemia management, and the second is Urea Reduction Ratio (URR).

Neither anemia nor URR as surrogate endpoints correlate with hard outcomes, such as death or cardiovascular complications. For example, raising the hemoglobin (Hb) concentration with epoetin-alfa (the Normal Hematocrit study) does not result in improved outcomes; on the contrary, there is a 30% higher rate of death or heart attacks. Likewise, as reported in the HEMO study raising the URR (or a related parameter KT/V) does not improve outcomes.

The big picture is that we still haven’t figured out for sure what interventions work in dialysis patients. We need a better mouse-trap, not metrics to see how well the current mouse-trap is working.

DaVita, as a profitable dialysis company (profits have doubled from last year), needs to invest serious money in trials to figure out the one thing that matters the most to dialysis patients: living longer and more fullfilling lives.

With approximately 1,777 dialysis facilities, serving approximately 138,000 patients, revenues of $1.86 billion and a gross margin of nearly 18%, DaVita is a powerful presence. It has ambitions to be even larger and control more of the health care spend of it's dialysis patients. However, DaVita's financial statements indicate a zero dollar R&D expense, even though I am sure that they do spend some money on clinical research. Who can blame them for running a commercially profitable and efficient enterprise? However, it is a fair criticism that they are not spending money on research figuring out how to improve clinically meaningful outcomes in dialysis patients (and here I am referring to large well designed RCTs).

What we need from DaVita, as one of the largest dialysis organizations (LDO's) around, is to get off the side-lines and invest in trials in their patients. Obsessing about QIP formulated outcomes like anemia and dialysis adequacy is failing to see the forest from the trees.

IMAGE QUIZ

The Question What does the non-contrast CT image demonstrate? What could be the possible cause?

Source: Dr. D. Doshi et al

The answer to the Image Quiz of Feb 21, 2012 is A: C-ANCA, B: P-ANCA 
(corrected 8/1/12)

The Question from Feb 21, 2012

What does the slide show in A and B? 

Explanation

The pictures show the characteristic immunofluorescence microscopy pattern of ANCA. Notice the negative staining of the nuclei in the c-ANCA image (B) due to the staining of cytoplasmic components; the proteinase 3-containing granules are stable and do not migrate during alcohol fixation. The p-ANCA image (A) was taken at a slightly higher magnification. Ethanol-fixation facilitates the migration of the myeloperoxidase-containing granules toward the nucleus; notice the seemingly “empty” cytoplasm (Source Dr. H. Rennke).

ELECTROLYTE QUIZ

A 48-year-old male smoker presents with confusion and drowsiness. His only medications are bronchodilator and steroid inhalers. On examination, his BP is 130/84, HR 70, moist mucous membranes, good skin turgor, jugular venous pressure 4 cm, lung fields clear to auscultation, no peripheral edema. Chest radiograph shows emphysematous changes but is otherwise normal.

Laboratory Studies

Serum sodium 117 mEq/L

Serum potassium 3.6 mEq/L

Serum osmolality 258 mOsm/kg

Urine sodium 90 mEq/L

Urine potassium 75 mEq/L

Urine osmolality 662 mOsm/kg

Which of the following would be appropriate to identify the cause of hyponatremia in this patient:

A. Thyroid radioiodine scan

B. Cosyntropin stimulation test

C. Water deprivation test

D. Computed tomography scan of the chest 

E. Psychiatry consult 

The Answer to the Electrolyte Quiz from Feb 25, 2012 is B

The Question

A 58-year-old woman with ischemic cardiomyopathy is admitted in pulmonary edema. Her medications include aspirin, metoprolol, furosemide, spironolactone, digoxin, isosorbide dinitrate, and lisinopril. On examination, the blood pressure is 97/54 mm Hg, pulse rate 85 per minute, jugular venous pressure 9 cm, moist mucous membranes, lungs with diffuse inspiratory crackles, heart with an S3 gallop, and cool, clammy extremities with 1+ peripheral edema.

Laboratory Studies

Serum sodium 126 mEq/L

Serum potassium 3.5 mEq/L

Serum chloride 88 mEq/L

Serum bicarbonate 33 mEq/L

Blood urea nitrogen 45 mg/dL

Serum creatinine 1.1 mg/dL

Arterial pH 7.46

Urine electrolytes (6 hrs after last diuretic dose):

Urine sodium 15 mEq/L

Urine chloride < 5 mEq/L

Urine osmolality 210 mOsm/kg

Which of the following would be appropriate in the management of the hyponatremia in this patient:

A. Intravenous isotonic (0.9%) saline

B. Restriction of free water intake

C. Hypertonic (3%) saline

D. Hydrochlorothiazide

E. Hydrocortisone

Explanation:
This patient presents with congestive cardiac failure and a low cardiac output state. The hyponatremia in this setting is due to effective circulating volume depletion and volume-mediated vasopressin secretion, which are caused by low cardiac output and therefore renal hypoperfusion; thus, the only available treatment is to minimize free water intake. She also has a primary metabolic alkalosis, likely due to diuresis by furosemide. In this setting, the urine chloride is a more reliable indicator of effective circulating volume than the urine sodium; the low value in this case is again consistent with her cardiac failure. Administration of isotonic or hypertonic saline would only worsen the pulmonary and peripheral edema and would not improve forward cardiac output, and therefore would not correct the renal hypoperfusion. Hydrochlorothiazide inhibits urinary dilution in the distal tubule and worsens hyponatremia. Hydrocortisone would only be helpful if the hyponatremia were due to adrenal insufficiency.


(Cases provided by Dr. Alan Yu, University of Kansas Medical Center, USA)

Dialysis Unplugged: Medicare QIP Program

Roberta Mikles, who is a Dialysis Patient Safety Advocate left a recent comment in response to an editorial I published November 9, 2011. (Here is the editorial if you'd like to read it again. I would also draw your attention to an editorial by Merrill Goozner in Gooznews published January 25, 2011.)

Ms. Mikles writes: "In searching for some information, I came across this editorial. Here we are, no win 2012, and have we seen improved quality? I think not.

I determine the level of quality NOT by the measures that CMS has developed, probably with more influence from the providers, versus patients, but by the patient's experience.

Quality, as I have been stating for over seven years, is more than anemia levels or degree of other measures. If a patient acquires a deadly infection what difference does it make if their hgb is 13 or 10, if they die of an infection or are hospitalized for an error (non compliance with a facility policy).

As I review surveys (inspections conducted by the state) in California, I see NO difference in the types of deficiencies cited since (a) the new revised ESRD Conditions, (2) the mandated rule for dialysis technician certification and (3) the QIP. Hence, if the cited defiencies are the same, e.g. staff not following their own facility policies/procedures, resulting in potential or actual negative outcomes, including death, then how can the QIP or the ESRD Conditions be focused on improved care.

Of course, let us not forget that the fact that there are minimal to NO consequences for negative outcomes that are preventable, or even staff not following policies, what can one expect."

Transplantation Unplugged: “It’s Now or Never”

Borrowing a line from that famous song from Elvis Presley, I am writing to ask you to support the petition to extend immunosuppression coverage for kidney transplant patients in the US.

Surprisingly, most of the 1200 or so people who have signed the petitioners are not doctors.

This is a time when we have to stand-up for our patient’s rights. Withdrawing insurance coverage after 3 years adversely affects low-income and minority patients. That’s not fair, and it certainly makes no sense.

Over the past 6 months this site has steadily built up a following. We now get over 20,000 hits and over 5,000 unique visitors each month. 70% of the visitors originate from the US and the rest from over 60 countries. So, we should have plenty of potential petitioners who haven’t as yet signed up.

Whether you live and practice in the US or not, I urge you to sign the petition. It’s for a good cause; it’s now or never!

Global Nephrology: Kidney Donation in India

The trials and tribulations that patients have to face world-wide to get access to kidneys are magnified in India.

In India, only a fraction (≈10%) of the estimated 100,000 individuals who develop kidney failure are able to receive dialysis – either because of the cost of chronic dialysis or the limited availability of dialysis spots. On the other hand, kidney transplant from a donor is also not that straight forward either.

I met my friend and long-time colleague Dr. Bharat Shah in Mumbai a couple of days ago in Mumbai. Bharat Shah is one of the leading nephrologists in India and has a large transplant practice in Mumbai. I recall reading an article in DNA, a local Mumbai newspaper, titled "It's easy: Fly to Singapore, fix kidney" that quoted Bharat extensively. The article was about the difficulties potential kidney transplant recipients face in getting access to an organ.

For example, a mother has to have the consent of her relatives in order to donate to a child. Only recently, grandparents were added in the list of family members who can donate a kidney. And, only family members are able to donate.

Perhaps, worse still, this past year the government introduced new guidelines that require every hospital conducting transplantation to convene an “authorization committee” to review and approve the kidney transplant. The committee needs to comprise of "members from civil society", in addition to the transplant unit designated doctors; and, each of these members needs to be approved by the state. The new committee also needs to have a DMER person (i.e., state government representative), a retired judge, a prominent person from  society (a retired member of the civil service [IAS officer of class I or class II]), and a representative from the hospital administration.

This is beaurocracy run amok because, according to the DNA article, the convening and processing of activities by the authorization committee frequently takes time and the delay can have consequences for the potential recipient. 

Those who can afford it go abroad for the kidney transplant – Singapore being a popular destination.

But because of the lack of proper co-ordination between the hospital and authorities the hospital finds it hard to obtain authorization letters on time and there are delays in scheduling the transplant that can be for months.

Why this overly intensive regulation and scrutiny? Probably because of an over-reaction to the illegal trading in organs and commercial transplantation.

The bottom-line: countries around the world are striving to address the shortage of organs by implementing processes and procedures to increase the availability of organs. India seems to be going in the opposite direction. An enormous tragedy given the very limited availability of dialysis. 

Electrolyte Quiz

A 58-year-old woman with ischemic cardiomyopathy is admitted in pulmonary edema. Her medications include aspirin, metoprolol, furosemide, spironolactone, digoxin, isosorbide dinitrate, and lisinopril. On examination, the blood pressure is 97/54 mm Hg, pulse rate 85 per minute, jugular venous pressure 9 cm, moist mucous membranes, lungs with diffuse inspiratory crackles, heart with an S3 gallop, and cool, clammy extremities with 1+ peripheral edema.

Laboratory Studies

Serum sodium 126 mEq/L

Serum potassium 3.5 mEq/L

Serum chloride 88 mEq/L

Serum bicarbonate 33 mEq/L

Blood urea nitrogen 45 mg/dL

Serum creatinine 1.1 mg/dL

Arterial pH 7.46

Urine electrolytes (6 hrs after last diuretic dose):

Urine sodium 15 mEq/L

Urine chloride < 5 mEq/L

Urine osmolality 210 mOsm/kg

Which of the following would be appropriate in the management of the hyponatremia in this patient:

A. Intravenous isotonic (0.9%) saline

B. Restriction of free water intake

C. Hypertonic (3%) saline

D. Hydrochlorothiazide

E. Hydrocortisone

The answer to the Electrolyte Quiz of Feb 22 is sarcoidosis

The Question

A 38 year old black female presents with a 1-year history of fatigue, malaise, mild dyspnea and weight loss. Key laboratory data: BUN 48, Cr 4.4 (was 3.7 mg/dL two months ago), Alb 3.9, Ca 11.6, PO4 5.2, Mg 2.5, ALT 104, AST 88, Alk phos 554, Bili 0.9, ESR 136; Urine: Ca 17.4, Cr 47.7, Protein 95; U/A: 2+ protein, 2+ blood, 2+ leuk est;  USed:  18-22 WBC, 25-30 RBC, 3+ Ca oxalate crystals; Ultrasound: Rt kidney 10.4 cm with multiple calculi, Lt kidney 10.5 cm with 3 calcifications in the region of the pyramids; no hydronephrosis; iPTH 2.8 pg/ml (NL10-65), 25-vit D 11.8 ng/mL (NL 9-43) , 1,25-vit D, 109.4 pg/mL (NL 15-60); Chest CT: Increased diffuse lung parenchymal density, enlarged lymph nodes in axillary, mediastinal and hilar regions.

What’s the diagnosis?

Hypercalcaemia in association with sarcoidosis was first described by Harrel et al. in 1939 and since then an increased risk of hypercalcuria and reduced bone density has also been demonstrated. The cause of the hypercalcemia is cctopic 1a-hydroxylation of 25-hydroxyvitamin D by macrophages.

Other key clinical features:

• Diffuse interstitial lung disease
• Lymphadenopathy
• Liver Bx: Non-caseating granuloma
• Renal Bx: Chronic interstitial nephritis, isolated granulomata, microcalcifications.

More reading, here.

A hypercalcemia algorithm:

Cases provided by Dr, Alan Yu (University of Kansas)

Dialysis Unplugged: Compassionate Witholding of Information, Damned if You Do, Damned if You Don’t.

The Doctor by Sir Samuel Luke Fildes, R. A. (1844-1927).

I can tell you right off the bat that I do not routinely tell my patients starting dialysis that, on average, they have a 20% chance of dying in the first year of starting dialysis. Nor, for that matter, do I tell my 70 year stage 5 CKD patient, who I am preparing for  initiation of dialysis, that she or he has, on average, 2 to 3 years longevity of dialysis. Of course I want to be truthful to my dialysis patients, but averages are misleading, and ESRD is not a terminal disease. Moreover, even two or three additional years of life - and in my experience it is frequently more than 2 or 3 years - isn’t something to shrug-off.

This dilemma brings me to a recent article published in the February issue of Health Affairs by Lisa Iezonni, a professor of medicine at Harvard Medical School and director of the Mongan Institute for Health Policy at Massachusetts General Hospital, in Boston. The paper reports the findings of a nationwide survey conducted in 2009 of 1,891 practicing physicians looking at physician-patient communication.

Iezonni et al identified their sample from a pool of all US physicians in primary care (internal medicine, family practice, and pediatrics) and four other specialties (cardiology, general surgery, psychiatry, and anes-thesiology).

The results of the survey are summarized in Table 1. One of the findings that has garnered a lot of press attention is that approximately one-fifth did not completely agree that physicians should never tell a patient something untrue.

Iezonni et al write “Some might argue that knowing when to breach or bend these rules—when individual patients require a different approach— constitutes clinical wisdom and true patient-centeredness. For instance, providing a patient with every detail about his or her case is rarely feasible, nor is it necessarily desirable. Physicians must sort through often contradictory and confusing information as their clinical assessments evolve and finally crystallize.”

However, medical ethicist Dr. Linda Emanuel from Northwestern University (Evanston, Illinois) argues that the survey results represent a "welcome wake-up call" for her profession. The study "is an indication that our medical culture needs a recess," Dr. Emanuel told Medscape Medical News. "We need to do some serious interventions to return to our ethical values. "I don't think there's any situation where a physician is justified in telling an untruth."

Here’s where I disagree. Linda Emanuel is taking what is often a complex situation and simplifying it. Worse still, she is arguing that deliberate withholding of information is unethical.  Of course we all agree that we need to provide a realistic assessment of prognosis to our patient’s and their families. However, there is a fine line between “realistic assessment” and “scaring people”. This is where knowing the patient and their family and applying the Oslerian “the art of medicine” comes into play. Compassion is important (read this story to know why). For example, I don’t tell all my dialysis patient’s that their prognosis is worse than if they had some forms of cancer. It might be on average, but it is certainly not true for everyone. Dr. Paul Beeson once said: “Our profession, after all, deals partly with guess work; we do not deal in absolutes.”

Global Nephrology: Kidney Donor Networks in the US

An article by Kevin Sack in the New York Times on February 18 very nicely demonstrates the power of organized networks in increasing kidney donation rates. In the article, Mr. Sack describes how chain 124, a kidney donor network, resulted in 30 kidney donations across the United States.

The article highights the work of Garet Hil, a Long Island NY businessman, who is the founder of a non-profit agency called the National Kidney Registry (NKR). This effort had it’s beginnings in 2008; Mr Gil is quoted in the article as saying: “The goal was very simple: get everybody transplanted in under six months if you had a living donor.”

Fig.1" Transplants facilitated by NKR
(Source: NKR Web site)

Briefly described, the disruptive innovation underlying NKR is a computer program that matches kidneys across states and hospitals in the US. In the past 3 years, the donation of 407 kidneys have been transacted through NKR (Fig. 1). And, most importantly, the wait time is down to less than one year (Fig. 2).

Sack writes: “Domino chains, which were first attempted in 2005 at Johns Hopkins, seek to increase the number of people who can be helped by living donors. In 2010, chains and other forms of paired exchanges resulted in 429 transplants. Computer models suggest that an additional 2,000 to 4,000 transplants could be achieved each year if Americans knew more about such programs and if there were a nationwide pool of all eligible donors and recipients.”

“Mr. Hil seized on the idea and set out to build an algorithm that would enable even more transplants. Nowadays, his pool typically consists of 200 to 350 donor-recipient pairs. That is enough to generate roughly a googol — 10 to the 100th power — of possible chains of up to 20 transplants if all of the pairs are compatible, said Rich Marta, the registry’s senior software designer.

Fig. 2 (Source NKR Web-site)

The program quickly eliminates matches that will not work because of incompatible blood types or antibodies, or because a transplant candidate insists that a donor be under a certain age or a close immunological match. It then assembles up to a million viable combinations at a rate of 8,000 per second.”

The computer program then matches by HLA antigens and then an algorithm provides a ranking of possible combinations based on patient’s with hard-to-match kidneys and the length of time a patient has been on a waiting list.

The algorithm ranks the possible combinations by the number of transplants they would enable, with weight given to chains that find kidneys for hard-to-match patients and those who have waited a long time.”

The bottom line: NKR exemplifies the disruptive innovation that could make changes in the care of kidney patients. Garet Hil, NKR's founder, shows that a good idea, well executed, can make a difference. 

Electrolyte Quiz

A 38 year old black female presents with a 1-year history of fatigue, malaise, mild dyspnea and weight loss. Key laboratory data: BUN 48, Cr 4.4 (was 3.7 mg/dL two months ago), Alb 3.9, Ca 11.6, PO4 5.2, Mg 2.5, ALT 104, AST 88, Alk phos 554, Bili 0.9, ESR 136; Urine: Ca 17.4, Cr 47.7, Protein 95; U/A: 2+ protein, 2+ blood, 2+ leuk est;  USed:  18-22 WBC, 25-30 RBC, 3+ Ca oxalate crystals; Ultrasound: Rt kidney 10.4 cm with multiple calculi, Lt kidney 10.5 cm with 3 calcifications in the region of the pyramids; no hydronephrosis; iPTH 2.8 pg/ml (NL10-65), 25-vit D 11.8 ng/mL (NL 9-43) , 1,25-vit D, 109.4 pg/mL (NL 15-60); Chest CT: Increased diffuse lung parenchymal density, enlarged lymph nodes in axillary, mediastinal and hilar regions.

What’s the diagnosis?

Image Quiz

What does the slide show in A and B?
The answer to the  image quiz of Feb 17: "crescentic glomerulonephritis". Slide 1 is a low power light micrograph, PAS stain, which shows the diffuse nature of the condition (most glomeruli are involved with some degree of "extracapillary proliferation“ (crescent formation) outside the tuft but inside Bowman's capsule. Slide 2 is a higher power light micrograph, again with PAS staining, that shows details of the cellular composition of the crescent. Notice   mostly mononuclear cells (monocytes, epithelioid cells, proliferated parietal epithelial cells from Bowman's capsule, some polymorphonuclear neutrophils) in the crescent and the collapsed, fragmented capillary tuft, as highlighted by the PAS positive basement membranes (center and right). Slide 3 shows fibrin staining by immunofluorescence. The slide illustrates the distribution of fibrin within the crescent. This finding is constant, regardless of the mechanism of crescent formation.

Slide 1 (click over image to enlarge)

Slide 2 

Slide 3

Global Nephrology: Organ Donation in Israel

There is a very interesting article (Feb 16, 2012) by Dr. Danielle Ofri in the New York Times about proposed changes in the organ donation system in Israel.

The issue is that Israel ranks low (see Fig.1) in its organ donation rate as compared to Western countries because Jewish law proscribes desecration of the dead. This has generally been interpreted as “Judaism prohibits organ donation”.  As well, there were rabbinic issues surrounding the concept of brain death, the state in which organs are typically harvested. Consequently, many patients died waiting for organs.

As Ofri writes: “So Israel has decided to try a new system that would give transplant priority to patients who have agreed to donate their organs. In doing so, it has become the first country in the world to incorporate “nonmedical” criteria into the priority system, though medical necessity would still be the first priority.”

Fig.1
Source: Rieu et al, J Med Ethics 2010 

Dr. Ofri continues “The Israeli program was initiated by Dr. Jacob Lavee, a cardiothoracic surgeon who heads the heart transplant program of Sheba Medical Center in Tel Hashomer. In 2005, he had two ultra-Orthodox, Haredi Jewish patients on his ward who were awaiting heart transplants. The patients confided in him that they would never consider donating organs, in accordance with Haredi Jewish beliefs, but that they had absolutely no qualms about accepting organs from others. That Haredi Jews would not donate organs was a well-known fact in Israel. But this was the first time anyone had openly admitted the paradox to Dr. Lavee.

Dr. Lavee then worked with many stake-holders, including rabbis, ethicists, lawyers, academics and others to introduce a new law that goes into effect this year where if two patients have identical medical needs for an organ transplant, priority will be given to the patient who has signed a donor card, or whose family member has donated an organ in the past. He also pushed through a law that defines brain death in a manner that is acceptable to the vast majority of rabbis (though not the ultra-Orthodox Haredi), as well as local imams, making organ donation acceptable to a large segment of the population. The new also provides “fair compensation” for living donors that covers 40 days of lost wages, plus expenses related to the donation.

Dr. Ofri writes that “This was accompanied by a huge public awareness campaign about organ donation, with radio, TV, billboard and newspaper ads promoting the new priority system and countering the perception that Jewish law forbids donation. Shopping centers and coffee houses were blanketed with organ donation information.”

“The response was overwhelming, as people registered in droves as potential donors. During the 10 weeks of the publicity campaign, 70,000 Israelis registered for organ donation cards. The consent rate from families has already increased, and the number of organs available for patients has increased in parallel. Transplants have so far increased by more than 60 percent over all this year.”

Bottom-line: This article shows how different countries are trying innovative solutions to grapple with the lengthening waiting list for organs.

Pain Management in Dialysis Patients: What to Do?

Source: Steve Thorpe

I recently admitted a dialysis patient with chronic severe pain. She came in because of altered mental status – the delerium was thought due to excessive dosing of Dilaudid (or hydromorphone). The question came up about what are the ideal drugs for pain management in dialysis patients? Are some better than others? 

5 practice points about the use of opiods in dialysis patients:

1. One needs to consider the properties of the parent opoid drug and its metabolites, as well as the dialysis prescription – the dialysis membrane, flow rate, the efficiency of the dialysis

2. Here are a list of do’s and don’ts on various agents (Table 1):

Table 1

3. A suggested approach to treating severe pain in dialysis patients (source-2):

• Start at 0.5 ‐1 mg PO hydromorphone q 4 hours plus 1 mg PO q 2 hours prn pain. Titrate dosage every 2 –3 days.
• If pain is not controlled, is continuous, and 24‐hour dose exceeds 12 mg, substitute transdermal fentanyl 25mcg/h for regular dose of hydromorphone.
• If further “as needed” hydromorphone exceeds 12 mg/24 hours, increase dose of fentanyl patch by further 25 mcg.
• Titrate upwards in similar manner if pain is not controlled.

4. Details on 2 key medications (source-2)

A. Hydromorphone:

• Start at 0.5 ‐1 mg PO q 4 hours plus 1 mg PO q 2 hours prn pain. Titrate dosage every 2 –3 days.
• If pain is not controlled, is continuous, and 24‐hour dose exceeds 12 mg, substitute transdermal fentanyl 25mcg/h for regular dose of hydromorphone.
• If further “as needed” hydromorphone exceeds 12 mg/24 hours, increase dose of fentanyl patch by further 25 mcg. Titrate upwards in similar manner if pain is not controlled.
• Caution: Toxic metabolite, H3G, accumulates if dialysis is stopped.

B. Fentanyl Transdermal Patches:

• Useful for patients with chronic, stable pain. Start after immediate‐release opioid dose is established. Analgesia may not be obtained for 12‐24 hours, so continue previous prn analgesics for 12 hours to ensure a smooth transition.
• Initial dose for opioid‐naïve patients is 12 mcg/h (increase dose every 3 – 6 days as needed for pain). Useful choice if dialysis non‐adherence or stopping dialysis are concerns.
• Fentanyl patches above 12 mcg/hr should not be used in opioid‐naïve patients due to risk of respiratory depression.
• Prescribe medication for breakthrough pain.

5. The most common reasons for stopping opioids are adverse effects, especially respiratory depression, hallucinations and confusional states, constipation, nausea and vomiting. Management of excessive sedation, compromised respiration with low O2 saturation

• Dilute 0.4 mg of Naloxone in 10 ml NS and administer 1 ml IV q 1‐2 minutes until patient arouses.
• Continue to monitor for return of sedation or slowed respirations (half‐life of Naloxone is shorter than half‐life of opioids).

Key sources for the above information, that are available open access, 1, 2 

iSEDIMENT

What is the cast?

The answer to the iSEDIMENT quiz of Feb 16, 2012 is: Calcium oxalate dihydrate crystals: Calcium oxalate dihydrate crystals are normally found in the urine sediment in small quantities. They are small square crystals with an "x" in their center.

Calcium-containing stones

The most common type of kidney stones worldwide are calcium-containing stones - 80% of all cases in the United States. Typically these stones are either calcium oxalate alone or in combination with calcium phosphate in the form of apatite or brushite. Factors that promote the precipitation of oxalate crystals in the urine, such as primary hyperoxaluria, are associated with the development of calcium oxalate stones. The formation of calcium phosphate stones is associated with conditions such as hyperparathyroidism and renal tubular acidosis.

Source: Junaid Mohamed

Image Quiz

Slide 2 

Slide 1 (click over image to enlarge)

Slide 3

These are 3 pictures: what do the slides show?

The answer for the Image Quiz of February 12, 2012 is "Reflux nephropathy with chronic pyelonephritis and secondary FGS." 

Slide 1 is an image using low power light microscopy using a PAS stain. It demonstrates chronic cortical atrophy with "thyroidization" in the upper part, right two thirds of  the slide. Notice the fibrosed and distorted papilla and chronic inflammation of the pelvic  mucosa. The empty space in the lower left corner represents the lumen of the dilated pelvis.

Slide 2 shows on medium power using PAS stain, 4 globally sclerosed or obsolescent glomeruli (right lower corner) and two glomeruli with segmental sclerosis, upper half, left and center. The glomerular lesion is indistinguishable from other forms of FGS, in particular, the idiopathic variant, especially if the biopsy is not examined by electron microscopy or the clinical or pathological context is ignored.

Slide 3 is a low power electron micrograph.  Although the visceral epitelium reveals extensive effacement of foot processes, many loops (arrow) and better-preserved glomeruli show preservation of the interdigitations.

I would recommend reading a great article by Michael Dillon published in JASN that summarizes key facts about reflux nephropathy.

The imaging of reflux nephropathy is also important and there is a nice open access article at the following link.

Slide 1 (click over image to enlarge)

Slide 2 (click over image to enlarge)

iSEDIMENT

What are the crystals in the slide?

Source: Junaid Mohamed

The answer to the iSEDIMENT quiz Feb 10, 2012 is cloth fiber. Cloth fibers are undoubtedly the most frequently occurring type of artifact.

What is the above structure in the urine sediment?