Anny Xiao Week 2 Nephrology Rotation Day 4 & 5

Yesterday, I was with the peritoneal dialysis nurse as she trained a caregiver on how to manage a new continuous ambulatory peritoneal dialysis (CAPD) patient. The patient is an elderly female who is scheduled to begin CAPD on June 30th and today was the caregiver's 2nd training session (out of 6 total). The PD nurse explained that training sessions not only involve the initial education but also require several review sessions to make sure that the caregiver or patient fully understands and is comfortable with the requirements of PD. For younger patients who are more independent, they themselves are trained in how to manage their own PD but for older patients, a caregiver is usually the one managing their PD.
I was amazed at how meticulous the PD nurse was when teaching the caregiver how to maintain sterility of all the PD equipment and PD fluid changing environment. Diligent care of the catheter insertion site and sterilizing of the PD equipment is extremely important in maintaining function of the catheter and preventing peritonitis. For elderly patients, caregivers must be extra careful because they could inadvertently cause a life-threatening infection while changing the dialysate (a dextrose solution). The dialysate must be changed in an enclosed room, with windows & doors closed and fans & AC turned off. The caregiver must wash their hands thoroughly and disinfect all surfaces the equipment touches and repeatedly disinfect their hands throughout the process. A cap is used to close the PD catheter attached to the patient's abdomen, and a new sterile cap must be used each time the cap is taken off the catheter. Once the cap is taken off the catheter, it must be quickly connected to the tubing for the new bag of dialysate and must not touch anything. If any part of this process is accidentally contaminated, the new fluid and tubing must be thrown out and replaced. The PD nurse told me they had a patient whose caregiver accidentally touched the dialysate tube opening and felt that it was a shame to waste a brand new bag so they used it anyways and the patient got peritonitis requiring hospitalization.
Caregivers and patients are trained to recognize signs of infection, including used dialysis fluid that appears cloudy, fever, abdominal pain, nausea or vomiting. They are instructed to bring in the used bag of dialysate to the ER so the hospital can culture the fluid for appropriate management. Despite the higher risk of infection, many patients prefer PD because it gives them more freedom and a better quality of life, and despite seeming complicated at first, many patients quickly get the hang of it and are able to avoid infection. The PD nurse said they had a 77yo patient who manages her own PD and another patient that had PD for 16 years without a single infection.

Educational posters in the PD training room: how to recognize catheter site infection, continuous ambulatory PD and automated PD

The model caregivers use to practice exchanging dialysis fluid during CAPD training

 

This morning in the outpatient department, we saw a case of minimal change disease in a 20yo male patient and I realized that these past two weeks have been really valuable in helping me see the connection between diseases described in textbooks & how they appear in real life. MCD classically presents at an earlier age and Dr. Chen explained that adults who present with nephrotic syndrome usually have FSGS (younger adults) or membranous nephropathy (older adults), but this was a case of adult-onset MCD. The patient had an acute presentation of nephrotic syndrome about 8 months ago but his response to prednisolone was not as quick as expected. Normally, MCD patients show improvement in response to steroid therapy in about 2 months, but this patient had been on treatment for 8 months, and while his proteinuria improved from >1000 to <600 mg/g Cr, he was still taking 30 mg of prednisolone qd and Dr. Chen said he would wait until further improvement of his proteinuria before tapering down his steroid dose. A few other things I noticed from clinic this afternoon is that Dr. Chen prescribed patients new diabetes medications and changed their hypertension medications, which surprised me since I have seen specialists in the US refuse to prescribe medications that are outside the realm of their specialty, so I was glad to see this example of a more patient-centered approach to healthcare. It also seems like the specialists here are focused on remaining well-educated and informed about general internal medicine in addition to their specialties.

This afternoon as we rounded on patients in the ward, I was reminded of the fact that patients often don't present with all the classical symptoms. Several elderly patients with UTI or acute pyelonephritis did not present with fever or elevated WBCs. Instead, their symptoms were more vague, including general weakness, poor appetite and dizziness. In contrast, a younger patient admitted for UTI had high fever spikes and a WBC level of 12,000 but on appearance she looked and felt better much sooner than the older patients who had seemingly less severe presentations.
Dr. Chen commented that the older patient without signs of toxicity may actually be more concerning than the patient with high fever and elevated WBCs, which indicates a better immune response. The atypical presentation of elderly patients often includes other complications or abnormalities that are not initially obvious. For example, one patient with dementia and past history of CVA was admitted for a UTI but the physicians later discovered she had cellulitis on her right lower leg. In addition to the erythema, some bruising was also present. Although the patient was bedridden, the doctor decided to order an X-Ray of the lower leg, which revealed a fracture in the distal part of the tibia. Because of the patient's mental status, she can only make incoherent sounds so she could not complain of any pain or tell us what her symptoms were. While you wouldn't normally expect a bedridden patient to have a fracture, Dr. Chen said that bruising is not a common sign of cellulitis but can indicate a bone-related problem, so all clinical signs must be considered carefully to discover the complete diagnosis. Because this is an elderly patient, her immune response to the UTI & cellulitis was diminished, and she must be managed carefully to prevent potential progression of cellulitis to fasciitis to osteomyelitis, since the location of the fracture is near the cellulitis infection.

Dr. Chen likes to end each day with a few "how-to-be-a-good-doctor" pearls. Today, after communicating with a few patients about when they can be discharged, he told me that it's important to speak with the inpatients and/or their families every day so you can identify any knowledge gaps between you and the patient. It's the doctor's responsibility to make sure that the discharge plan is developed before the day of discharge, ideally once the patient is stable, and communicated to the patient's family so arrangements and preparations can be made. The more you help a patient throughout their hospital admission, the more likely it is for them to be discharged sooner and for you to reduce readmission rates. If the inpatient's family members are not present when Dr. Chen does his rounds, he always asks the caregivers when they will be back so that he can return to communicate with them, since constant communication between doctor and patient is highly important for quality of patient care.