Nephrology W1D1&2

We began the day by rounding with Dr. Chen on the dialysis patients, who were all packed in one room. He explained the basics of dialysis. Dialysis is indicated in end stage renal disease and takes considerable physician and patient consultation until it is started. There are three methods:

1. AV fistula (http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/images/fistula.jpg)

• A surgeon connects an artery to a vein in the forearm. Increased blood flow from the artery into the vein makes the vein stronger. The vein is made stronger so that it can withstand many needle insertions that is needed for hemodialysis. One cool thing is that if put your fingers on the fistula you can feel the 'thrill' of the faster blood flow. You can also listen for bruits. 
• this is the most ideal form of dialysis because it is the least likely method to cause clots.
• it takes a while for the fistula to "mature", sometimes up to 24 months, before use.
• a fistula is basically an abnormal connection between two things that are not supposed to be connected. In this case it is an artificial fistula created solely for the purpose of dialysis.
• if stenosis or occlusion occurs in the fistula, balloon dilatation or thrombectomy can be used to get rid of it.

2. AV graft (http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/images/graft.jpg)

• this is an artificial tube created to connect artery to vein. used if the small veins do not form into a proper fistula. 
• tends to have more clotting and infection compared to the AV fistula. 

3. Venous catheter for temporary access  (http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/images/catheter.gif)

• If there is a need for immediate dialysis, venous catheter for temporary access is indicated.
• it is an insertion of a two way catheter into the neck, chest, or groin.
• much more prone to infection and clotting than the other two methods, only meant for temporary use. We saw one patient with a temp catheter and it was only indicated because his fistula was still maturing. 

The dialysis machine is basically an artificial kidney with two compartments separated by a semi-permeable membrane to filter out toxins. The blood from the artery flows to the artificial kidney, gets filtered, and flows through another tube back to the vein, "cleaning" the blood. In Chinese, dialysis means literally"washing the kidney".

Several interesting points about dialysis:

• Dialysis is performed 3x per week, MWF. Depending on how much weight is gained between each dialysis treatment, the time spent washing your blood is longer or shorter. We watched a patient argue with Dr. Chen about how much weight she actually gained over the weekend. It is an uncomfortable process to undergo dialysis, and most patients want to spend as little time there as possible. It was also Monday, which means there is an extra day that the patient accumulated toxins. Monday dialysis usually takes longer.
• Venous Pressure is measured to monitor for clot formation. IV heparin is constantly administered to lower the risk of clots during dialysis.
• Temperature of the dialysis fluid can be adjusted. To increase blood filtration, dialysis fluid temperature is lowered => vasoconstriction => increased blood filtration. 

Sonography: 
After hemodialysis, Dr. Chen whisked us to sonography where he systematically looked at 20+ patients' kidneys. Here are things he measured:
1. size of the kidney
2. echogenicity of kidney (how 'bright' it is). It should be less bright than the liver. If it is brighter, that indicated calcium deposits as well as other obstructions.
3. cysts. He was mostly monitoring the cysts and noting parenchymal loss of kidney.

The Wards: 
In the wards we saw mostly UTI, acute and chronic pyelonephritis, and end stage renal dz cases. The majority of the patients we saw were older, and often had a family member or helper speak for them. We also saw two cases where the patient was allergic to the medication given to them, prolonging their hospital stay. Causes of UTI were more complicated than the classic cases we learned in class (young sexually active female, treated with-TMP SMZ). Here are a sample of the cases we saw:

1. DM on ESRD old female patient having symptoms of uremia:

• hyperkalemia -> bradycardia
• GI symptoms, vomiting, nausea
• anemia (lowered EPO production): Failure of kidney to produce renal erythropoietic factor (REF) to activate EPO. 
• fatigue
• epistaxis, bruising, and prolonged bleeding - abnormalities of primary hemostasis such as platelet dysfxn and impaired platelet-vessel wall interaction. Uremic platelets synthesize less thromboxane A2 and blood vessels in pts with uremia produce greater quantities of platelet-inhibitory prostaglandin. This was most evident in her legs and arms, which were severely bruised from needle insertions or probably accidentally bumping into things. 

2. 71 y/o male with BPH unable to void. Treatment for BPH is to insert a foley catheter to drain fluid.

The second day consists of rounding on wards, an ICU patient, and outpatient care. Again I was amazed at the sheer volume of patients that Dr. Chen saw. Not only did he continue patient care on the wards from yesterday, he saw around 25+  outpatients in the afternoon. Each patient had very unique problems, yet he effectively changed dosage, provided advice, and arranged for follow up in an effective manner.

I will speak generally about outpatient care because there were just to many to go into detail about. Most of the patients he saw were old and were accompanied by a younger family member. These patients were generally very worried about their health - they were aware of diet restrictions, what medications they were on, and afraid to begin dialysis. Dr. Chen attempted to convince one patient to start thinking about dialysis, but the patient was reluctant and hesitant. Dialysis is a life-changing decision. It is 3x a week and sometimes takes up to 12 hours per day. These patients also invariably had co-morbidities - DM II,  CAD, HTN, and gout were all common notations I saw in their charts. Dr. Chen also ALWAYS checked for lower leg edema - in outpatient care, the wards, and hemodialysis patients.

The culture of this hospital, and of Taiwan healthcare in general, is incredibly fast paced. Patients can see specialists in big hospitals at will, leading to a huge glut of patients that a specialist has to see. There is extremely little time for the patient and physician to interact, yet there are small ways that Dr. Chen expresses care - greeting each patient, speaking in taiwanese hokkien (70% of Taiwan speaks this). There is always time to be empathetic, sympathetic, and friendly.

History Lesson:
A large number of Fujian folks who spoke Hokkien from mainland China emigrated to Taiwan in the 1600s. As mainlanders from different provinces trickled in throughout the 1600s, the original Hokkien language began to deviate from its Fujian origins. The first sino-japanese war at the end of the 19th century led to Japanese colonization, further influencing the Hokkien language. The last big change of the language was when the KMT lost to the communists in 1949 and fled to Taiwan, leading to a huge influx of Mandarin speakers. The establishment of KMT in Taiwan led to the declaration of Mandarin as its official language. Among doctors and nurses, mandarin is usually spoken. Among patients, it is usually Hokkien, or "tai yu".