Today began with an Internal Medicine Morning
Meeting, which is a 1 hour presentation and discussion of a research
study that occurs every morning at 8am and is attended by physicians
& residents of various specialties. Today a cardiologist gave a
presentation about the RALES study which looked at the effect of
spironolactone in improving morbidity & mortality (M&M) in
patients with diastolic heart failure ( with preserved ejection
fraction >55%). A previous study found that spironolactone decreased
M&M in patients with severe heart failure (EF<35%), but
interestingly, this study found that there were no differences between
the study arm that received spironolactone and the one that received a
placebo.
Attending this morning meeting
reminded me of attending grand rounds or lunchtime conferences at a
hospital in the US and I thought it demonstrated the physicians' effort
and dedication to practice evidence-based medicine and further their
medical education.
This morning I went with Director Chen as we saw
patients in the hemodialysis center. He explained that Taiwan has the
highest incidence & prevalence of end-stage renal disease in the
world, with the runner-ups being Japan and the US. The incidence of new
cases is high but the prevalence is also high due to the quality of ESRD
management allowing long periods of survival after ESRD diagnosis and
initiation of hemodialysis.
As we rounded on the
HD patients, he explained that each patient has a dry weight in their
HD chart and is weighed before and after each dialysis session. The
nephrologists adivse patients to keep weight gain <1 kg/day during
the week, and if they have to go 3 days between HD sessions to limit
weight gain to <2.5kg. If a patient has gained too much weight
between dialysis sessions from consuming too much fluid, a faster
ultrafiltration (UF) rate and higher UF goal is needed to return the
patient to their dry weight. However, with a faster UF rate, the patient
has a higher risk of experiencing a drop in blood pressure, dizziness,
muscle cramps, and abdominal pain during dialysis as well as other
cardiovascular risks. The first patient we saw had actually just
experienced a sudden BP drop due to a moderately high UF rate that was
the result of increased weight gain from his poor control of fluid
intake over the weekend. Because of this, patients who are on HTN
medications are often told to hold their medication before dialysis
since a BP drop may be prevented by initially starting dialysis with a
higher baseline BP.
An interesting thing I
saw in the HD center was the use of infrared lights placed over the arms
of patients with recently created arteriovenous fistulas, which has
been shown to improve the maturation and patency of new AVFs and
decrease thrombus formation. Dr. Chen said that they also instruct the
patients to apply heat packs to their arms at home and do arm exercises
to strengthen the AVFs since it is used so frequently in ESRD patients
and must be maintained. Despite how busy the HD center was (there were
40+ beds and not a single one was empty), the paper charts for each
patient were organized and there was a portable computer station for
recording the data from each HD session.
Diabetes
is the most common cause of ESRD in Taiwan, and we saw many patients
with DM in the HD center, in the renal ultrasonography lab, and on the
inpatient nephrology service today. While Dr. Chen saw the patients for
renal echo, I learned that a common reason patients are referred for
renal echo is flank pain. Many patients had multiple acquired cysts, which appear as dark circles with decreased echogenicity on
the echo. Dr. Chen said that polycystic kidney disease usually presents
as an enlarged kidney with multiple cysts, and if an elderly patient
presents with cysts in a smaller kidney, it's more likely acquired cysts
and not PKD. Additionally, the nephrologist often has to distinguish between renal stones and calcifications within the kidney
and Dr. Chen explained that renal stones are impenetrable by the
ultrasound waves so they create an acoustic shadow on the echo, whereas
calcifications do not. Lastly, separation of central echogenicity
indicates hydronephrosis, which is most often due to obstruction or
reflux in younger patients, and must be referred to urology for
determination of the etiology of hydronephrosis.
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