MANASA DISSERTATION
2020-2022
TITLE:
Factors influencing clinical decision making around therapeutic interventions for critically ill renal failure patients in a rural medical college
NEED FOR STUDY :
Renal failure is increasingly recognized as a global public health problem.
The clinical decision to continue conservative medical management vs dialysis in a patient with acute on chronic renal failure (particularly in low resource settings), is dependent on factors that have not be characterized well in the global literature although there are absolute and relative indications for dialysis, there are many clinical grey areas around them.
Aim:
To study various events related to and influencing treatment decisions around patients with critically ill renal failure
Objectives :
1) Document the events and symptoms leading to the patient presenting with renal failure
2) Study the associations between the events and certain symptoms influencing the therapeutic decision taken
3) Document the patient outcomes resulting from the therapeutic decisions
Methodology:
It is a prospective, observational study with 50 random cases of renal failure satisfying my inclusion and exclusion criteria .
After taking informed consent a thorough evaluation was done by a detailed history, physical examination, urinary analysis, CBC, RFT, Renal USG with abnormal kidney size and abnormal cortico medullary differentiation and other investigations ABG, ECG, ,2D echo and chest xray for patients admitted in icu.
Few other investigations like blood and urine cultures whomever required .cases are divided into AKI (RENAL CAUSE) based on AKIN criteria and AKI ON CKD based on egfr.
The patients were started on medical therapy . If not responded and severity of illness is increasing , here the therapeutic decision is to do renal replacement therapy or not and outcomes are studied in dialysis patients during my study period.
STUDY DESIGN : Prospective observational study
Inclusion criteria
a) All patients of renal failure defined by biochemical azotemia and radiological indicators ( To rule out post renal causes )
b) AKI was defined as increase in serum creatinine of 0.3 mg/dl or more within 48 hours with a baseline serum creatinine < 1.53mg/dl or a percentage increase in the serum creatinine concentration of ≥50% within 7 days.
Exclusion criteria:
Renal failure patients with clear diagnosis at presentation such as pre renal or obstructive uropathy of all cases
PLACE OF STUDY: General Medicine department kamineni Institute of Medical Sciences Narketpalli Nalgonda
STUDY PERIOD: October 2020 to october 2022:
SAMPLING SIZE: 50
PROFORMA:
Serial No:
Name:
Age:
Sex:
Occupation:
Address:
IP / OP No:
D.O.A:
D.O.D/D.O.E:
Heart rate on admission:
blood pressure on admission:
Smoking:
Alcohol:
DM:
HTN
Other substance abuse
CKD stage
Blood Urea in mg/dl:
Sr. Creatinine in mg/dl:
Sr. Sodium in mEq/L:
Sr. Potassium in MEq/L
Hemoglobin in g/dl:
Ejection Fraction
Indication of dialysis
Number of sessions/week
Complications:
Outcome:
INVESTIGATIONS:
Hemogram
ECG
CUE
RBS
LFT
RFT
USG
2D Echo
Viral markers
Chest X ray PA view
RESULTS , DISCUSSION, CONCLUSION AND BIBLIOGRAPHY in link below
https://1drv.ms/p/s!Av7DWVJIXT3agSFjnLv8fTDFkI8G
Learning points :
I choose the topic of nephrology as prevalence of kidney disease is increasing rapidly irrespective of age and sex ( which I knew by one of my relative who was expired at age of 35 due to renal failure with strong family history ). Earlier i thought that renal failure patients will have only issues related to excretion of nitrogenous waste and in some with hypertension . Later i learned that multiple dimensions of issues in them like nutrition, physical and physiological aspects which are all important to improve their quality of life .
In learned that iv bicarbonate perse will not improve the patient from renal failure nor its protective in increasing the life expectancy of acute renal failure though it's has little benefit in chronic kidney disease. I learned placing the central lines which earlier i don't know, learned about the dialysis process and setting .
During my study period i came across the complications of central line ( CLABSI) with the help of our hod Dr . Rakesh Biswas sir i learned it's because of dialyser disinfectant and long term catherisation. I learned renal failure patients are more prone to multiple infections which I have seen are infective Endocarditis secondary to fern cath, cervical vertebral abscess, lung abscess .
Heart failure is also present in most of the cases ,i observed that heart failure with reduced EF as low life expectancy . Anaemia is other issue which needs multiple blood transfusions which is burden for both family and patient .
Therapeutic intervention ( Dialysis ) should be initiated only if there is definitive indication and in some dialysis can be withdrawn if they improve after few sessions which we have done in one my patient of AKI on CKD and 9 patients of AKI .
Not every patient with metabolic acidosis require dialysis , as in my present study group 2 patients were not initiated on dialysis though they have metabolic acidosis as they responded well to medical management and there is no worsening of acidosis .
Pulmonary odema secondary to acute LV failure secondary to HTN need emergency dialysis and Pulmonary odema secondary to fluid overload ( Hypoalbuminemia ) intiatially managed with preload and after load reducing agents , but they also required dialysis at later stage.
There is no difference in survival based on early or late initiation of dialysis.
Finally I would like to say that survey in community has to be done for early recognition of renal failure as most of the patients are unaware of it and presented to us in end stage
PATIENT INFORMATION SHEET
English:
https://drive.google.com/file/d/12LLDgFBVfnTxDdNv5K715uSyLYPUEgrY/view?usp=drivesdk
Telugu:
https://drive.google.com/file/d/13Df9wCu9zhjECpPxcHEULSAphv6-tDHl/view?usp=drivesdk
Template of this "patient information sheet" is borrowed from this website:
https://www.ncbi.nlm.nih.gov/books/NBK261334/
And modified accordingly to my thesis topic.
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