00:01
Okay, so we would just
talked about interventions
that can help to slow
the progression of
chronic kidney disease.
00:07
But how do we care
for these patients
when they're sitting
in front of us?
One of the things that I want
you to really keep in mind
particularly if you were
going to into Primary Care
is how you can refer these
patients to a nephrologist
in an appropriate amount of time
so that we can help to slow the
progression of their disease.
00:23
So we really want patients
referred early in their course.
00:26
Typically when that GFR is less
than 45 to 60 mils per minute.
00:30
Or if they have albuminuria
severely increased albuminuria,
like greater than 300
milligrams per day
and that we find
that early referrals
may be associated with
not only helping the patient
but lower healthcare costs
and a decrease in morbidity and
mortality to that patient population.
00:46
So I do want you to think
about referring that
patient to a nephrologist
who has experience in treating
chronic kidney disease
to help that patient population.
00:54
Remember cardiovascular
risk factor modification
if you don't take anything
else away from this lecture,
I do want you to remember that
patients who have
chronic kidney disease
are at an increased risk of
having cardiovascular events.
01:06
And this is what
they succumb to.
01:08
So it's critical to be a
good cardiologist in a sense
and think about modifying
those risk factors.
01:13
So those patients really
should be on HMG-CoA reductase
Inhibitors like statins
for their hyperlipidemia,
and we need to really think
about lifestyle modifications.
01:21
They should be
exercising if able
150 minutes per week,
weight loss,
tobacco cessation is critical.
01:28
And again,
I think using a holistic approach
where you have resources that
you're calling on from the community
to help your patient is going
to be critical in their success.
01:37
And finally preparing our patients
for renal replacement therapy.
01:40
So for those patients
who are stage for chronic
kidney disease and we know
they're going to progress.
01:46
It's important to educate them
and discuss options of
renal replacement therapy,
which is typically initiated
when that GFR drops
to somewhere between 6
and 15 mils per minute.
01:58
Now interestingly,
renal replacement therapy should
be initiated regardless of GFR
if they develop
symptoms of uremia,
and those include patients
who are constantly nauseated
who have emesis repeatedly
vomiting and retching
there anorexic,
they're just not
hungry for food.
02:13
They complained of dysgeusia,
meaning that they have an
altered taste sensation food
either tastes like
metal or cardboard.
02:19
They might have
itching pruritus,
altered sleep habits
where they have impaired
ability to sleep or they're
hyper somnolent during the day
and people who have
mental status changes
who can't think clearly
and of course anybody
who has a pericardial effusion
or hemorrhagic pericarditis
from uremia automatic
indication to start
to start renal
replacement therapy
again regardless
of what the GFR is.
02:42
So when it comes to renal
replacement therapy,
there's a couple
of different ways
that we can provide
this to our patients.
02:48
We have In-center hemodialysis.
02:50
And this is I think what most
people traditionally think
about when it comes to
renal replacement therapy.
02:56
These are people who go
to a dialysis center.
02:58
Maybe three times a week.
02:59
They dialyze for 4 hours a day.
03:02
But there's also
home hemodialysis.
03:04
This is fantastic for
people who are working
or people who want
to remain at home
and do this within the comfort
of their home, their own home.
03:12
We'll talk a little bit more about
this in our renal replacement lecture.
03:16
There's peritoneal dialysis
again a home therapy
that actually uses your
peritoneum as a dialyzer.
03:21
It's very cool concept.
03:22
Again, people can do this at
home while they're sleeping
and finally there's
kidney transplant.
03:28
That's that golden opportunity
and that's what I strive
for as a nephrologist.
03:32
When that patient is
sitting in front of me
because I know that gives
them the best quality of life
and certainly the best survival.
03:40
So again, when you're talking
about renal replacement therapy,
what's really important
is that patients
need to be educated.
03:47
They need to be
educated and informed
because when they do
they become more engaged
they're more proactive
and they can participate
in shared decision making
with their providers,
which is so important
when choosing the right
dialysis modality for them.
04:01
So please be cognizant
of really kind of putting
that education in their early.
04:05
So those patients have time
to think about the options
they know exactly
what they want to do
when that time comes.
04:11
It is also important to
notice pre-emptive transplant
is going to offer the
best survival advantage,
but it's not always possible.
04:17
So again when that patient
sitting in front of me,
I'm always thinking about how
can I transplant that patient
but if they're medically
unsuitable or psychosocially
they just don't have a
supportive environment
or perhaps they
have advanced age.
04:29
I might not be able
to give them that.
04:32
And finally in our patients
it's who are choosing
hemodialysis.
04:36
It's important to put in
permanent vascular access.
04:39
So essentially that
is that connection
between an artery and
vein called a fistula
so that can be ready
for that patient
to do hemodialysis
if that's what they're choosing
and it takes about 8 to 12 weeks
for that fistula to mature.
04:52
We'll talk a little bit
more about that again
in the renal replacement
therapy lecture.
04:56
So what I'd like to really
kind of before we conclude
what I'd like you
to keep in mind
is that although there is a high
burden of chronic kidney disease
and many of the diseases that we
talked about today are progressive.
05:09
With vigilance,
and with care,
along with some of the newer
therapies that are coming along.
05:15
I think we can
really make an impact
in the life of
these CKD patients
and with that we've
concluded our CKD lecture.