Diabetes Care

For patients suffering from type II /adult onset diabetes :

In type II diabetes, diagnosis is often late (after the disease has already been present for some time). In early days T2DM (short for the adult type of diabetes) are often without symptoms. Hence the delay in diagnosis. This means complications will be seen early after diagnosis.

Foot Care :

Foot disease in diabetes may lead to difficulty in walking, pain and may lead to infections. If neglected amputation may be required.

Inspect feet with a mirror before going to sleep every night.

Use well fitting shoewear.

Do not walk bare feet even in the house.

Socks should be clean and correct size.

In case of deformities of feet, special shoes can be worn.

Eye Care :

It is nowadays the commonest cause of blindness throughout the world.

Check for refractory error at the time of diagnosis and once sugars are controlled.  In T2DM every year examination for changes in retina are required. If there are already changes, check up is required more often.

Retina is checked after dilating pupil with an ophthalmoscope.

Kidneys :

It is one of the common causes of kidney failure leading to requirement of dialysis and renal transplant. Early treatment may reverse diabetic kidney disease or slow its progression.

In early cases urine is checked for passage of extra amounts of albumin. This can be quantified to see response to therapy. This test is called urine for microalbuminuria, and urine albumin /creatinine ratio. If the disease is already present, USG, S Cr and testing for voiding function (Uroflowmetry) etc may be useful.

In those without evidence of kidney disease these tests are carried out every year. Frequency otherwise may depend on the stage of involvement. More severe involvement necessitates more frequent reviews.

Nerves :

Nerve involvement is checked by touch, pain, vibration sense.

During winters, hot water should be checked with either a thermometer or elbows. If fingers are used for checking temperature, very hot water may lead to burns.

Precautions should be taken to avoid falls.

Sugar Levels :

HbA1C level may be done every 3 months to monitor overall sugar control in blood. In most cases a level of < 7 is desirable.

If hypoglycaemia is frequent , a level of < 8 may be  all that can be achieved safely. In cases of some microvascular complications, a level < 6.5 may help but is difficult to achieve. Home sugar monitoring is done from capillary blood. The levels are different from venous blood levels tested in laboratories. Only sides of fingers should be used and not the areas used for holding functions of the hand. In T2DM once weekly sugars may be enough. In T1DM almost daily or before each meal sugars are required. Levels for control should not be done within 2 hours of meals. Check if there is uncertainty about diagnosis of hypoglycaemia. Do not wait for giving sugars, if testing takes time or symptoms are severe (loss of consciousness, confused talk, fits etc.) Treatment presumptively may prevent permanent damage to the brain. However sugar is not the treatment in diabetics for every small symptom. Record times of sugar checking and dates in a notebook for planning of drugs. Lipids and Statins : If there are more cardiovascular risk factors, age > 50 yrs in man, smoking, lower levels of LDL cholesterol are desirable. Daily 75 or 150 mg  of aspirin or statins may decrease risk of heart attacks. Bleeding complications however increase with aspirin.

Regular exercise, monitoring weight, smoking cessation all are essential parts of diabetic care.

MYTHS AND FACTS ABOUT KIDNEY DISEASE

Myth : All kidney diseases are serious and incurable

Fact : Most kidney diseases are treatable. Some are self-limiting and occur only once in a lifetime. Some progress towards renal failure but this progression can be slowed down if the disease is detected early. Even in late cases, treatment may help in reversing or slowing down the loss of kidney function.

Myth : only one kidney is affected by kidney diseases.

Fact : All medical diseases (high BP, diabetes, glomerulonephritis, nephrotic syndrome, poisonings, infections of urinary tract etc) affect both kidneys.

Some structural diseases like tumours, stones, abscesses, renal artery or vein clots, ureteral narrowings, may affect only one kidney.

Myth : I am passing enough urine. Hence my kidneys are not obstructed.

Facts : Most obstructions of the bladder and partial obstructions of the ureter  (stones or accidental ligation during surgery) cause more urine to be formed and passed. Only bilateral total obstruction or obstruction below bladder neck cause reduced urine output.

Myth : I am passing enough urine. Hence my kidneys are healthy and I do not require treatment or dialysis.

Fact : Some kidney disease cause decreased urine output or oliguria (< 400 ml urine/day). Most, however, are nonoliguric or Polyuric (urine output > 3000 ml/day). Even with normal or large urine production, waste material like acids, potassium, urea, creatinine and many more may not be excreted. A person then may require treatment at times dialysis as well.

Myth : Drinking more water will keep my kidneys healthy. This is the treatment for kidney diseases.

Fact : Usual water intake is well managed by thirst in healthy people. Drinking 2-3 litres of fluid may avoid some stone formations and urinary tract infections. Continuing to drink fluids when kidneys are failing or have failed may cause fluid in the lungs (pulmonary edema) or poor control of hypertension. The consequences may be deadly. Follow your doctors’ advice.

Myth : Dialysis once started is required life long.

Fact : In temporary or reversible renal failure, dialysis is required till kidney recovers. In CKD or ESRD with no reversibility, dialysis is required for emergency treatment of high potassium or fluid in the lungs. Maintainance dialysis for uremic symptoms, neuropathy, encephalopathy, pericarditis etc usually means either lifelong dialysis or renal transplant.

Hypertension in Dialysis Patients

Hypertension in Dialysis Patients I

About ½ of dialysis patients have high BP while on regular dialysis. A pre-dialysis BP > 140/90 mm Hg is required for the diagnosis of hypertension in this group.

Mortality, cardiovascular events including heart attacks, congestive heart failure, strokes are more common in hypertensive dialysis patients.

Systolic BP < 110 mm Hg Or >160 mm Hg is also associated with poor outcome in dialysis patients. Hence the BP has to be optimised and kept somewhere between these two limits.

Causes of high BP in dialysis population:

Expansion of body water and blood volume

Reduced blood supply to kidneys

Salt accumulation

High Calcium level

Thickened arteries

Preexisting essential hypertension

Increased sympathetic nervous activity

Poor water compliance

Poor drug compliance.

BP is measured before and after dialysis. For better overall BP, 24-hour ambulatory recordings are made.

Coming up Treatment of hypertension in the dialysis population.

Life After Kidney Transplant

Life After Kidney Transplant

Kidney transplant is preferable to lifelong dialysis as it usually provides a better quality of life. After initial 14 days, the risk of death is less in transplant recipients compared to patients on dialysis.

The human body tries to throw out the transplanted kidney as it is perceived as a foreign body by the tissues.

To overcome this tendency of the body, drugs are required to be taken lifelong by transplant recipients. These drugs are called immunosuppressives.

These drugs also reduce body’s reaction in case an infectious agent gains access to the body. Hence infections can occur more often, with smaller doses of bacteria and viruses. These infections may be severe and life threatening. At times bacteria and viruses which do not cause infections in other healthy individuals may also cause infections in transplant recipients.

These infections have to be suspected more often, investigated more aggressively and treated vigorously with appropriate antibiotics by a physician. In India, most  deaths take place with a functioning graft due to infections. Hence the importance of preventing these.

How to prevent infections in transplant recipients:

Infections spread by food, water, contact and by inhalation of droplets containing pathogens( bacteria, virus, fungi etc). They can also be introduced during surgery, by IV lines, tubes placed in the body and during various medical procedures.

Infections from water are prevented by drinking filtered / RO and clean water only. Tubewells, river, ponds, most municipal water in cities and towns may be having infectious agents. Hence it is not safe to drink untreated water. In case of dire necessity, boiled water as in tea can be consumed.

Food should be fresh, made from clean ingredients in clean utensils and consumed early. Food kept in refrigerator (especially as power cuts are common place) can be contaminated and when consumed may cause infectious diarrhoea.

Close contact of persons with obvious respiratory infections eg common cold, influenza, pneumonia, chickenpox, measles, sore throat etc should be avoided. Good quality masks (as used for preventing the spread of swine flu) are used for prevention of respiratory infections. Vaccines against pneumonia are similarly useful to protect against pneumonia.

Hygiene should be immaculate. In hospitals etc ensure absolute asepsis to prevent any infections during sampling, IV infusions, injections or surgical procedures.

If adequate care is taken a person can lead an active life. He can live a normal long, productive and useful life.

Next coming up

Various drugs after a transplant.

 Renal Transplant : Survival after kidney transplant.

Renal Transplant : Survival after kidney transplant.

Renal transplant is the treatment of choice for patients of End Stage Renal Disease. Compared to Hemodialysis and peritoneal dialysis, the patients live longer and overall have a better quality of life. After the 1st 2 weeks of transplant, the death rate in transplant patients is lower than patients on dialysis.

In the USA, survival recipients of living donor kidneys at 5 yrs is now 91 % while in the case of cadaver kidneys, it is 84 %. If not so well functioning kidneys (called extended donor kidneys ) are transplanted survival at 5 yrs is 70%. This does not mean that all kidneys are working, but the patients are living.

Survival is better in children and less in those over 40, men compared to women, smokers, those suffering from diabetes and heart diseases.

The death when it occurs is usually due to heart diseases or due to infections. The no of cancers also increases after transplant and this is another major cause.

Compared to normal population , renal transplant still is a serious risk for mortality. For example in US in the 1st year after transplant death risk in patients is 14 times compared to age and sex matched population.

 

Dialysis Dosage

Dialysis Dosage:

Human body continuously generates waste products which have to be removed regularly.

Dialysis removes these products present at the time of dialysis process. Over the subsequent days, these products will accumulate again and hence need to repeat dialysis again and again.

In Chronic Kidney Disease dialysis is required lifelong.

This process is done for 4-5 hrs on 2-3 occasions every week. While most countries do dialysis thrice weekly, in some only twice weekly dialysis can be done due to constraints of facility, economy or travel.

If dialysis dose is less the following disadvantages may occur:-

The quality of life (ability to live a near normal quality) is poor.

Some of the uremic symptoms may continue to occur. Both appetite is poor and exercise tolerance is limited.

Returning to gainful employment (usually sedentary occupation) is not possible.

Complications are common in cases of underdialysis and are in the form of

  • Weight loss,
  • Poor nutrition,
  • Collection of fluids in chest and abdomen,
  • Decreased heart performance,
  • Decreased ability to fight infections ,
  • Repeated hospital admissions and all resulting in decreased survival

How to measure dialysis dose:

Most newer hemodialysis machines have an option of directly calculating dialysis dose delivered to patient by online KtV monitoring. If this option is not available at your dialysis center patients should have it checked manually at least every 3 months. Estimated dialysis efficacy and delivered dialysis dose may differ. Dialysis efficiency needs to be checked for ensuring that patients get  adequate dialysis.

Dialysers

Dialysers

Dialysers are small plastic cylinders. These have an inlet for blood entry and outlet for blood exit.

It also has an entry opening for dialysate and exit for the fluid.

Its main body has hundreds of small tubes all connected to a common plate at the top and bottom portion of the dialyser. Blood enters at the entry point and flows through these tubes. These tubes are again joined at the exit and then blood goes out through a common tube back to the patient.

These tubes are nowadays made of synthetic material of different types. Some common types are polysulfone, polymethamethyl acrylate, poly acrylonitrile and polyamide. Earlier cellular or semisynthetic membranes were also in use (hemophane, cuprophane, cellulose etc. ) These membranes are now gradually being replaced by synthetic membranes. Synthetic membranes are comparatively inert and produce fewer reactions. These are easy to clean and sterilise.

The large no of tubes (called capillariesin medical parlance) increase the surface area to about .5 to 1.8 sq meters. Thus larger amount of blood can interchange impurities across the membranes.

Dialysate fluid flows outside the capillaries and the exchange of water, ions and waste material occurs through the membrane. Membranes have small micropores to facilitate this exchange.

Dialysis reuse : its benefits and harms.

Dialysers are reused in many centers across the world. This has the advantage of reducing dialysis costs. The protein loss (due to protein stuck on membranes) is less when dialysers are reused.

Some patients react when their blood comes in contact with dialysis membrane. This is called a first use effect. In reuse cases this is not seen.

The dialysers are checked prior to reuse to see that capillaries are intact. A large no of capillaries are functional (measured by total volume of capillaries.), and harmful chemicals used in cleaning dialysers are cleared.

Dialyser reuse is done semi-automatically by machines which also check for its safety before reuse is permitted. Manual washing and checking only by visual estimates is not useful and hence discarded by good centers. After cleaning of blood products dialysers are sterilised and kept separately for each patient in a clean container.

 

Hemo – Dialyser

 

Dialysis Access

Dialysis Access

Blood flows on one side of membrane while dialysate flows on the other side. To ensure effective dialysis a high blood flow is required for taking blood from the body to the dialysis machine. The blood flow required is about 5ml/kg body weight /min. Usually 250 ml to as much as 500-600 ml if tolerated.

The way to achieve this is through creation of dialysis access. This may be temporary or permanent.

A temporary access is made in those patients who will require dialysis for a few days to few weeks as in acute kidney injury ( also called earlier as ARF or acute renal failure), while awaiting creation of a permanent access.

Temporary access is obtained by inserting a tube in neck veins (Int Jugular Vein) usually on right but sometimes on left side. It is uncommon nowadays to use subclavian (behind collar bone ) or upper thigh veins. The advantage of this is that it is ready to use immediately however it often gets infected and may cause clot formation in the vein in which it is placed. It should be used for less than 2 weeks and never handled by patient. Sudden dislodgement may cause bleeding. In case long term dialysis is required and AV fistula( read further on to know about AVF) is not yet ready a permanent dialysis catheter which is useful for a few months is a far better though costly choice.

The method of choice is creation of arterio-venous fistula (AVF). It is usually made in the wrist but if blood vessels are small or thrombosed it is at times made in arm near elbow. This requires surgery usuaally under local aneasthesia. The failure rates are higher if done by inexperienced surgeons (1 in 2 to 1 in 4 AVFs may fail.)

It takes 2 to 3 months to mature and hence should be made much before the need of dialysis arises. It should be checked to see that it is working. If there is stoppage of flow early treatment may make it work again but if delayed another AVF creation is required.

If injured rapid bleeding may occur. So protect these from injuries. Do not allow these to be used for drugs and samples other than in dialysis room by dialysis personnel.

A good AVF is a life line for patients. Get it made early & keep it functional !!

Dialysis

Dialysis

When the kidneys fail to maintain the body in a healthy state, the condition is called chronic renal failure. In advanced stages of chronic renal failiure, symptoms arise. These are called uremic symptoms and may consist of one or more of the following:-

Weakness, decreased appetite, nausea, vomiting, hiccups, breathlessness, swelling of the body, decreased amount of urine etc. Later on a person may develop fits or increasing drowsiness, unconsciousness, extreme weakness, muscle paralysis etc. Initially these symptoms are mild but later on they do not allow a person to live a normal life and still later they will kill a person unless treated.

The process of taking over of failed kidney functions by treatment is called Renal Replacement Therapy (RRT). This mainly comprises of Dialysis and Renal Transplant.

Dialysis is the process through which the accumulated waste products are removed. It also removes extra water salt, potassium, acid, phosphorus and molecules of middle size.  Thus it attempts to return the body to a healthy state.

Dialysis is mainly of two types:- Hemodialysis and Peritoneal dialysis.

Hemodialysis

In this a membrane called dialysis membrane is used as a filter. It is folded many times over to increase its area to about .5 sq meters to 2 sq meters (for children and adults of various sizes). This membrane allows only small molecules to move from one side to the other.

Blood flows on one side of the membrane and dial sate fluid flows on the other. The dialysate fluid is produced in the dialysis machine by diluting commercial concentrates. The composition of the dialysate is similar to Blood without cells, proteins, fats and other larger molecules.

Smaller molecules present in high concentration in blood and dialysate move across because of difference in concentration (called electrochemical gradient) from a higher concentration to lower concentration. Pressure can be applied across the membrane to create pressure to push water and salt across as well.