Nephrology

The level of GFR should be estimated from prediction equations that take into account the serume creatinine concentration and variables such as age, gender, or weight, or by measurement of creatinine clearance using timed (for example, 24 hours) urine collection. https://www.kidney.org/sites/default/files/docs/ckd_evaluation_classification_stratification.pdf Guideline 4, p 81

Absolutely. It is a tailored therapy and you should re assess frequently (monthly, but depends on type of patient and issues along the way).

I really appreciate everyone's response and I would like to provide more detailed information regarding the case. 

Yimin Lu, 24h urine showed 2.5 - 3.0 levels which is less to call it proteinuria. No gross hematuria, office urine stripe test showed just traces of "hemoglobin". Microalbumin/creatinine ratio at presentation  was 8129 ug/mmol and it drastically dropped on steroids to 46.6.
Mild lymphocytic and plasmacytic interstitial infiltration was observed in biopsy specimen.

Singh Shivakumar, screening for heavy metals was done (serum and bioptat) - negative. Eosinophils - rare ( in urine and bioptate).  IHC for IgG, IgA, C1q,C3 were noticed as negative.IgM was diffusively presented at 1+ expression level. No fibrosis or granular tissue. 

KUS with doppler showed mild delay in upstroke but no raised velocity seen along the course of the main renal arteries ( 77 cm/sec on the right and 62cm/sec on the left).

Irama Maldonado, it may explain the acute situation. The case is observing for 6 months for now. Urine c&s did not show significant growth. Any possible source of toxins has been checked. The creatinine started to rise on waning steroid regimen. Urine microscopy was not done.

 Thanks Marvin ! Its worthwhile to work on this syntax.

Dear Dr Turani,

Thanks for your promptly reply, I talked with Prof. Dr. Cristina Granja (head of our ICU) and we are also interested to CPFA. My e-mail is teresa_jeronimo@hotmail.com, it would be wonderfull to colaborate with your project and plan a multicenter protocol. I'm looking forward to hear from you.

Kind regards,

Teresa

Dear Dr Adekanmbi,

Thank you very much for your email and interest. PaedSurg Africa, our first collaborative study, includes gastroschisis, anorectal malformation, appendicitis, intussusception and inguinal hernia. The first Global PaedSurg study will be focussed on congenital anomalies that require a similar package of NICU care. This is likely to include gastroschisis, ARM, OA/TOF, intestinal atresia and CDH. However, this is yet to be confirmed. 

Although the initial focus will be on general neonatal and paediatric surgical conditions we certainly hope to evolve in the future to cover all children's surgical specialties and it would be fantastic to have your input with that.

In the meantime, you may wish to get involved in the Global Initiative for Children's Surgery which has a urology working group. The Lead for the group is Prof Rouma Bankole on bankoleroumanatou@gmail.com. More information on GICS can be found on their website:

http://www.globalchildrenssurgery.org

Thank you for making contact and I hope we will have the opportunity to work together in the future.

Kindest regards,

Naomi

Thank you for the response, Daniel & Michaela

Good suggestion ,it is our routine practice to the volumetric analysis of the opposite lobe. thankyou

Does this help? See what this says about ibuprofen and fenoprofen

Doppler sonographic measurement of phasic renal artery blood flow velocity in patients with chronic glomerulonephritis
Authors
Yura T,Yuasa S,Sumikura T,Takahashi N,Aono M,Kunimune Y,Fujioka H,
 Miki S,Takamitsu Y,Matsuo H
 First published: 1 April 1993Full publication history
DOI: 10.7863/jum.1993.12.4.215  View/save citation
Cited by (CrossRef): 2 articlesCheck for updatesCitation tools
 
Abstract
The phasic arterial blood flow velocity at the renal hilus was measured by Doppler sonography in 25 healthy subjects and 78 patients with chronic glomerulonephritis. Doppler velocity waveform was analyzed to give peak systolic velocity (S), end-diastolic velocity (D), resistive index (RI), and pulsatility index (PI). Creatinine clearance correlated with S (r = 0.76), D (r = 0.80), RI (r = -0.74), and PI (r = -0.85). Color Doppler sonography facilitated the detection of blood flow and permitted the measurement of absolute blood flow velocity, which previously had been difficult to determine. These results suggest that renal arterial blood flow as detected by Doppler ultrasonography may be useful for noninvasive, direct, rapid, and simple evaluation of renal function, although various modifying factors also need to be considered.

I wonder if any of the clinicians reading this are interested in helping answer this question by participating in this survey that I running.  It will only take a couple of minutes. Please click on the link:

As prognosis in CIN usually is very good, diuresis and creatinine as marker of renal function are sufficient. Further studies, e.g. renal biopsy, is not necessary in clinical routine, but it may be indicated if there is an atypical course. with another treatable cause.

Hi Sal,

PAE for symptomatic patients with BPH has been widely performed with low complication rates, however, there is a potential for severe complications, including technical and clinical treatment failures. Long catheter time after the procedure and repeated catheterization are seen frequently due to failed trials of voiding without catheter. We have experienced such worse outcome during conducting a comparative RCT between PAE and green light laser prostate ablation.

Furthermore, PAE has many limitations, including  lack of significant improvement in IPSS or Qmax in 25% of patients,  unknown long-term durability,  need for high dose ionizing radiation dose and contrast material for procedural guidance, can not be technically achieved on one or both sides as a result of  atherosclerosis, small artery size, and/or tortuosity and  collateral circulation may be present, and maintains vascularity.

To date, no high-quality multi-center RCTs have been published on safety, efficacy, and cost-effectiveness of PAE for BPH.  Most of the studies are of low quality due to their case series design. Therefore, advantages of PAE must be weighed against the risk of technical and clinical failures requiring a second intervention. 

Regarding your question, bladder neck will not be affected by a selective technique done by an expertise.

Regards

Multi-center = Many investigator sites involved in the clinical trial

Prospective =  Planned study

Observational = Not  a randomized trial.  They belong to the design 'Catch as catch you can', much like fishing in a pond.

I think not.

eGFR estimates glomerular filtration rate based on a serum creatinine. In order for this to be meaningful, the Cr needs to be stable. Pre-dialysis creatinines in a maintenance hemodialysis patient may still be rising at the time of measurement. The post-dialysis creatinine doesn't represent a stable creatinine either.

This is one of the issues of patients with AKI: their creatinine may be rising each day; as such, their creatinine may not represent their true GFR; it may rise by 0.5 mg/dL to 2 mg/dL (depending on cause of AKI). I'd been taught that if a patient's creatinine rises by mg/dL per day for several days, the GFR may be less than 10 ml/min, a lower value than the MDRD or CKD-EPI formula may result for a given creatinine.

So these patients have had good appetite, not fasting and have well controlled diabetes with medications.

I agree with all the authors comments. Inferior venacava diameter in echo or usg might help to guide fluid therapy in such conditions. Thanks... 

Thank you for your good wishes.

why

Sreenivasa,

From what I'm reading, it appears to occur in about a third of all ICU admissions. Septic patients are statically more like to develop SIADH. Please see references below.

Regards,

Christopher

Pasha, S. A., Pasha, S. A., Prabodh, V. S., Vidya, S. D., & Suhasini, T. (2016). Frequency of Hyponatremia in Critically ill Patients. Indian Journal of Applied Research, 6(6).

Padhi, R., Panda, B. N., Jagati, S., & Patra, S. C. (2014). Hyponatremia in critically ill patients. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 18(2), 83–87. http://doi.org/10.4103/0972-5229.126077

That is true, also, well pointed. The question for all those things is: could any of them or an association of them produce such a remarkable difference in creatinine excretion?

Iv IG is one if the traetment modaluties for GBS,  after the 1St Dose if there was no response or even the patient showed deterioration another dose of 2gm per kg can be given,  Plasmapharesis is another option but should be done by qualified personelle in qualified centers.  There is a category in GBS Response to treatment called Treatment Related Flactuation in GBS 

Thank you Jasenko

CKD OF COURSE MICHAELA

There was a fear of using antidiabetic drugs especially in the dialysis patients earlier.

In our institution we use oral hypoglycemic agents modified to the renal function and according to the sugar control achieved

We do use dextrose can containing 100 milligram per decilitre but have not found episodes of hypoglycemia in such patients

Actually planning to study them prospectively

Your question is too general and there won't be a easy answer for it. Depending on size, shape, surface charge, surface modification as well as the stability of the surface functional groups. Majority of NPs can not be treated as one type even with the same composition.

Please see page 15 of this document for toxicology of this drug.

http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Public_assessment_report/human/002154/WC500103073.pdf

It could be too much pirfenidone. In this paper, rats were fed a diet containing 0.6% pirfenidone. It doesn't say in the abstract how much pirfenidone they actually ingested.

https://www.ncbi.nlm.nih.gov/pubmed/14564477

When you say "to leave" you probably mean "to remove." I would posit restricting body skin surface areas to allometrically correct usages (https://en.wikipedia.org/wiki/Allometry). For example, for predicting fluid replacement needs as proportional to 3rd degree burn skin area. The success of BSA for chemotherapy is due to the exponent of weight (the 2/3rds power), being closer to metabolic demand (the 3/4ths power of weight) than the first power of weight. (error 3/4-2/3=1/12 versus 1-3/4=1/4). From this, in humans, GFR is often spuriously scaled by formulas of weight and height mimicking BSA, which we have shown is incorrect (doi:10.1097/01.mnm.0000237988.52572.2c). For veterinary medicine, GFR is still scaled using the first power of weight, which is even sillier than BSA scaling, because BSA scaling itself does not scale well enough to predict the metabolic demands of both animals and humans.  This gives some indication of what would have happened if Pinkel did not propose using BSA for dosimetry; we would still be dosing by the full power of weight. Asking people to use correct metabolic scaling for the appropriate metabolites is asking them to change their thinking on the subject. However, since thinking is not involved in copying answers from others, we face an uphill battle from proverbial somnambulists, who, when awakened, are more disoriented than receptive.

I have some experience with MACS but not with PDGFRB. My advice would be to make sure your cells will stain for IF with the same antibody you are using for the sorting. If the antibody doesn't bind well on IF, you won't get adequate binding for associating your cells with the beads. I believe there are Rabbit, Mouse and Streptavidin conjugated heads available so this might broaden your options.

I use the MS columns and find any more than 25 million cells takes a long time to pass (the PI says 50 million but I add another column if sorting more than 25 million - I'm also sorting kidney cells). Keep everything on ice and work fast and smart. Finally the Miltenyi Biotech protocol says to plunge the plunger into the column after it is removed from the magnet and MACS buffer added. I use chilled media instead (whatever I'm planning on culturing them in) which obviates the need to spin them down again prior to culture. Also, I apply gentle pressure only with the plunger and it is clear that the cells come out in the first few drops so no need to be aggressive with flushing them out in my opinion.

Ultimately the quality of the MACS will be determined by the quality of the dissociation and you will need single cells. I use Accutase and a 20um vacuum cell strainer to maximise separation and yield.

Best of luck!

Once procure your rat pancreas transfer to HBSS solution mince it with fine scissors, then discard supernatent add 10ml of HBSS solution with 10mg of Collagenase, do shaking water-bath in 7.5 minutes in 120 to 150 oscillation per minutes. Then arrest the digestion with cold HBSS, centrifuge remove supernatent. Again re-suspend with HBSS transfer to petri dish give small shaking continuously the islet will entrap in the center and to see in dissection microscope. My rat islet picture i attached.

regards

Soosai Manickam Amirtham

Some reports of case series include tamoxifen in the treatment scheme of idiopatic retroperitoneal fibrosis. i included this drug with succes in some patients, drug you can follow in yhe long term, in opposition with CE.

• Pity that the graft is lost. I hope she is on the pathway for a fresh transplant.

Thank you for your answer! Your explanation is very helpful.

Regards,

Charisse 

I have  no expertise in this area. My nephrology skill set is as a direct care nurse and as an educator

Beverley Jones

Interesting perhaps, but as renal ptosis can cause hypertension, there is a differential diagnosis to consider, and it is not straight forward. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628267/ Thus, one should check kidneys position and BP supine, and then repeat that erect, prior to exercise. Especially since ptosis repair is easy, with few complications.

Thanks mate

Thank you for your answers. In my department there was controversy about the management of this case. I agree with you that plasmapheresis is not indicated, but I wanted to know the opinion of some experts in this field.

Thank you  Liz. 

You must use creatinine and the standard (a reference molecule)
Optimal use of electrophoresis.
Which option you choose?

The answers above have expertly summarised that:

• Vasopressors (noradrenaline and vasopressin) cause less arrhythmias than dopamine (De Backer et al, Avni et al.)
• Those with cardiogenic shock may (probably?) do worse with dopamine as compared to noradrenaline. It might be extrapolated that those with septic shock and concurrent heart disease (ischaemic, cardiomyopathy) may also do worse
• Early renal replacement therapy in patients with AKI (KDIGO 2+) is advantageous (Zarbock et al)
• The neuro-endocrine effects - predominantly thyroid disfunction, and predominantly in those on dopamine continuously for more than a week.
• Dopamine does not have an effect on the rate of development of renal failure i.e. it is not renally protective of its own right (balanced against the first point below).

balanced against:

• raising the renal perfusion pressure by any means (pressors/inotropes) is probably renally protective if the renal perfusion pressure has fallen below a critical level, whatever that blood pressure happens to be for the individual patient
• dopamine moderately increases urine output in a subset of patients (anecdotally, rarely in those who are completely anuric) (Bellomo et al).
• dopamine can be administered more safely than noradrenaline through a peripheral IV, and some (non intensive care) wards allow its administration

Therefore as all the other answers, vasopressors are preferred to dopamine for septic shock (and probably the majority of forms of shock). However, it is important to note that they are not comparing pressors with nothing. there are 2 situations when a clinician might reasonably consider dopamine:

• working in non-OECD nations, I have run out of a particular (preferred) inotrope or vasopressor, and in the setting of fluid refractory shock, anything to raise perfusion pressure to vital organs is probably preferable to nothing
• There are some patients for whom active interventions are indicated, but admission to ICU, central line insertion and RRT are not. If blood pressure and urine output are almost but not quite acceptable , a short run of low dose dopamine on the ward might  get them through (from a perfusion pressure and urine output point of view) for long enough for the other treatments (antibiotics, nephrostomy etc) to treat the underlying condition.

Hi 

I hope that following article will help you.

Regards 

In Chinese medicine, pain is caused by blocking Qi and blood free flowing.

Qi flowing inside the body can bring away toxins, cells metabolism waste, dead cells, brings in nutrients, neurotransmitters, white cells, hormones, etc. to the site to do defense and repair jobs. It can renew cells.

Back pain can block qi flowing in the Urinary-bladder meridian and the governor meridian qi flowing to nourish organs. It causes organs functions weaken. Thus, generated fatigue.


If western medical schools, medical researchers can get well trained in Chinese medicine, especially the ancient traditional Chinese medicine, your research achievements will be tremendous boosted up. If you want, I can open classes for researchers and MDs.

date of diagnosis minus birth date in Excel?

I will suggest you to try with RUN48 as endogenous control for RT-qPCR. We worked with this and is fine with human samples. You will get the universal primer from kit that you will use for cDNA conversion.

OR=operating room. We have used our instrument on the calf during brain surgery and the compartment volumes have tracked the fluid input/output from the patient rather well.

ER=emergency room. we can monitor the changes in intravascular/interstitial fluid during administration of infused fluids (saline goes straight into both vascular and interstitial compartments. Hespan initially only alters intravascular volume then later flows into interstitial).

Ri = resistance from bioimpedance spectroscope that is attributed intracellular tissue. Most commercial spectroscopic units provide Ri (intracellular resistance) and Re (extracellular resistance) only. We then deconvolute the Re to provide measures of interstitial and intravascular volumes and the transfer of fluid between the three compartments.

We temporarily pause the spectroscopic mode at desired intervals and input a 50KHz signal through the segment and record the pulsatile waveforms at 200 Hz. We use these recordings to calculate blood flow and several (34) other parameters regarding pulse transit time, venous tone, arterial tone and contractility.

We have several papers submitted or in preparation regarding these points.

In asking if anyone has data or Ri during dialysis - I am hoping to find anyone with continuous recordings during dialysis to see the extent?? of fluid uptake by the cells. If Ri decreases it is a sign of cell hydration that is independent of our 3 compartment calculations.

I hope this helps.

les montgomery

Pulsed solumedrol would likely be most effective for HLH when treating a causative auto-immune disorder, such as the above article on Still's Disease or MCTD.

thank you very much for your answer.

Apologize for my late respond

this patient is health care workers

so his medication was stopped by herself.

but we reduced gradually her drug dossage  because of  recurrent lung infection disease.

I think I would use a partial UUO  model, where you insert a very thin wire or stiff suture in the knot around the UUO, and then pull it out after the suture is secure. Full occlusion does too much damage in my study. Consistency with a given size diameter helps.

Don't use HEK293 for cytotoxicity test with MTT or other dye. Cell are not attached well. Finally dye will be gone with aspiration out MTT before adding Solvent. So, never give actual results at all. I have tried many times. It is crazy. Just sharing. 

Due to the hypercoagulability condition after surgery, often the AV fistula spntaneously closes. If not, in the case of cardiac disease should be closed, otherwise no need to by closed

The following investigations might help in treatment of this patient - measurement of urine Na & osmolarity .  A low urine Na & high urine Osm would suggest hypovolemia as a cause of Hyponatremia . A normal urine Na & high urine Osm with euvolemic status would suggest SIADH . A similar urine Na & Osm status can also occur in hypervolemic status , such as cardiac failure .

   The fact that he had thiazide diuretics & enema suggest that he would have had hypovolemia as a cause of hyponatremia & in addition , his anti - depressant might have also contributed to hyponatremia . The improvement of hyponatremia from 103 to 139 mEq suggest that the restricted water & high salt intake has worked  His 133 mEq , at present might also suggest hypovolemia which needs evaluation . Please continue the same protocol of treatment as this has corrected his hyponatremia during his previous admission .

Thank you kindly Dr. Gillain-Martin for the resource.  It is an excellent read.

I am uncertain if these patients are truly iron deficient or functionally iron deficient.  I was hoping that prior research might have already answered this question of significance.

Is an exaggerated change a clinically significant finding and how would "exaggerated change" be best defined? 

On a deeper level, I wonder about mitochondrial iron metabolism especially in this subset of dialysis patients.

I am revisiting the data on these patients looking for any patterns or clues.  However, I was hoping that large data base analysis would have already offered useful insight.

Does the three month testing as suggested by the article reduce the chances of capturing these patients?

In the US, electronic decision support protocols suggest dosing and frequency of parenteral iron prescribing for the overwhelming majority of dialysis patients using the surrogates of ferritin, TSAT and also commonly using elevated hemoglobin cutoff levels.  The testing frequency is usually every 30 days with the exception of at least a week post last administration of parenteral iron (which might not be long enough ?)

Also, as mentioned in the article, other markers may not be as practical for broad use.  To my knowledge, IV iron prescribing in the US HD population does not usually consider exaggerated response to IV iron (exaggerated change in parameters/markers) beyond the cutoff parameters as set by the algorithm.    

_______________________________________

Excerpts from the referenced article:

"Combined use of CHr and high-fluorescence reticulocyte count allowed for very high accuracy in the early prediction of the response to intravenous iron therapy in hemodialysis patients, with a sensitivity of 96% and a specificity of 100% (10). However, neither CHr nor the percentage of hypochromic RBC has the ease of use, cost-effectiveness, and widespread availability of the traditional tests, such as ferritin and TSAT (34)."

"Diagnosis of iron deficiency and guidance of iron supplementation should be made in stable patients with ESRD by ferritin and TSAT measurements at 3-mo intervals."

Clinical Aspects of Iron Use in the Anemia of Kidney Disease

Walter H. Ho ̈rl

Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
J Am Soc Nephrol 18: 382–393, 2007. doi: 10.1681/ASN.2006080856

It depends on indications and clinical conditions (fist of - all hemodynamic stability). What is the cause of renal failure? For example - sepsis - CRRT (hemo- or hemodiafiltration) 12-24 or more hrs. Pre-renal failure after massive blood loss and risk of haemorrhage - short-term dialysis may be better, and so on. Can anybody compare such different patients in a trial?

Yes,I do agree.

However the key element being anemia ,if treated at the earliest has an immense positive impact on the overall prognosis.

http://www.sciencedirect.com/science/article/pii/S0026049514001954

http://www.ncbi.nlm.nih.gov/pubmed/14758530

https://books.google.com.tr/books?id=pwajBQAAQBAJ&pg=PA486&lpg=PA486&dq=measure+urine+bicarbonate+(HCO3-)&source=bl&ots=KTAcs3Qd2p&sig=kgFwdPtp5JwRb9bWVJF_9hT3WKs&hl=tr&sa=X&ved=0ahUKEwjPyMOP0KjKAhXIiywKHXezDMcQ6AEIVTAH#v=onepage&q=measure%20urine%20bicarbonate%20(HCO3-)&f=false

http://pediatrics.aappublications.org/content/100/4/675

Avoid using at all cost, esp in those with any stage of CKD or proteinuria, those on inhibitors of the renin ang system, in obesity, or anyone who may be predisposed to AKI. De novo oligiric AKI can occur even in young patients who have no CKD.

So many better ways to measure or estimate GFR

i think there is no definite answer. It is important to know if you are talking about  rATG or eATG..meaning of rabbit or equine origin as vials are 25mg and 250 mg respectively

She is doing very well, except being tired, as described above.She is looking foreward to starting school in 1 week. She has had 2 renal biopsies due to delayed graft function, both of which were normal.

I do agree that it is very difficult to differentiate the two but this may still be possible to develop a clinical algorithm.Although it is going to be a lengthy process.

After all that, I would treat a 69-year old woman with normal renal function not specifically, because treatment may cause more harm.

Hi Ramin 

Find attached link to helpful paper

Intermittend peritoneal dialysis (IPD) was used earlier in severe uremic patients to avoid a dialysis disequilibrium syndrome or as a longterm treatment. IPD has been replaced by short daily hemodialyses on the start of intermittent hemodialysis dialysis (IHD) or continuous ambulatory peritoneal dialysis (CAPD).

See the relevant chapter in my wonderful new book. CARDIORENAL CLINICAL CHALLENGES.  Eds Goldsmith, Covic, Spaak. Published by Springer Jan 2015.

Hello jeremy

1-By one machine do you have this problem or with all machines you have high TMP during pre dialyzer fluid ?

2-How long does it work ( pre dilution modality ) when it starts allarming ?

3-Did you have similar problem while using post dilution ?

4-Did you try changing dialyzer ?

regards

I am agree with Mario Barac-Nieto, Urine flow increases due to osmotic diuresis, and  normal rate of filtration is 125 ml/min, equivalent to 80 times the daily blood volume. Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney function so you can correlate the kidney impairment with the GFR

Have you studied autoimmunity of  your patients?
the presence of anti-ANCA antibody, anti-PLA2R, anti-DNA ...?

Thanks for your response Dr.Vellanki

In 1995, the Ministry of Health and Welfare of Japan approved recombinant ANP (carperitide) for intravenous administration in patients with acute heart failure (AHF) and acutely decompensated heart failure (ADHF). However, the recombinant form of BNP (nesiritide) was not approved for therapeutic use in Japan. In contrast, in the USA, the Food and Drug Administration (FDA) approved nesiritide in 2001. Therefore, the clinical evidence for ANP has been compiled mainly in Japan, whereas the evidence for BNP is mainly from the USA. Several reviews and meta-analyses concerning BNP use were generated using data obtained in the USA. In this context, this review focuses on recent clinical data regarding ANP as a therapeutic agent in several diseases, as well as experimental data from genetically engineered mice which may rationalize the clinical usefulness of ANP.

google base data....

No antiviral is really effective "in vivo"...the only treatment  is reducing immunosuppression until T-cell immunoreactivity against  BKV  (monitored by means of Elispot or a similar assay) develops.

To my best knowledge Eculizumab is to treat for acute antibody mediated graft rejection in renal transplant recipients. I do not have personal experience in using Eculizumab.  In our setting we used to treat antibody mediated cell rejection with Plasma exchange and IV immunoglobulin therapy.  It seems Eculizumab can combined with plasma exchange-IV Ig therapy for better outcome. 

I feel there is no need for a new Journal, however the need of the hour is to get more data from countries like China. Being not so accomplished in English or other European languages many countries are not reporting interesting data. Instead of adding new Journal we should strive for bringing out more quality data from such countries. It will also be interesting to see if we can change the policies in dialysis particularly as the current data is heavily based on Caucasean population studies.

the following sources may be consulted:

 1. BMA and RPSGB. British National Formulary; Number 59, March 2010

2. Ashley C and Currie A. The Renal Drug Handbook-3rd edition 2009. Radcliffe Publishing Ltd.Oxford.

Hi Pankaj,

I view this nephrology "clearance" in two parts, depending on the source of the referral. Firstly and more commonly, is the expectation that nephrologists will identify the relevant risk factors for contrast-induced nephropathy in order to help optimize the patient's condition and minimize the risk of CIN. Others have already provided suggestions as above. Secondly, there is also perhaps a medico-legal aspect to this "clearance" as it relates to procedural informed consent, particular regarding the possibility of AKI requiring renal replacement therapy (particularly in high risk patients and existing CKD). It also means that "clearance" implies that the nephrology team will then provide supportive RRT if the worse case scenario eventuates. In some cases of multi-morbid and elderly/frail patients, RRT may not be tolerated or possible and these issues need to be discussed beforehand.

So, I totally agree with your comments that nephrology residents "clearing" a patient for CECT without due diligence and consideration of the issues, is risky not just for the patient but also potentially from a medico-legal perspective (depending on the environment you work in).

Keep it simple and break the access project into two staged procedures whenever possible and your life will be much easier, I promise. Stage 1: create the fistula. Stage 2: superficialize it. Today I usually do a simple elevation, creating a 10 cm cannulation segment.

  I tell you this having done 13 fistula liposuctions, 20 lipectomies, A hundred or two  transpositions with new tunnels or big flaps, and 6 venous window needle guides

Keep it simple!

Today I put HeRO grafts in sick, elderly patients who I think will probably die in a year or two and I do  femoral vein fistulas (Superficial Femoral Artery to transposed femoral vein) in healthy patients expected to live for several years.

I recently presented a paper "Fewer HeRO Grafts and More Thigh Fistulas: Our Changing approach to Management of Bilateral Central Venous Stenosis". I am working on the manuscript. My presentation is attached.

Eric

Hi we have had in our Maternity some cases of hypernatremic dehydration, and in the study through the root cause analysis, which we have seen is that most of them had been instrumented deliveries (suction cup, forceps with epidural anesthesia) as well as some other contributing factors including unmotivated breastfeeding health personnel. I think the most important is to reinforce good BFHI practices and good control at 48 hours after discharge.