Creative Approaches to Complex Patients Lessons learnt from

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Creative Approaches to Complex Patients : Lessons learnt from patients with Chronic Kidney Disease

Creative Approaches to Complex Patients : Lessons learnt from patients with Chronic Kidney Disease Namirah Jamshed M. B; B. S Associate Professor of Clinical Medicine Georgetown University School of Medicine Med. Star Washington Hospital Center ©AAHCM

Case Presentation 76 year old AA lady PMH ◦ ◦ ◦ ◦ CKD CHF

Case Presentation 76 year old AA lady PMH ◦ ◦ ◦ ◦ CKD CHF CAD CVA HTN Peripheral neuropathy DM Anemia SH ◦ Home/Son ◦ PCA services 14 hrs/day Medications ◦ ◦ Lantus Metoprolol Hydralazine Furosemide ©AAHCM

Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD ©AAHCM

Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD ©AAHCM

Epidemiology ~ 44% in ≥ 65 years 60% -69% ≥ 80 years age Stage

Epidemiology ~ 44% in ≥ 65 years 60% -69% ≥ 80 years age Stage III 70 -77% ↑CHF, CAD, CVA, PVD, HTN Lesley A. Stevens et al. Am J Kidney Dis 55(S 2): S 23 -S 33. © 2010 by the National Kidney Foundation, Inc ©AAHCM

Prognosis Age Comorbidity Functional status Albumin Cognitive impairment ©AAHCM

Prognosis Age Comorbidity Functional status Albumin Cognitive impairment ©AAHCM

Delaying Progression Glycemic Control ACE inhibitor or ARB therapy Blood Pressure Control Dietary restriction

Delaying Progression Glycemic Control ACE inhibitor or ARB therapy Blood Pressure Control Dietary restriction of protein ©AAHCM

Challenges in Managing Elderly Paitents with CKD Mental Health Disturbance ◦ State of Mind

Challenges in Managing Elderly Paitents with CKD Mental Health Disturbance ◦ State of Mind ◦ Cognitive Abilities Falls Multimorbidity management ◦ Willingness or capacity to comply Medication maangement ©AAHCM

Ethical issues Beneficence Paternelism RRT: Default pathway? ©AAHCM

Ethical issues Beneficence Paternelism RRT: Default pathway? ©AAHCM

Advance Care Planning What one can to ensure that their wishes and preferences are

Advance Care Planning What one can to ensure that their wishes and preferences are consistent with the health care treatment they might receive if they were unable to speak for themselves or make their own decisions. http: //www. cdc. gov/aging/advancecareplanning/ ©AAHCM

Key aspects in CKD Initiate prior to the need for dialysis Include family in

Key aspects in CKD Initiate prior to the need for dialysis Include family in discussion Family support Family influence Family involvement Provide detailed information as part of predialysis education Logistics of scheduling and transport ©AAHCM

Typical Illness Trajectories For Chronic Murray S A et al. BMJ 2005; 330: 1007

Typical Illness Trajectories For Chronic Murray S A et al. BMJ 2005; 330: 1007 -1011 ©AAHCM

Surprise Question Moss, Clin J Am Soc Nephrol 3: 1379 -1384, 2008 ©AAHCM

Surprise Question Moss, Clin J Am Soc Nephrol 3: 1379 -1384, 2008 ©AAHCM

CPR in HD 8% vs 12% survival to hospital discharge 3% vs 9% alive

CPR in HD 8% vs 12% survival to hospital discharge 3% vs 9% alive in 6 months Neurolgical compromise or mechanical ventilation Moss AH, Holley JL, Upton MB. Outcomes of cardiopulmonary resuctitation in dialysis patients. J Am Soc Nephrol. 1992; 3(6); 1238 -1243 Expectations ◦ 87% wanted CPR ◦ Blacks > White (OR 6. 56, CI 95%) Moss AH, Hozayen O, King K et al. Attitudes of paitens toward cardiopulmonary resucitation in the dialysis unit. Am J Kidney Dis. 2001; 38(4): 565 -568 ©AAHCM

Case Summary ICU admission for CHF 2009 AKI and hyperkalemia; GFR 45 GFR 23;

Case Summary ICU admission for CHF 2009 AKI and hyperkalemia; GFR 45 GFR 23; Cr 2. 52 2010 • Referred to nephrologist • Strategies to delay progression Low albumin Anemia CHF Exacerbation CKD Stage 3; stable azotemia 2011 2013 2012 Strategies to delay progression Twitching; Myoclonus; seizure ? 2014 Admitted with AKI/CKD; anasarca, CHF, pulm HTN ©AAHCM

Summary CKD Status Co-morbid Conditions Knowledge Prognosis HTN DM Stage CVD Advance Care Planning

Summary CKD Status Co-morbid Conditions Knowledge Prognosis HTN DM Stage CVD Advance Care Planning Pyscho-social issues Cognition Support Adherence Burdens of Dialysis Physical Financial Logistics Caregiver ©AAHCM

National Approaches to Adaptation Some Lessons learnt fromNational Approaches to Adaptation Some Lessons learnt from
Buildings for the Future Lessons Learnt Lessons SharedBuildings for the Future Lessons Learnt Lessons Shared
Buildings for the Future Lessons Learnt Lessons SharedBuildings for the Future Lessons Learnt Lessons Shared
COTRIMOXAZOLE PROPHYLAXIS LESSONS AND WAY FORWARD LESSONS LEARNTCOTRIMOXAZOLE PROPHYLAXIS LESSONS AND WAY FORWARD LESSONS LEARNT
What we learnt We learnt what are forestsWhat we learnt We learnt what are forests
Creative Project Revised 302 Creative Project Examples CreativeCreative Project Revised 302 Creative Project Examples Creative
Creative NonFiction Creative Non Fiction Creative nonfiction isCreative NonFiction Creative Non Fiction Creative nonfiction is
The Creative Person Creative Process and Creative DramaticsThe Creative Person Creative Process and Creative Dramatics
Creative Thinking What is creative thinking Creative ThinkingCreative Thinking What is creative thinking Creative Thinking
Introduction Introduction Software is Complex Complex complicated ComplexIntroduction Introduction Software is Complex Complex complicated Complex
Complex analysis Chapters 13 16 Complex numbers complexComplex analysis Chapters 13 16 Complex numbers complex
The Complex Plane The Complex Plane The complexThe Complex Plane The Complex Plane The complex
constructors u i class complex public complex complexconstructors u i class complex public complex complex
Complex Numbers the Complex Plane Demoivres Theorem ComplexComplex Numbers the Complex Plane Demoivres Theorem Complex