16-01-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PA - Patient history of Sugar & BP
From Dec 2012
250 was sugar,
Glymer/Glycomet 1000mg tablet (from 2012 to 2022)
Telsarten/Telimstar - 40 mg (both times) (2012 to jun 2024)
Nebivolal - (2022 to jun 2024)
From Jun 2024 (only if BP is more than 150/90 - Nicardia 20 mg)
PPM 1- What are his current requirements from us?
To be able to decide that we need you to:
describe your patient's sequence of events that led to the current problems. Please begin the sequence of events from the time your patient had absolutely no problems at all.
Please describe your patient's hourly routine over 24 hours when he was perfectly alright
Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life
Please mention specifically which part of the patient's hourly routine was disrupted
If we had to give him a single medicine which problem would they prefer it to address?
Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:
PPM 1 - Also ask him to share his daily urine output here.
PA - What is the current requirement 👇
Need to cure his CKD disease and get him out of dialysis (he went through 3 dialysis as of now)
Sequence of events which lead to this 👇
- 12 years of Sugar and BP and medication used
- Admitted for Covid Treatment @ Dec 2020 and treated with steroids
- Took voluntary retirement June 2023
- Went through Stress and mental tension due to family situations from (sep 2023 to Aug 2024)
Patient @ 24 hrs from 1991 to Jun 2023 👇🏻
Approx - 7:30 am or 8 am wakeup
Freshing up and bathing immediately and going to the office
Breakfast in house (idly & dosa)
Reach the office by 10 am
Lunch taken from home @ 2pm
Desk job and Working on the computer till 7 pm in Blue lights (computers came in 2010)
30% of the days.. Walking 1 hr
Any other home work and watching TV
And sleeping by 11 pm
Patient 24 hrs from jun 2023 till now
24 hrs @ After voluntary retirement 👇🏻
Waking up not fixed.. Anytime at 9 or 10
Sometimes breakfast and sometimes no
Lunch
Sleeping in afternoons and other times also
50% walking 1 hr
Watching TV
And sleeping
When disease took over @ 24 hrs 👇
- Mostly not so much active
- feeling weak
Which hourly routine is affected ? 👇
Night sleep.. Most of the times night sleep is not possible... So he use to sleep in the morning and he lost his appetite also
If only 1 medicine is given? 👇🏻
He is asking for over all health (But kidney should become good for now)
PPM 1 - 👍
PPM 2 - 👍
PA - Will send the below details by night
- CKD details and Medication used during CKD
- Photos required
- Other Scans and test done
PPM 1 - Was seeing a similar patient right now in the ward and I have shared his details in the collective group @PPM2, @CR.
PA - Recent Scan report.
PA - Recent 2D Echo. 👇
PA - Recent RFT. After Dialysis. 👇
PA - Free Light Chain latest report. 👇
PA - RFT before 3rd Dialysis. 👇
17-01-2025
PPM 1 - What medications is he currently taking for his diabetes and hypertension and at what time?
Please share his regular food plates as shown by other patient advocates in their case reports
here 👇
PA - He went through 3 dialysis and
Before dialysis.. His Creatine hit to 23 and urea was at 250
Now.. his creatine is at 9 and urea is at 125.
PPM 1 - Thanks for sharing.
When have the local doctors there planned his next dialysis?
PA - Not yet informed... They said weekly twice.
Maybe day after tomorrow.
As of now.. He doesn't have edema and any water accumulation.
PPM 1 - 👆his hands look swollen here.
PA - Because of canla.
PA -
Current symptoms
- Heavy cough
- Breathlessness if he walks for more time
- Mucus in the mouth
- Vision little less or blur
Improvement
Appetite is good
No pedal edema
No nausea, fatigue or dizziness.
PPM 1 - Any recent chest X-ray image?
PA - This was done after 1st dialysis on 10th.
PA -
My question is
What makes docs say.. To stabilise creatine at 5 with dialysis
And what makes them decide.... If a patient wants weekly once or twice? .. Is it symptoms and fluid accumulation or numbers
And Generally, Urea leads to uremic symptoms right?
Then... Why dialysis is not based on urea count
Because I have seen my patient with creatine 10 and his urea came down to 75 and he was alright without any symptoms
And one more question... Is there any chance that... If we make a patient accustomed with one frequency (say twice a week dialysis) .. Will his body get used to it?
PPM 1 - Good questions👏👏
1) Symptoms is the main guide in dialysis decision making as dialysis is not curative but simply a symptomatic life saving support
2) Creatinine is a better marker of severity of uremia than urea as urea levels are more variable depending on other factors other than renal function
3) This has been tried in many centers in the past and wasn't a great success in terms of outcomes.
PA -
And as a person stays long on dialysis..
Is there a chance that his kidney will further deteriorate as it's work is done by outside machine..
Like it will become lazy and stop even little bit functioning?
PPM 1 - Yes you are right!
Continued dialysis eventually makes the person's own kidney deteriorate in terms of function.
Absolutely well observed.
PA - 🙏
I really want my patient to be coming under your guidance as to how much of dialysis he require..
Will it be possible to make the process quick and
If require.. I can bring the patient to your hospital.
🙏🙏🙏
I am afraid... As these people without any deep. Understanding told... For dialysis twice a week
@PPM1 sir, please guide.. If required.. I can physically bring the patient tomorrow to your hospital. 🙏
Because I don't want not even one unnecessary dialysis for the patient 🙏
I hope last 3 dialysis didn't so much deteriorate his kidneys 🙏
PPM 1 - Well it's a very difficult and challenging situation but yes nothing is impossible if there's a person like you who can really dig deep into all the current available data around this and then work with the caregivers to design a better data driven optimal management strategy tailored to the requirements of the patient.
But just to provide a whiff of how challenging and complex this is take a look at this paper 👇
And after reading it share your learnings and best possible strategy for your patient that you would want your current caregivers in your city to go by.
I don't think you need to come here but if you can share all the data from your nearest center we can work together to guide you in a data driven manner.
PPM 1 - @PPM3 is my student from Bangalore. Still the nephrologist @PPM4 working there in Vijayawada or has he left?
PPM 3 - He is still working there and Associate of the Nephrology department sir.
PA - @PPM4 is treating the patient.
PPM 1 - 👍Let's hope we can all work together as a team along with @PPM4.
PPM 3 - 👍
PA - That would be super cool sir 🙏
Patient is feeling terrible after removing canla
Is there anything we can do about this pain 🙏
Sorry for asking this silly question 🙏
PPM 1 - This is a most important question
Can apply thrombophob gel locally.
PA - Got and applied.. Thank you doc.
PPM 1 - 👍
PA -
Docs have recommended these many medicines... I am against some of it
Sodocel 3 times.. His sodium is always in the bracket from past 4 months
Febutat.... His current uric acid is stable from past 4 reports
Shavelmar 800 mg (twice) his inorganic phosphorus is 5.7
I am. Not sure.. If ecosprin is really required... As the blood will be already in diluted form because of fuilds
Cilnidipine and prazopress and nebimac for BP... Patient is very accustomed with nicardia 20 from 6 months.. That we will give only if his BP is more than 150/90
Dytor.. (No comments on this.. But Pedal edema is not there from 2 days)
Fersome - His blood is at 6.9 .. I hope this will improve it
PA - @PPM1 sir can u please guide.. What is must and what I can eliminate 🙏
PPM 1 - 👍
PA - If these many medicines are going inside... Patient was only frustrated and asked for Pantoprezol 😅 (which doctors didn't recommend initially 😅😅)
PPM 1 - Yes unfortunately if we dig into the scientific evidence of efficacy for most of our drugs we may always find that the evidence is marginal.
While these drugs are a routine strategy for most such similar patients it would be important to review and audit the data around each patient 's outcomes while on these multiple drugs and how may one attribute causality to each drug intervention and their expected outcome.
18-01-2025
PA -
TRACKER OF VALUES FROM JULY 2024 TILL JAN 2025 ⚡
Creatine 🌳
7th July - 8.6
8th July Morning - 6.5
8th July evening - 7.8 (Kamineni)
12th July - 9.42
16th July - 9.78
19th July - 6.9 (AIIMS)
20th July - 7.6 (AIIMS)
21st July - 7.2 (AIIMS)
Ist August - 11.77
7th August - 11.9
13th August - 14.9
9th Sep - 11.4
19th Sep - 10.3
4th Oct - 10.3
14th Oct - 9.4
18th Nov - 13.5
27th Nov - 11.6
5th Dec - 12.7
28th Dec - 18.7
1st Jan - 17.8
5th Jan - 18.3
9th Jan - 23 (before HD)
10th Jan - 18.9 (Next day after 1st HD)
12th Jan - 9.9 (Next day after 2nd HD)
15th Jan - 13.7 (before 3rd HD)
16th Jan - 9.1 (Next day after 3rd HD)
Urea 🪴
7th July - 107.7 (Vij lab)
8th July - Not Tested (Kamineni)
12th July - 118.39 (before hiims)
16th July- 122.92 (4 days of hiims)
19th July -130 (AIIMS)
20th July - 129 (AIIMS)
21st July - 126 (AIIMS)
Ist August - 175.5
7th August - 163
13th August - 156
9th Sep - 113.7
19th Sep - 117.1
4th Oct - 115.5
14th Oct - 86.2
18th Nov - 147.5
27th Nov - 157.3
5th Dec - 169.3
28th Dec - 207.5
1st Jan - 209
5th Jan - 230
9th Jan - 256 (before HD)
10th Jan - 202
12th Jan - 105 (Next day after 2nd HD)
15th Jan - 123 (before 3rd HD)
16th Jan - 81 (Next day after 3rd HD)
Uric Acid🍁
7th July- 8.1 (vij lab)
8th July- Not Tested (Kamineni)
12th July - 7.5(before hiims)
16th July- 8.2 (4 days of hiims)
19th July - 5.9 (AIIMS)
Ist August - 8.3
7th August - 8.9
13th August - 7.8
9th Sep - 7.4
19th Sep - 7.4
4th Oct - 8.4
14th Oct - NA
18th Nov - 6.4
27th Nov - 6.8
5th Dec - 7.6
28th Dec - 10.5
1st Jan - 9.7
5th Jan - 10.5
9th Jan - NA
10th Jan - NA
12th Jan - NA
15th Jan - 5.7
16th Jan - NA
Haemoglobin (Blood understand) 🌹
7th July - 12.4 (Vij lab)
8th July- 11.5 (Kamineni)
12th July - 10.3 (before hiims)
16th July - 10.4 (4 days of hiims)
Ist August - 13.4
7th August - 10.5
13th August - 10.3
9th Sep - 10.8
19th Sep - 11.0
4th Oct - 9.9
14th Oct - 9.8
18th Nov - 8.6
27th Nov - 9.5
5th Dec - 7.6
28th Dec - 7.3
1st Jan - 6.9
5th Jan - NA
9th Jan - 6.7 (before 1st HD
10th Jan - 6.9
12th Jan - 6.9 (After 2nd HD)
15th Jan - NA
16th Jan - NA
PPM 1 - Well done!
Will be interested to also see brief texts around the numbers depicting the life events of the patient in parallel to give more meaning to those numbers.
PA - I will. Be giving a detailed explanations of series of events happened in the patient's life, Medicines he used, treatment he was taking care, and various other things..
During every increase and decrease of values 🙏
This was my work from past 6 months... Everyone including Many neurologists laughed at what I am doing...
I am happy that.. Finally it's getting used and happy to know that this will help in treating the patient further 🙏
Can u add our physician to the group ..she also saw the detailed patient journey... It will. Be good to have her here.
And there are various docs and health experts interfered in between and helped for the patient health in many ways
Will acknowledge all of them in detailed report by EOD
And let me know... If we can add some of them.. Who would be interested to help us.. Even right now 🙏
PPM 1 - Yes please go ahead and add them. We need to scale ASAP through like minded people.
PA - 🙏
Namaskaram everyone,
This group is created by PaJR team..
They are helping me to understand my patient's health issue and the Source of the problem behind it..
I have added you all because.. You have been the people.. Helped my patient in his treatment at various levels 🙏
Hope this case study will help you to treat further patients 🙏
This is headed by @PPM1 Who is HOD of a reputed hospital in Telangana 🙏
The first one is a health scientist and he had done an extensive work and protocols in treating many people's health.
The second one is a MD Cardio vascular surgen turned to be an Ayurvedic Doctor with MD in ayurveda and naturopathy and Founded of SGP an Poly scientific Ayurveda Hospital and he got thousands of End stage disease people out of their problems.
The third one is based out of Chandigarh and she is BAMS Holder and Head of IP in HIIMS Chandigar and Founder of Namo Hospital and brings many people out of CKD 🙏
The fourth one, He is a Naturopathy practitioner from last 20 years and associated
The fifth one, she is a Psychology grad and have been together for 6 months and understands the patient's journey 🙏
@PPM1 sir, Please have a brief introduction for your methodology and your team 🙏
I will post the remaining data and we will get into the full case study ASAP 🙏
PPM 1 - I'm just a physician.
We just try to help people using data and call the process "medical cognition" as an important component of data driven healthcare
More about our methodology archived here:
https://userdrivenhealthcare.blogspot.com/2022/10/medical-cognition-tools-to-resolve.html?m=1
PPM 2 - Was a kidney biopsy done after this free light chain test report?
PPM 1 - 👍
PA - No, not done.
PPM 2 - Should strongly consider getting one - if the suspected diagnosis is indeed Amyloidosis (from free light chain deposition in kidneys)
PA - Exactly I felt... But the nephrologist said... His report is alright and He will go for liver endoscopy in future.
PPM 2 - Which report? The free light chains one?
PA - Yes.
PPM 2 - Also why did the doctor ask for a liver test / endoscopy?
PA - I think... For future transplantation or probable correlation of it with kidney problem.
TRACKER & EVENTS ⚡
1. Pre Actute-CKD Events 👇(2012 to 2022)
- BP and Diabetes from Dec 2012
- Covid Treatment with steroids Dec 2020
2. Risk of Kidney Disease (Dec 2022) 👇
Creatinine was 1.7 on Dec 2022 (Coimbatore) during his regular checkup and Doc little bit warned about risk of kidney disease in future
3. Voluntary Retirement and Fear of Kidney disease👇(June 2023 - July 2024)
The patient took his retirement in June 2023 and his life style has changed completely without any activity (In between this period he was scared and didn't check with the doc at all)
And with fear he used Neeri Juice (atleast 10 bottles) and vrukka doshantaka vati (Without any doc Consultation on his own)
4. Found Creatinine at 8 (July 2024) 👇
After 10 days of pedal edema, forced to take a RFT and found creatine to be 8
5. HIIMS Treatment @ Chandigarh 👇
Dates - 10th July to 17th July
Creatinine - 9.42 to 6.9
Treatment Done
- Ayurveda medicine
- Hot Water Tub (Water Dialysis)
- Panchakarma
- Lape for Pedal Edema
- And few Allopathy medication also
6. Admitted to AIIMS
Dates - 19th July to 22nd July
Creatinine - 6.9 to 7.2
Treatment - Allopathy Medicines (lasix inj) and declares this as Acute CKD
Note - There is a theory that.. This report in AIIMS is wrong (as for the first report they told.. For everyone numbers got wrong in lab)
7.Treatment with a Health Scientist 👇
Dates - 19th July to 13th Aug
Creatinine - 11.7 to 14.9
Treatment -
- Punarnava juice and wheat grass
- Type of water (alkaline) quantity per serve very less
- And Food and walking and exercise
8. Restarted Water Dialysis & Siddha medication 👇
Dates - Aug 17th to Sep 9th
Creatinine - 14.9 to 11.4
Treatment - Water tub and siddha medication
9. MD Ayurvedic Doctor Treatment (Ayurveda) 👇
Duration - Sep 5th to Dec 5
Creatinine Values
9th Sep - 11.4
19th Sep - 10.3
4th Oct - 10.3
14th Oct - 9.4
18th Nov - 13.5
27th Nov - 11.6
5th Dec - 12.7
Treatment
- Ayurveda Medicines
- Oil Application to body
- Exercises and Asanas
- Breath Exercises
- Food restrictions and no sour or spice at all (reduced patient appetite and interest to words food)
On our own we did Water Dialysis treatment
And water tub was missed from Nov 2nd to Nov 18th and due to demise of patients sister in law and there is a unusual spike in creatine (My understanding)
10. No Medication and Nothing 👇
Duration - 5th Dec to Dec 28th
Creatinine - 12.7 to 18.7
Treatment - Nothing
Condition and event - Patient developed a heavy cough and mucus in lungs and couldn't follow Ayurveda protocol and didn't do even water dialysis treatment
And his mother was hospitalised and died on 26 Dec
11. Dialysis period 👇🏻
Duration - 9th Jan to 16th Jan
9th Jan - 23 (Creatinine) (morning)
9th Jan Evening
1st Dialysis of 2000 UF in 3hrs (for water)
10th Jan - 18.9 (Creatinine)
11th Jan - 2nd Dialysis of 3000 UF for 6 hours
12th Jan - 9.9 Creatinine
15th Jan - 13.7 (Creatinine) (morning)
15th Jan - 3rd Dialysis of 2000 UF for 4 hours
And Iron injection of 100ml was given
16th Jan - 9.1 is the latest creatinine report
12. Present Status ❤👇
- Patient is with Dialysis tube on neck
- Taking sun regularly
- Taking allopathy medication
- Restarted Siddha medicine and Hot water dialysis
- And eating food with very good appetite
- Patient still has Occasional cough and mucus
🙏🙏🙏🙏
PA - 30% Vision is feeling blurred for the patient
PPM 2 - Can we explore why he took alternative medicine like Ayurveda and Siddha etc?
PPM 1 - Thanks for sharing the sequence of events so very well 👏👏
One of the most interesting features in this case report is surely the convergence of various systems of medicine in one patient that is perhaps much more frequent than it is actually reported.
It would be important to be able to nurture these confluences without conflict to achieve the best possible outcomes of what is currently termed "integrative medicine"
PA - I only have taken that decision..
Because I haven't found a proper nephrologist.. Who study's the problem in depth instead he is only eager to do dialysis even without symptoms..
The nephrologist in AIIMS.. When my dad creatinine is at 7 .. Was telling.. Anyway in future we need to start dialysis... Why don't we start today itself... This was the approach they had..
I am. Not against the dialysis.. But I am against if it's unnecessarily done.. If there is no need.
PPM 2 - I understand your perspective, however not finding a good nephrologist should not push us towards non evidence based practices?
Did those alternative medicine practitioners study the patient's problem in depth?
PA - I guess.. They understand the human system in a different way... And depth differs from system to system
While Allopathy deals with Human Chemistry and it's changes
Other systems observe them differently
For example ayurveda dwells with Vatta, pitta and kapha and their balance
And disease is an Imbalance of these Factors
While naturopathy has a different approach and understanding on human system
They see the human to be naturally health if they are insync with nature they understand..
And diseases are reasons and problems which disturbs that sync..
PPM 1 - 👍
PA - I am not saying that allopathy is not seeing things in deep..
I am just expressing the problem...
Because of having a focused view on a particular organ which sometimes removes the eye to see the human as an entire person (organism)
And sometimes Due to Following the same protocols without seeing every case as different and new.
PPM 1 - 👍
PA - @PPM1 sir Doctor requesting you to guide the patients further steps
And further understanding the source of the disease and what would be the possible treatment protocol Or diagnosis needs to be done 🙏
PPM 1 - From the dominant mainstream medicine perspective, I guess the next step is renal transplant but from the other systems perspective it would be trying other systems approaches along with dialysis sos.
Wish I knew more about other systems approaches. As pointed out by @PPM2 our training in general medicine doesn't cover these other approaches well enough as the evidence generated for these other approaches currently don't make it to the mainstream but I have added @PPM3 here who has been a collaborator with us in our attempts to learn more about how to integrate all these approaches and I shall be looking forward to his inputs.
PA - Do you think.. Biopsy is required and any other views on the Kidney effects ?
And can u guide as to.. How we decide the dialysis frequency is it based on number or symptoms?
PPM 2 - I would recommend you to check out The Liver Doctor.
PPM 1 - For mainstream medicine it's useful to be able to visualise the anatomical location of the problem at a microscopic level by taking a tissue sample aka biopsy although it may not change the current treatment plan and one of the reasons it's difficult to decide about whether we should test or not is because there's an old adage suggesting that if we know that the treatment doesn't change with a test result then the test may not have been necessary in the first place.
Having said that biopsy is a necessity in academic centres as it would help us to gather a collective shared understanding of the problem in micro anatomical terms.
In the article on what are the mainstream approaches to preserve residual renal function that I shared above earlier, there's some mention of twice daily dialysis as one approach along with meticulous avoidance of any triggers toward further renal injury and the article more or less well covers all mainstream medicine may have to offer in this situation.
PPM 3 - December 2022 to July 2024 appears to be the period when Creatinine spiked to 8. Was he evaluated/followed up during that period as to why was it escalating ?
The narrative says he used some ayurvedic medicine during that period on self, and after that pedal edema and spiked creatinine to 8 (prior to that 1.7). Any other creatinine values just before starting that self medication and immediately after can give us a picture if the the initial assault could be DIKI (Drug Induced Kidney Injury)?. I just happened to see a similiar case last week where patient landed into DIKI post usage of a unnamed herbal decoction from a folklore healer.
PPM 1 - 👍
PA - No values in that period nor he went to any doctor.
PPM 3 - Okay.
PPM 2 - In your critical thought - what do you think are the pitfalls or harms of alternative medicine?
You've clearly highlighted the ones with modern medicine. Curious to hear your views.
19-01-2025
PPM 1 - An AI assisted attempt to integrate mainstream and alternative pathways to patient centered care 👇
Looking forward to real world critiques:
[19/01, 08:37]: Can we think of the complement activation system and it's alternative pathways analogous to the connection between mainstream medicine and alternative medicine?
[19/01, 08:37] Meta AI: What an intriguing idea!
The complement activation system, a part of the innate immune system, can be seen as analogous to the relationship between mainstream medicine and alternative medicine in several ways:
Classical Pathway (Mainstream Medicine)
1. Triggered by specific antigens: Mainstream medicine is often triggered by specific, evidence-based diagnoses and treatments.
2. Well-defined and regulated: Mainstream medicine follows established guidelines, regulations, and standards of care.
3. Activation leads to a coordinated response: Mainstream medicine involves a coordinated response from healthcare professionals, following established protocols.
Alternative Pathway (Alternative Medicine)
1. Triggered by non-specific factors: Alternative medicine may be triggered by non-specific factors, such as patient preferences, cultural influences, or personal experiences.
2. Less defined and regulated: Alternative medicine often operates outside of mainstream medical regulations and standards.
3. Activation leads to a diverse response: Alternative medicine encompasses a wide range of practices, such as acupuncture, herbalism, and homeopathy, which may not be universally accepted or evidence-based.
Lectin Pathway (Integrative Medicine)
1. Bridges the classical and alternative pathways: Integrative medicine aims to combine mainstream medical practices with evidence-based alternative therapies.
2. Recognizes the importance of both pathways: Integrative medicine acknowledges the value of both mainstream and alternative approaches, seeking to integrate the best of both worlds.
This analogy highlights the complex relationships between mainstream medicine, alternative medicine, and integrative medicine. While mainstream medicine provides a foundation for evidence-based care, alternative medicine offers diverse perspectives and approaches. Integrative medicine seeks to bridge the gap between these two pathways, promoting patient-centered approach to healthcare.
26-01-2025
PA - Pregabalin Methylcobalamin Capsules. This medicine was suggested by doctor for leg burning in Feb 2023.. And used for 2 months.
Made patient so drowsy and he eventually stopped it.
PPM 1 - Yes that's a bad side effect
I guess he's good since stopping it from May 2023?
27-01-2025
PA - Namaskaram everyone,
My dad's hemoglobin is at 6
And till now 2 (500ml) of fcm iron injections were givenfrom past 2 weeks
But hemoglobin.. Didn't get increased
When some one suggested to do blood transfusion
There is resistance.. I don't know why?
Some one told me that.. We should do blood transfusion.. If u r going for transplantation in future..
Any one knows why?
Want to Tell you very openly something patient creatinine level went to 23 and even before that for 6 months the creatinine values were above 10 but right now the value is 10 constant but because of the dialysis the symptoms that he is facing is so much...he is having constant cough and his very restless
What happened in past 2 weeks for him is more troubling than what happened in 6 months.
Only the number got down from 23 to 10 but the symptoms got increased.
And there is a theory that.. If hemoglobin or blood increases in the body..
The creatinine and urea in the blood will also look low.. Because of the quantity of blood getting increased..
Like a proportionate decrease happens?
PPM 3 - Is anytime Erythropoietin advised or used by him?
PA - Yes sir, he has used the erythropoietin in the past.
After every dialysis.. They are giving Erythropoietin.
PPM 3 - Okay.
PPM 1 - To answer your question regarding efficacy of blood transfusion before renal transplant here's a longish answer:
Historical Context
In the 1970s and 1980s, blood transfusions were commonly used to modulate the immune system and improve graft survival in renal transplant patients. The idea was that blood transfusions would induce a state of immune tolerance, reducing the risk of rejection.
Efficacy:
Numerous studies have investigated the efficacy of pre-renal transplant blood transfusion. A meta-analysis published in the New England Journal of Medicine in 1999 found that:
- Blood transfusions reduced the risk of acute rejection by 27%
- Blood transfusions improved graft survival at 1 year by 12%
- Blood transfusions had no significant effect on patient survival
However, a more recent Cochrane Review published in 2011 found that:
- There was no significant difference in graft survival or acute rejection rates between patients who received blood transfusions and those who did not
- Blood transfusions may actually increase the risk of certain adverse events, such as transfusion-related infections and malignancies
Current Practice
Given the mixed evidence and potential risks associated with blood transfusions, this practice is no longer widely recommended or used as an immunomodulatory strategy in renal transplantation.
Instead, modern immunosuppressive regimens and desensitization protocols have become the standard of care for managing immune responses in renal transplant patients.
In summary, while pre-renal transplant blood transfusion was once thought to be beneficial, the current evidence suggests that its efficacy is limited, and it is no longer a recommended practice.
PPM 3 - 👍
PPM 1 - To answer the question as to why his hemoglobin isn't improving, we may have to confirm if the team has addressed all the issues enumerated below:
Also we need to see his Hb trends since when he was first diagnosed
1. Erythropoietin deficiency: Erythropoietin (EPO) is a hormone produced by the kidneys that stimulates red blood cell production. In CRF, EPO production is reduced, leading to decreased red blood cell production.
2. Iron deficiency: Iron is essential for hemoglobin production. In CRF, iron deficiency can occur due to blood loss during dialysis, reduced dietary iron intake, or increased iron requirements.
3. Chronic inflammation: Chronic inflammation is common in CRF and can lead to anemia by reducing EPO production, increasing hepcidin levels (which reduces iron absorption), and promoting the production of inflammatory cytokines that suppress erythropoiesis.
4. Vitamin deficiencies: Deficiencies in vitamins such as B12 and folate can contribute to anemia in CRF.
5. Blood loss: Blood loss during dialysis or due to gastrointestinal bleeding can contribute to anemia.
6. Bone marrow suppression: Certain medications used to treat CRF, such as ACE inhibitors and NSAIDs, can suppress bone marrow function, leading to anemia.
Diagnostic Approach
1. Complete Blood Count (CBC): To evaluate hemoglobin, hematocrit, and red blood cell indices.
2. Iron studies: To assess iron deficiency, including serum iron, transferrin saturation, and ferritin levels.
3. Erythropoietin (EPO) level: To evaluate EPO production.
4. Vitamin B12 and folate levels: To assess for deficiencies.
5. Bone marrow biopsy: To evaluate bone marrow function and morphology.
Therapeutic Approach
1. Erythropoiesis-stimulating agents (ESAs): To stimulate red blood cell production, such as epoetin alfa or darbepoetin alfa.
2. Iron supplementation: To address iron deficiency, either orally or intravenously.
3. Vitamin supplementation: To address vitamin deficiencies, such as vitamin B12 or folate.
4. Blood transfusions: To rapidly increase red blood cell count in severe anemia.
5. Addressing chronic inflammation: Through medications or lifestyle modifications to reduce inflammation and promote erythropoiesis.
6. Dialysis optimization: To minimize blood loss and optimize dialysis treatment.
The therapeutic approach should be individualized based on the underlying cause of anemia, the patient's clinical status, and the presence of any comorbidities.
PA - 
Free Light Chain latest report.
Is this light chain test.. Something to do with bone marrow?
If yes.. Why did we talk about bone marrow biopsy?
PPM 1 - It's a test used to look for multiple myeloma in patients of renal failure.
However it cannot totally alone confirm multiple myeloma as for that bone marrow will be necessary.
As in your patient it was negative the matter may not have been pursued further and rightly so.
We have another 57 year old patient on follow up of another PaJR Team member here where this ratio was strongly positive that helped in her diagnosis of multiple myeloma 👇
No comments:
Post a Comment