FAQs about Dialysis Patients

We’ve just started a new academic year, so now’s a good time to review some uncertainties and myths surrounding the care of dialysis patients.

Hey the patient is on chronic dialysis = total kidney failure, therefore iodinated CT contrast is A-Okay?
It depends.
Residual kidney function (the patient still has urine output) means better outcomes in terms of survival, nutrition, quality of life and better control of electrolytes and anemia. The kidneys work 24/7 to clear toxins and volume, and are better than dialysis at clearing middle molecules like phosphorus and protein-bound uremic toxins.
So if the dialysis patient still makes urine, avoid nephrotoxins including iodinated CT contrast unless there is strong medical necessity. Protect those kidneys!

Well we really need to give the CT contrast, so we’ll just coordinate dialysis afterward and that will save the day right?
Evidence is mixed but suggests that dialyzing out IV contrast is ineffective. You sucker punched the kidneys, and there’s no take-backsies.
However if there is concern that the amount of contrast led to volume overload and is compromising lung function – dialysis can remove volume and help with that.

How about MRI gadolinium contrast? Is the answer also “it depends”?
Gadolinium = never ok! Nephrogenic systemic fibrosis. Rare, but BAD. Look it up.

The nephrologist threw a fit when I asked for a PICC line for IV antibiotics. Why is she so loco?
Please recite daily: NO PICC LINES IN DIALYSIS PATIENTS. This also applies to predialysis patients with advanced chronic kidney disease who are heading toward dialysis dependence.
To do dialysis requires a dialysis access. For hemodialysis patients, the preferred access is an arm arteriovenous fistula (AVF). For peritoneal dialysis patients, peritoneal membrane failure eventually occurs and they will have to switch to hemodialysis. PICC lines cause vein trauma thus predisposing to future AVF failure. Along the same lines, radial artery approach for left heart cath should be avoided in patients with advanced chronic kidney disease.
Switch to PO antibiotics if possible. Or pick IV antibiotics that can be given during dialysis (cefazolin, vancomycin, cefepime are examples). If prolonged IV access is absolutely necessary, a small-bore internal jugular tunneled catheter (like a Hickman) can be considered.
There will be exceptions based on an individual patient’s clinical situation and life expectancy – please discuss with your favorite nephrologist!

The dialysis diet is low sodium, low phosphorus, low potassium. My patient is diabetic so she can’t even have carbs. Can she eat anything??
We’re not saying zero. Daily limits are sodium 2 gm, potassium 2 gm, phosphorus 800 mg. The dialysis diet is complex – that’s why every dialysis unit has dedicated dietician(s).
She should eat a lot of protein. Dialysis is a catabolic treatment and patients are encouraged to eat high protein diets (1.2-1.5 g/kg/day) to avoid protein calorie malnutrition.

Are all renal supplement drinks good for all kidney disease patients?
No! The supplement drinks that are for dialysis patients (Nepro, Novasource) are HIGH protein (see above, dialysis patients are recommended to eat a lot of protein). These are NOT good for predialysis patients with advanced chronic kidney disease, who need to be on LOW protein diet which may be beneficial in slowing progression of kidney failure. An example of a low-protein supplement for predialysis patients is Suplena Carb Steady.

My patient is on chronic hemodialysis and does not have a clinic follow up scheduled with his nephrologist. What is this craziness?
Most hemodialysis patients are in-center (they go for scheduled dialysis treatments at a dialysis unit, typically 3 days per week) and their nephrologist will round on them at the dialysis center. So they don’t need a separate clinic appointment.
Patients who do home dialysis will see their nephrologist in clinic once per month.

My hemodialysis patient was started on a blood thinner. Do I need to let the nephrologist know?
Please ALWAYS let the nephrologist know when a dialysis patient is started on warfarin or apixaban. (Apixaban is currently the only FDA-approved direct oral anticoagulant for dialysis patients.) Heparin is often used in the dialyzer circuit to prevent clotting. If a patient is started on anticoagulation, heparin may be held since the oral anticoagulant may be sufficient.
From a big picture standpoint, the use of anticoagulation in dialysis remains controversial (see my prior blog).

Ok we decided anticoagulation is no longer needed (or maybe the patient self-discontinued her apixaban… true story). Everything ok now?
On the flip side, if oral anticoagulation is stopped, please notify the nephrologist so that heparin can be re-introduced. If a dialyzer circuit clots and blood cannot be returned to the patient, this is equivalent to losing a half unit of blood.

Wei Ling Lau Headshot
Wei Ling Lau, MD FASN is Assistant Professor in Nephrology at University of California-Irvine. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology. Follow her on Twitter @Kidneys1st.


Social Media In Medical Education: #mindboggling IMHO

I have always been late in the game in terms of catching up with social media.  When I started college in Canada, it took some convincing before I joined Friendster as a way to keep in touch with friends and family in Southeast Asia.  Friendster lost popularity soon after, thus I was not jumping on the boat when Facebook surfaced a few years later.  When it became apparent that FB was here to stay, I created an account and have found it to be valuable for maintaining connections in various circles (family, friends from elementary / high school / college / medical training, and last but not least, parents of my kids’ friends because that’s how I meet people now).  But until very recently I still viewed social media as “social” and kept it separate from “work” and professional development. 
Social icon collageThat all changed when I was accepted into the AHA Early Career Blogger team this recent November and was given an ultimatum to start a Twitter account.  I wanted to throw a fit right there on that comfy sofa in the #AHA17 Early Career lounge.  We already spend too much time with electronics – for research, scientific writing, patient care, charting, email, Facebook lurking.  I had the impression that Twitter was an avenue for self-promotion, cutesy looping videos and sales ads.  Why would I create a social media “work” account that wouldn’t get me grants or patient referrals?
This is what I have learned during my first 2 months on Twitter: a lot of great information.  I was correct to have misgivings in the sense that I am spending a *little* more time with my laptop.  (Had to get over the fear-of-missing-out mentality with an obsessive need to refresh that Home icon…)  The access to medical knowledge and peer experts is really quite amazing.  For a succinct discussion on the benefits – and limitations – of social media for medical professionals, check out the recent article by #AHAEarlyCareerBlogger @chadialraies.  From a nephrologist’s standpoint, below are some of the highlights of my Twitter experience to date:
Doctors and scientists doing each other’s homework: Posting a query to @askrenal or @nephjc taps into the collective Twitter nephrology community.  There are dedicated educators out there who regularly provide feedback and links to helpful publications.  Personal anecdotes from fellow clinicians are also valuable.  As an example, I was curious as to how other nephrologists were monitoring for severe hypocalcemia which can happen when denosumab (a relatively new osteoporosis drug) is given to patients with advanced chronic kidney disease; @hswapnil offered his approach and @edgarvlermamd forwarded a Japanese cohort study that had a lot of useful information (but may not have popped up on my radar as it was not PubMed indexed).
Gender and minority representation: It is encouraging to see the diversity and achievements showing up in the posts with #WomenInNephrology, #IlookLikeADoctor or similar hashtags.  (But don’t buy into this #ILookLikeANephrologist post.)
Live discussion forums: @nephjc hosts journal clubs where take-home points are summarized in high-yield visual abstracts and participants can join chat forums at designated times to contribute comments and questions to a live feed.  It was especially neat when both the lead author and senior author from the PRESERVE trial were online to answer questions – equivalent to a celebrity sighting in our world.  (See my prior blog about the PRESERVE trial.)
Inter-disciplinary learning: Who knew there were so many smart people out there besides nephrologists?  (just kidding!)  I read about platypnea-orthodeoxia syndrome, DNA-sensor technology to diagnose rare diseases, updates to the Infectious Diseases Society of America treatment guidelines for infectious diarrhea, and fascinating @neiltyson musings such as “If you accumulate all the flora, fauna, and metal your true love gives you each day in the “Twelve Days of Christmas” song, you’ll own 12 Trees, 40 Gold Rings, 140 Humans, and 185 Birds of 6 different species.”  I know some of this info will serve me well during Internal Medicine boards recertification.
Of course, careful judgment is warranted since no policies are in place to guarantee that social media reflects evidence-based medicine.  This an honor system that assumes medical professionals are engaging with social media in a responsible and ethical manner.  Medical education through social media has evolved as an area of research in itself; a search on PubMed using the keywords “social media AND medicine” yields >7000 reports.  When approached correctly, there is no doubt that social media is a powerful tool that connects patients, clinicians, scientists and industry, and facilitates learning via a global collective of experiences and differences.


Wei Ling Lau Headshot
Wei Ling Lau, MD is Assistant Professor in Nephrology at University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.