Metabolic Flashcards
Prevention of AKI
Maintain perfusion
Correct hypovolaemia, cardiac output and blood pressire
Glycaemic control
Avoid nephrotoxic drugs
How often does a patient require hamodialysis
3 days a week
4 hours each session
Advantages and disadvantages of haemodialysis
Adv: treatment free days
Disadv: timely and costly travel, restrict fod and drinks
Explain how peritoneal dialysis works
Continuous Ambulatory Peritoneal Dialysis (CAPD): Portable but 2h a day dialysing (30-40 mins 4x a day)
Automated Peritoneal Dialysis (APD): Overnight
Advantages and disadvantages of peritoneal dialysis
Adv: easily at home, portable, fewer food restrictions
Disadv: risk of peritonitis, low protein/malnutrition
General advantages and disadvantages of dialusis
Adv: Life saving, relief from oneliness, can still exercise, swim and go on holiday
Disadv: depression, dependence on hospital, time consuming, impact social life, sie effects
Effects of incontinence
Stigma, distress, embarrassment, inconvenience, self-esteem , quality of life
Increases morbidity, depression and institutionalisation
Where are transplant patients registered
UK national transplant database
Who determines allocation
Medical professionals, DoH, advisory groups
Which transplants are urgent
Heart and liver
What is the allocation based of?
Tissue match (ABO/HLA) and number of points (length of time on list and age)
Types of donation
Cadaveric (brain death or cardiac death) Live donor (related or unrelated)
Brain death common then living then cardiac least common
What is the role of an independent assessor
Independent of transplant team
Sees donor and recipient
Ensures no coercion or compensation
Ensures donor is informed, has capacity, explores relationship
Licensed by the human tissue authority
Factors that affect the choice to transplant
Availability of organ
Waiting lists
Other recipients
Compliance with anti-rejection medication
Likelihood of organ abuse and effective transplantation
Adverse effects of organ donation
Organ rejection
Non-compliance with medication
Patients continue to drink/take drugs
What is the role of the Human Tissue Act
Regulates the removal, storage and use of human tissue
Define DNA theft
It is unlawful to have human tissue with the intention of DNA being analysed without consent from the donor
Offences under the human tissue act 2004
Removing, storing and using human tissue for purposes without consent or for another purpose than specified
Trafficking in human tissue
DNA theft
No license
Who cannot become an organ donor
Active cancer, HIV, Hep C
What system does the UK currently have
Opt out from spring 2020
The family will be approached before the donation and their decisions respected
Groups excluded from UKs opt out system
Under 18
Lack mental capacity to understand new arrangement
Visitors to england
Living in england less than 12 months
Organ donation in children under 18 years
The family will be asked to make a decision and provide consent
If a child wants to donate, parents must consent
What can individuals do if they want to donate but their family are against it
Nominate two representatives to be asked for you
How can an individual indicate their willingness to donate
Making wishes known to family and friends
Carrying a donor card and registering on the register
Difference between soft and hard opt out
Soft: e.g. spain, if relative hasn’t opted out then relatives can refuse
Hard: e.g. australia relatives views aren’t taken into account
Arguments for opt out system
Saves more lives at no cost to the individual (ethically correct thing to do)
UK law: corpse is not considered properly but relatives wishes will be taken into account (soft)
Positive stigma to donation
Still a choice to opt out
People might want to opt in but have never had the opportunity to
Arguments against the opt out system
People who believe in the afterlife may feel as though they are forfeiting access
Many religions do support donation
Upsetting to next of kin
Stigma to opting out - people might not want to but feel ashamed to
Shifts from autruistic giving organs to taking them
True consent (autonomy?)
Define altruism
Basis of donations in the UK, any other system would make it a market system
Arguments for and against a market system for donation
For: supply increased if remove donors, financial rewards lower healthcare costs, donation is cost-effective, each property has rights over their own body
Against: erodes sense of community, redistributes blood from poor to rich
Blood demand and supply
Demand drastically outweighs supply
Demand for surgery and medicine
Supply: 2 million donors a year, highest supply is A+/O+, lowest supply is O-ve (universal donor)
Risks of blood transfusion
Wrong blood type
infections
Contraindications for donation
Tattoo/piercing
Received blood since 1994
MSM in 12 months
Blood infections
Alternative to transplant
Dialysis - very expensive
What are PSA levels affected by
Levels affected by enlarged prostate, prostatitis, urine infection, exercise, ejaculation, anal sex, biopsy, medication e.g. finasteride
Who can get a PSA screening test
Men over 50 after talking to the GP (or over 45 with FHx)
Advantages of PSA
Helps to detect prostate cancer before symptoms
Early treatment
Save lives
Screening follows utilitarian logic - gives patient an informed choice
Disadvantages of PSA
Normal range can still indicate cancer
High range - commonly normal
Biopsy can cause pain, infection
Treatment can have side effects: incontinence, ED
Overdiagnosis: people who are diagnosed with cancer that will never cause sx during lifetime
Overtreatment: people treated unnecessarily for tumours that would unlikely be harmful
Diagnosis of diabetes for asymptomatic and symptomatic individuals
Symptomatic: fasting glucose 7, random or OGTT glucose 11.1
Asymptomatic: same on 2 occastions
HBA1c diagnostic
48 mmol/mol (6.5%)
When can HbA1c not be used
Haemoglobinopathies: Increased red cell turnover
Roles of the diabetes care team
Specialist nurse: care, support and advice, education programmes
Podiatrist: screen for foot problems which impact QOL, recommend footwear, debride wounds and refer to orthoticcs
Dietician: help pts make informed and practical decisions about their diet
Doctors
What doctors are involved in diabetes care
Endocrinologist: complex cases Nephrologist: renal complications Ophthalmologist: diabetic retinopathy Cardiologist: CV complications Neurologist: neuropathy/strokes
Diabetes targets
BP: 140/80 (130/80 if end organ damage)
HbA1c less than 7%
Cholesterol less than 5%
First line drug for diabetes htn
ACEi
Complications of diabetes
Microvascular: retinopathy, nephropathy, neuropathy
Macrovascular: peripheral vascular, cardio and cerebrovascular disease
Other: impaired would healing and infection
When does nephropathy occur in diabetics
15-25 years after diagnosis
Initial diagnosis of diabetes
Enter to diabetes register Full examination CV risk factors Medication review Educate! Refer to dietician Refer to screening programmes
Develop personalised management plan
Psychological and social impact of diabetes
Increased depression
Hide diagnosis
Unsure how to cope - fear of complications
Anxious about hypos
Monitor glucose
Affect insurance and driving
Psychosocial impact of endocrinological disease e.g. thyroid, pituitary, adrenal
Psychiatric disorders
Impact mood, weight and fatigue
Impact of regular medication and appointments
Change in appearance e.g. eyes
Causes of weight gain
Calorie intake is higher than calorie expenditure
Genetics Hormonal Medical conditions Behaviour: unhealthy eating habits Environment: fatty foods Social: unhealthy foods are cheaper, limited transport Modernisation: convenience food Urbanisation: more transport, less exercise
BMI
Healthy: 18.5-24.9
Overweight 25-30
Obese 30+ (5 mild, mod, severe)
Waist circumference
Men over 94 is high
Women over 80 is high
Medical conditions that increase if you’re overweight
Arthritis Cancer Carpal Tunnel Gout Surgical complications T2DM Renal disease Gallbladder and liver disease Sleep apnoea Urinary stress incontinence CVD Chronic venous insufficiency DVT/PE Stroke HTN
Assessment for obesity
Underlying causes Eating behaviours Comorbidities Risk asssessment (lipid, bp, HbA1c) FHx
When is referral needed
Complex disease state (e.g. learning disability)
Underlying cause
Surgery considered
Management for obesity
- advice, lifestyle intervention, 600cal deficit for weight loss
Medication: Orlistat (BMI above 30)
Bariatric surgery: BMI above 40, fit for surgery and committed to LT follow up
4 ways to tackle obesity
Increase exercise: cheaper gyms, more cycle paths and parks
Education: balanced diet
Legislation: advertising and tax
Schools: encourage activity and healthy dinners
Define impaired glucose tolerance
Blood glucose raised beyond normal levels but not enough for diabetes
Blood glucose between 7.9 and 11.1 after 2h OGGT
There is a long period of impaired tolerance that precedes diabetes, screening can identify these people and risk factors can be addressed
There is still a high risk of developing diabetes
Define prediabetes
Impaired glucose levels which are above normal but not high enough for diabetes
Impaired glucose tolerance or fasting glucose
Best method of reducing CVD risk in diabetes
Exercise and lifestyle modification is better than metformin at reducing risk
Goals of the diabetes prevention programme
Primary goal: to delay the development of T2DM in patients with impaired glucose tolerance
Secondary goal: Reduce CV disease events and risk factors
Define alloimmunisation
What increases the risk of it
Blood transfusion may immunise the recipient against the donor through antigens
Increased risk with repeated transfusions
Explain the ABO and RH blood system
ABO: IgM anti-A and anti-B antibodies
RH: IgG RhD antibodies
How often can you give blood
Men every 12 weeks
Women every 16 weeks
What happens during pretransfusion compatibility testing
ABO and RH groups determined
Atypical antibodies are screened
Tested against 2 O donors and red cell antigens
Selection of donor blood and crossmatching
Process of blood ordering
Elective: blood ready
Emergency: Two units O- (emergency)
10-15min: blood with same ABO and RH
45min: crossmatch
Complications of blood transfusion
Alloimmunisation (subsequent transfusions)
Haemolytic transfusion reaction (pain, rigor, sob, hypotension, hb in urine, DIC)
Non-haemolytic transfusion reaction (febrile reactions)
Urticaria (plasma protein incompatibility)
Infection
Avoidance of unnecessary transfusion
Strict criteria for blood products
Stop drugs that might cause bleeding in surgery
Treating anaemia prior to surgery
Anti-fibrinolytics
CHECK that the correct product is being transferred
transfusion associated deaths
Death via serious hazard of transfusion (SHOT)
Explain the structure of blood transfusion services
NHS Blood and Transplant
Health authority within the NHS that deals with blood, platelets, stem cells, tissues and organs
