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confirmation of irreversible loss of consciousness along with irreversible loss of capacity to breathe and relies on the fact that key component of consciousness and respiratory control which are

Despite apparent differences, the clinical implication of brain death and brainstem death is identical. The patients with preserved cortical activity and cerebral blood flow will be regarded dead by brainstem criteria but not in the criteria where whole brain death criteria are applied.

death have been refuted because to adhere to standard guidelines9, 10 example using very high dose of fentanyl in a patient with hepatic or renal failure who suffered cardiac arrest and treated with hypothermialO. The adherence of guidelines is as important and as excluding the confounding variablesand therefore clinical examination should be thorough.

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Consensus on the criteria of brain death has a divide­ majority of centers follow US and UK guidelines which advocates that clinical diagnosis is adequate for determination of brain death. The discrepancies in the criteria for brain death in different countries differ basically on the following points:

  1. 2nd clinical examination to reduce errors in diagnosis but,

    1. It delays the diagnosis- loss of organs

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patient aged 65-69 years

for an aged matched person in general population 13.Two recent studies have developed risk scores to predict 6 month mortalityl4,15. These may be useful in informing discussions with patients but predicting individual prognosis is clearly imprecise. (With increasing age and dependency, progression of underlying medical conditions, or the emergence of new medical problems, life on dialysis may become difficult to bear. In such situations, it is important to recognise that end oflife may be approaching, signalling the need to re-focus the emphasis of care, from prolongation of life to relief of symptoms, maintenance of comfort and attention to psychological, social and spiritual concerns).

There is evidence that nephrology health care professionals


  1. Sanerl E, Nitsch D, Descoeudres C, et al. Outcome of home haemodialysis patients: a case-cohort study. Nephrol Dial Transplant 2005;20:604-610

  2. Nitsch D, Steenkamp R, Tomson C, et al. Outcomes in patients on home haemodialysis in England and Wales,1997-2005: a comparative cohort analysis. Nephrol Dial Transplant 2011; 26:1670-1677

  3. Ghossein C, Serrano A, Rammohan M, et al. The role of comprehensive renal clinic in chronic kidney disease stabilization and management: The Northwestern experience. Semin Nephrol2002;22:526-532

  4. Levin A, Lewis M, Mortiboy P, et al. Multidisciplinary

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    Journal of Renal Nutrition and Metabolism Vol 2 No 2 April- June 2016 RRT Counselling 9

    association between pre-dialysis education and delay in the need for dialysis initiation, often by many months, an effect which has been attributed to improved pre-dialysis management . Another consistent finding is that patients, who as part of pre-dialysis education have received adequate


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    Principlesof shared decision-making



information about available treatment options, were more

likely to choose a self-care based therapy as first modality - peritoneal dialysis in particular, but alsohome haemodialysis and minimal care haemodialysis. Patients malting a "good decision" about treatment options are more likely to adhere to treatment regimes and tolerate complications better than those not fully involved in the decision making processesl9,20. Incomplete presentation of treatment options may be a major reason for the under-utilization of home dialysis therapies and contribute to delayed access to transplantation . Pre-dialysis education may also influence employment status. People who had undergone pre-dialysis education were more likely to continue in workl 7. Finally, pre-dialysis education may also have a beneficial effect on both short-term23 and long-term survival. The risk of death in patients who did not receive pre-dialysis education has been estimated as double that in those who had received this education, and similar to that inlatereferrals .

In 2010, the IDEAL (Initiation of Dialysis Early and Late) study reported its findings from 828 incident adult patients commencing dialysis in 32 centres in Australia and New Zealand. Patients were randomised to receive dialysis early (eGFR 10-12 ml/min/1.73m2 based on the Cockcroft and Gault formula) or late (eGFR 5-7 ml/min/1.73m2). Although many of the late starters commenced RRT at an eGFR greater than 7 owing to the onset of symptoms, the study showed no benefit for starting dialysis early, before the onset of symptomsl7. Therefore, there seems to be no evidence to support the commencement of RRT prior to onset of symptoms. This emphasises the need to include patients in the discussion over timing ofinitiation of RRT.


Late Presentation CKD requiring immediate


dailysis

Late Presentation CKD requiring immediate


dailysis


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Tunnelled line Acnte PD

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Transolant assessment


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Not Fit for Tx


Discussion re: Dialysis No immediate live

donors

Fit for Tx


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Live dovors


Hospital -based therapy


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Home based Rx


HD


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Refer for AVF

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Indeuendent PD Assisted PD


Workup donors and proceed with Trasulant

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Although transplantation is shown to have the best outcomes, this may not be possible for many patients due to co-morbidity, lack of a donor or, sometimes, patient choice. When pre-emptive transplantation is not possible, timely referral for placement of either a peritoneal dialysis catheter or formation of definitive vascular access is essential (Table 1).

There are no adequate randomized controlled trials comparing outcomes of peritoneal dialysis (PD) versus haemodialysis (HD) or of home versus centre based therapies but there is considerable observational data which suggests


approach to renal replacement therapy"'

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'• All medically suitable patients should be informed about the advantages of pre­ emptive living kidney transplantation and efforts made to identify potential donor to allow pre-emptive transplantation before the need for renal replacement therapy'

prepare for RRT'

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Touma! of Renal Nutrition and Metabolism Vol 2 No 2 April- Tune 2016 Universal Precautions 6

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contamination of hands is likely to occur when in contact with mucous membranes, body fluids, and other secretions contaminated with blood, and serousfluids.

What tobeusedforhandwashing

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image ..._ ,.., ,_.._,,, .. -..,,-,... -, n..,·...,,.., .,... -.,.,-O"f.V-llo•­


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Soap, and water are best antiseptics. Hand rub is not a substitute to hand washing. In most circumstances non medicated soaps and detergents are effective in removing most transient contaminants. In demanding circumstances, in handling potentially harmful infections, use ethyl or isopropyl alcohol. Detergent formulations containing chlorhexidine, povidone, or hexachlorophene are effective in prevention of spread of infections Figure 1 shows steps of hand washing.


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Figure 1 Steps Of Hand Washing.

Use of Gloves: Use of a pair of disposable plastic gloves can protect if chances of contact with blood or body fluid is anticipated or inevitable.

Useofl\1ask,Cap,EyeWear

This protection will certainly protect from splashes of blood or body fluids. The importance of use of cap and mask should not be underestimated. It equally protects patients. Stringent use of mask and cap can save several lives in the hospital.

UP recommends the use of Personal Protective Equipment like gloves, aprons, gowns , protective eyewear, face shields, masks

Use Of Foot Wear:

Wearing foot wear covering entire sole protects the entry of microbes from the contaminated floors with blood and body fluids asmany of us have cracks onour feet.

While putting pressure to stop a bleeding wound, always wear gloves. Gloves should never be reused. Apply new bandage over bandage if saturated with blood

A simple thin plastic apron underneath the linen is of great help in preventing the soaking our inner clothes and exposure toharmfulmicrobes.

Universal Precautions also include: Proper handling and disposal of needles.

Taking precautions to prevent injury from scalpels, needles, and other sharp instruments.

Disposal of Needlesand Sharps

All used needles and sharps should be deposited in thick walled puncture resistant containers.Bending and reshaping, should be prohibited. Do not recap the needles to avoid needle stick injures. All used disposable syringes and needles should be discarded into bleach solution at the work station before final disposal.

Decontamination of Hospital Linen

All the linen contaminated with blood or body fluids should be soaked in 1: 100 bleach solution for 30 minutes. Autoclaving, is the most ideal procedu re for decontaminating linen

Blood borne pathogens cause Hepatitis B, Hepatitis C, acquired immunodeficiency syndrome (HIV). Hepatitis B is transmitted byblood,unprotected sex, intravenous (IV) drug users, household contacts (sharing razors, toothbrushes, drinking after person) .It can be treated with medications and vaccine is available.

Hepatitis C is transmitted Primarily by blood

,unprotected sex, non-sterile tattoos, syringes, cuts, etc. Vaccine for this infection is not available therefore, it may be treated with medication if chronic hepatitis develops and causes liver damage.

HIV/AIDS is transmitted by blood or unprotected sex. No vaccine available. Following universal precautions suchas hand washing, proper handling and disposal of sharps/contaminated materials, cleaning/disinfecting after anycontact with blood can prevent transmission of infection. Personal protection barriers like gloves, masks, goggles, etcas needed should be used.

Importance of Vaccination in Hepatitis B Infection.

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We have > 4.0 crore carriers with Hepatitis B infections. Every HCW is at risk of contacting infection. Vaccination is safe. Genetically engineered vaccination remains the great


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hope for prevention, apart from major component of

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due AIDS related complications. Eighty sixthousand (86000) new cases are added everyyear.

Prevalence of HBV and HCV

According to National Centre for Control of Disease (2001), in India the prevalence of HBV IS 3%, there are 4.0 crores carriers. 7.8 lacs people die due to HBV related complications . Ten lacs are always at risk for chronic hepatitis B.The Prevalence of HVC IS 1%, 1.22 lacs carrier state. Only 10- 30% people develop chronic hepatitis C, or hepatocellular carcinoma in 15-30 yearrs. WHO (200) report estimated 2.5% HIV, 40% HBV, 40% HCV cases m health care workers were due to related exposure. Studies have shown that knowledge and understanding of UPs were partial, and UPs compliance was suboptimal, only 32% wore

iillSHlH.CICU by

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washing is the single most important activity to decrease the spread of infections of all kinds

Method of Hand Hygiene

Apply a sufficient amount of soap/cleaner to hands. Rub hands vigorously for 10-15 seconds, scrub between fingers, under nails, tops of hands and wrist.Washing with simple toilet soap - reduces the rate of transmission of common infections including the HBV, HCV and HIV.

Indications for Hand Washing

Indications for hand washing are prolonged contact with patient, before taking care of immune supressed, new born infants, patients in ICU / ICCU, dialysis units, bum's nnits, before and after touching wounds, when microbial

Touma! of Renal Nutrition and Metabolism Vol 2 No 2 April- Tune 2016 Gliptins in CKD 4

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Only 1patient had a single hypoglycemic episode which could be attributed to his concomitant insulin therapy.Further, all patients maintained stable weight and stable renal function. A little reduction in creatinine clearance could be attributed to natural course of diabetic nephropathy.

Since gliptins were used as they became available in the market, we had only 1patient on vildagliptin and linagliptin. We could however compare saxagliptin and sitagliptin on which a majority of our patients were started. As canbe seen from table 1,there was no significant difference in characteristics of patients in the 2 groups. The glycemic control and changes in weight and creatinine clearance were not significantly different (p > 0.05).

The number of patients included in the study are few because this is an ongoing study and we have included only those patients who have completed atleast 6 months of follow-up

In our study, we excluded patients with end stage kidney disease requiring maintenance dialysis. Therefore, this study cannot be extrapolated to patients on maintenance dialysis. However, considering that linagliptin is not cleared by kidneys it should not be a problem using it in patients with ESKD on maintenance dialysis.

In summary,our studyshows that gliptins provide clinically useful glycemic control in patients with T2 DM and CKD. This is achieved without hypoglycemic episodes, without weight gain, and without unacceptable side effects. The renal function remained stablein all studypatients.

References

  1. Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India.AMJ 2014; 7:45-48

  2. Matsushita K, van der Velde M, Astor BC, Woodward M,Levey AS, de Jong PE et al. Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate

    and albuminuria with all-cause and cardiovascular mortality in general population cohorts: acollaborative

    meta-analysis. Lancet 2010; 375:2073-2081

  3. Patel A, MacMahon S, Chalmers J, Neal B, Billot L,Woodward M etal.;

    ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.N Engl J Med 2008;358:2560-2572

  4. Davidson MB, Peters AL: An overview of metformin in the treatment oftype 2 diabetes mellitus. Am JMed 1997;102: 99-110

  5. Krepinsky J, Ingram AJ, Clase CM: Prolonged sulfonylurea­ induced hypoglycemia in diabetic patients with end-stage renal disease. Am JKidney Dis 2000; 35: 500-505.

  6. Snyder RW, Berns JS. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease.Semin Dial 2004; 17:365.

  7. CHAHAL H AND. CHOWDHURY T.AGliptins: anew class of oral hypoglycaemic agent. QJMed 2007; 100:671-677.

  8. Cockcroft DW, Gault MH.Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41.

  9. Rajapurkar.M, Dabhi M, Burden of disease-prevalence and incidence of renal disease in India. Clinical Nephropathy 2010;74:9-12.

  10. UK Prospective Diabetes Study Group. Intensive blood­ glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.Lancet.1998;352: 837-53.