tasks for week 11

overview of diabetes mellitus,insipidus and insulin pen_sri

nephrotic syndrome

pathophysiology( parts of kidney affected,what?where?how?)
overview of oedema( in relation to nephrotic syndrome + albumin levels + cholesterol levels)
acquire hospital form_ ji keon and madhura

signs and symptoms, risk factors_vivian

Investigations and blood test_christine

GFR,normal vs pathological
24hr urine test( comparison b/w normal and pathological)_lawrence

management, prognosis and complications_shantz
_________________________________________________________________________

epidemiology of diabetes mellitus and nephrotic syndrome in m'sia, aus and around the world_john

antipathy of patient towards the healthcare system
management of the antipathy_chris
_________________________________________________________________________

groupings for research on treatment of diabetic complications
1)vivian, sri and ji
2)lawrence, shantz, chris
3)the rest

hey,sri beware of THE CHAIRMAN.oh,sorry about being late today,in view of my lateness,i shall bring some food on friday to make everyone happy!!!ahahahha,ok,i betta NOT forget that.hmm.

LOTS OF LOVE AND HATE
THE CHAIRMAN

Components of Blood, Blood Transfusion, Units of Blood & IV Drips

(Note: Main points are in bold, and highlighted)

Components of blood:

Also,

Albumin: really useful when treating anyone who's been severely shocked or burned, or anyone who's lost large amounts of blood.

Clotting factors : One of the major agents in plasma is Factor VIII.

Immunoglobulins: protective antibodies which form when you're recovering from an infection or have received some immunisation. Basically they're proteins generated by your white blood cells which attack whenever any foreign proteins enter your body.

Non-specific immunoglobulins: contain the antibodies to treat deficiencies of immunoglobulin, the kinds associated with certain diseases or inherited conditions. This helps in preventing any unpleasantness like hepatitis A, and is made from the plasma from normal donors, many of whom already have antibodies to hepatitis A.

Specific immunoglobulins contain specially selected antibodies, chosen to treat a specific infection. For example, donors who have had chicken pox will have high levels of chicken pox antibodies. So their plasma will be ideal for children with leukaemia who have been exposed to chicken pox, and also to prevent any potentially life-threatening diseases.

Anti-D immunoglobulin which is given to pregnant women: If a Rh negative woman is pregnant with a Rh positive baby, some of junior's blood may enter her system during birth. Her blood may then start producing anti-D (or anti-Rh) antibodies. And if her next baby happens to be Rh positive, then her blood will go on the attack. This can be neutralised by giving her an anti-D immunoglobulin injection straight after the birth of her first baby.

Blood Transfusion:

A blood transfusion is the transfer of blood or blood products from one person (donor) into another person's bloodstream (recipient).

Autologous Blood (using your own blood):

Pre-operative donation - donating your own blood before surgery; for non-emergency (elective) surgery.

Intra-Operative Autologous Transfusion - recycling your blood during surgery. Blood lost during surgery is filtered, and put back into your body during surgery; for emergency and elective surgeries.

Post-Operative Autologous Transfusion - recycling your blood after surgery. Blood lost after surgery is collected, filtered and returned to your body; for emergency and elective surgeries.

Hemodilution - donating your own blood during surgery. Immediately before surgery, some of your blood is taken and replaced with IV fluids. After surgery, your blood is filtered and returned to you; for for elective surgeries.

Apheresis - donating your own platelets and plasma. Before surgery, your platelets and plasma, which help stop bleeding, are withdrawn, filtered and returned to you when you need it later; for elective surgeries.

Homologous/Donor Blood (Using someone else's blood):
All donor blood is tested for safety making its risks very small, but no screening program is perfect and risks, such as contraction of the hepatitis virus, still exist.

Volunteer blood - blood collected from the community blood supply (blood banks).

Designated donor blood - blood is collected from the donors you select. You can select people with your own blood type who you feel are safe donors.

Cross-matched blood - Before the blood is administered, the personal details of the patient are matched with the blood to be transfused, to minimize risk of transfusion reactions.

Uncross-matched blood - If there is no time, the blood is called uncross-matched blood; it is O-positive or O-negative. O-negative is usually used for children and women of childbearing age.

Blood can only be administered intravenously. A unit (1 pint; abt. 500 ml) of blood is typically administered over 4 hours. On average an adult has approximately seven to nine units of blood. Acetaminophen and/or an antihistamine such as diphenhydramine are sometimes given before the transfusion to prevent a transfusion reaction.

Examples Of Blood Use	Average # Of Units Required
Automobile Accident	50 units of blood
Heart Surgery	6 units of blood 6 units of platelets
Organ Transplant	40 units of blood 30 units of platelets 20 bags of cryoprecipitate 25 units of fresh frozen plasma
Bone Marrow Transplant	120 units of platelets 20 units of blood
Burn	20 units of platelets

Intravenous drip: continuous infusion of fluids, with or without medications, through an IV access device. This may be to correct dehydration or an electrolyte imbalance, to deliver medications, or for blood transfusion. There are two types:

Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules.

Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid.

The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). The sodium concentration of isotonic saline is equivalent to the normal sodium concentration of plasma water.

Saline is indicated to repair an inadequately filled intravascular volume or to replace ongoing or anticipated losses of sodium-containing fluid from the vascular space. Saline stays in the extracellular space (about 20% of body weight) and it therefore effectively expands intravascular volume. Normal saline is typically the first fluid used when dehydration is severe enough to threaten the adequacy of blood circulation and is the safest fluid to give quickly in large volumes.

Planning of saline therapy should be based on the desired amount of volume expansion—a percentage of the normal ECF volume, monitored by measuring body weight—and saline prescriptions should include the total amount of fluid to give, not just the rate of infusion.

Other solutions that are used:

Ringer's lactate or Ringer's acetate (ASERING, patented brandname of Otsuka Indonesia) is another isotonic solution often used for large-volume fluid replacement.

A solution of 5% dextrose in water, sometimes called D5W, is often used instead if the patient is at risk for having low blood sugar or high sodium.

The choice of fluids may also depend on the chemical properties of the medications being given.

Sources:

http://qjmed.oxfordjournals.org/cgi/content/full/96/8/549
http://www.answers.com/topic/saline-solution-
http://www.bloodtransfusion.com/facts.asp
http://www.blood.co.uk
http://www.answers.com/blood%20transfusion?ff=1

Urinary catheter

-Catheters come in a large variety of sizes, materials (latex, silicone,Teflon) and
types (Foley catheter, straight catheter, coude tipcatheter).
-It is recommended to use the smallest size of catheter,if possible. Some people may
require larger catheters to control leakage of urine around the catheter or if the
urine is thick and bloody or contains large amounts of sediment.
(Be aware that larger catheters are more likely to cause damage to the urethra)
-Some people have developed allergies or sensitivity to latex after long-term latex
catheter use. These people should use the silicone or Teflon catheters.

HOW TO CARE FOR YOUR CATHETER

Most experts advise against routine changing (replacing) of the catheters. If the catheter is clogged, painful, or infected it may require immediate replacement. Routine care of the indwelling catheter MUST include daily cleansing of the urethral area (where the catheter exits the body) and the catheter itself with soap and water. The area should also be thoroughly cleansed after all bowel movements to prevent infection. Experts no longer recommend using antimicrobial ointments around the catheter as they have not been shown to actually reduce infections.

HOW TO INSERT A CATHETER (MEN)

1. Assemble all equipment
2. Wash your hands.
3. Apply the sterile gloves.
4. Lubricate the catheter.
5. Hold the penis on the sides, perpendicular to the body. Stretch the penis away from the body.
6. Begin to gently insert and advance the catheter.
7. You will meet resistance when you reach the level of the external sphincter.
Try to relax by deep breathing, and continue to advance the catheter.
8. Once the urine flow starts, continue to advance the catheter to the level of the "Y" connector. Hold the catheter in place while you inflate the balloon.

Caution : Some men have developed urethral injuries due to the balloon being inflated in the urethra. Care must be taken to ensure the catheter is in the bladder. You may try to irrigate the catheter with a few ounces of sterile water. If the solution does not easily return, you may not have the catheter far enough in the bladder.

9. Secure the catheter, and attach the drainage bag.

HOW TO REMOVE A CATHETER

Indwelling catheters may be removed in 2 ways. One method is to attach a
small syringe to the inflation port on the side of the catheter. Draw out
all the fluid until you are unable to withdraw any more fluid. Slowly
pull the catheter out until it is completely removed.

Some health care providers instruct their patient's to cut the inflation
port tubing before it reaches the main tubing of the catheter. After all
the water has drained out, slowly pull out the catheter until it is
completely removed. Be careful not to cut the catheter anywhere else.
If you cannot remove the catheter with only slight pulling, notify your
health care provider immediately.

Notify your health care provider if you are unable to urinate within 8
hours after catheter removal, or if your abdomen becomes distended and
painful.

Learning Objectives for PCL Week 8 (A Big Night Out)

1. Understand that the kidney is a key regulatory organ, integrated into a whole body system
2. Describe the structure and function of the kidneys
3. Understand the mechanisms of glomerular filtration
4. Understand some of the potential consequences of kidney failure
5. Appreciate the importance of the renal tubules in the fine regulation of sodium and water balance
6. Understand the importance of road trauma as a cause of death and appreciate some of the strategies to minimise it

(Posted by: Vivian)

signs and symptoms of acute renal failure

Signs and symptoms of acute renal failure(ARF)

Clinically there may be no symptoms or signs of ARF but oliguria is common( urine output < 400ml/24h). ARF can be detected with rising plasma urea and creatinine.

In normal person
Urea 1.8g/dl conc, 21g/day output,2.5-6.7mmol/l in serum
Creatinine 150mg/dl, 1.8g/day output, 70-50 micromol/l in serum



Patients with acute renal failure, tx underlying cause

Pre renal uraemia ( uraemia: raised serum urea concentration): impaired perfusion of the kidneys with blood

Signs and symptoms
Anorexia
Nausea
Pruritus
Clouding
Drowsiness
Fits
epistaxes

kumar and clarke
oxford clinical medicine

signs and symptoms of chronic renal failure

Signs and symptoms of chronic renal failure

Early stages of CRF are often asymptomatic.
Symptoms are common when the serum urea concentrations exceed 40mmol/l but many patients develop uraemic symptoms at lower levels of serum urea.

Symptoms include:
malaise, loss of energy
loss of appetite
insomnia
nocturia and polyuria due to impaired concentrating ability
itching
nausea, vomiting and diarrhoea
paraesthesiae due to polyneuropathy
Bone pain due to metabolic bone disease
Paraesthesiae and tetany due to hypocalaemia
Symptoms due to salt and water retention- peripeheral or pulmonary oedema
Symptoms due to anaemia
Amenorrhoea in women, erectile dysfunction in men

In more advanced uraemia ( serum urea >50-60 mmol/l), symptoms are more severe, and CNS symptoms are common
mental slowing, clouding of consciousness,seizures
myoclonic twitching


anaemia: pallor, lethargy, breathlessness on exertion
platelet abnormality: epitaxis, bruising
skin: pigmentation, pruritus( itching)
GI tract: anorexia, nausea, vomiting, diarrhoea
Endocrine/ gonads: amenorrhoea, erectile dysfunction, infertility
CNS: coma, confusion, fits
CVS: uraemic pericarditis, hypertension, peripheral vascular disease, heart failure causing oedema
Renal: nocturia, polyuria, salt and water retention causing oedema
Renal osteodystrophy: osteomalacia, muscle weakness, bone path, hyperparathyroidism, osteosclerosis

Kidney function tests

'Kidney function test' is a collective term for a variety of individual tests and procedures that can be done to evaluate how well the kidneys are functioning.

Blood tests

There are also several blood tests that can aid in evaluating kidney function. These include:

Blood urea nitrogen test (BUN).
Urea is a by-product of protein metabolism. This waste product is formed in the liver, then filtered from the blood and excreted in the urine by the kidneys. The BUN test measures the amount of nitrogen contained in the urea. High BUN levels can indicate kidney dysfunction, but because blood urea nitrogen is also affected by protein intake and liver function, the test is usually done in conjunction with a blood creatinine, a more specific indicator of kidney function.

Creatinine test.
This test measures blood levels of creatinine, a by-product of muscle energy metabolism that, like urea, is filtered from the blood by the kidneys and excreted into the urine. Production of creatinine depends on an individual's muscle mass, which usually fluctuates very little. With normal kidney function, then, the amount of creatinine in the blood remains relatively constant and normal. For this reason, and because creatinine is affected very little by liver function, an elevated blood creatinine is a more sensitive indication of impaired kidney function than the BUN.

Other blood tests. Measurement of the blood levels of other elements regulated in part by the kidneys can also be useful in evaluating kidney function. These include sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphorus, protein, uric acid, and glucose.



Urine Tests

There are a variety of urine tests that assess kidney function. A simple, inexpensive screening test, called a routine urinalysis, is often the first test administered if kidney problems are suspected. A small, randomly collected urine sample is examined physically for things like color, odor, appearance, and concentration (specific gravity); chemically for substances such a protein, glucose, and pH (acidity/ alkalinity); and microscopically for the presence of cellular elements (red blood cells, white blood cells, and epithelial cells), bacteria, crystals, and casts (structures formed by the deposit of protein, cells, and other substances in the kidneys' tubules). If results indicate a possibility of disease or impaired kidney function, one or more of the following additional tests is usually performed to more specifically diagnose the cause and the level of decline in kidney function.

Creatinine clearance test.
This test evaluates how efficiently the kidneys clear a substance called creatinine from the blood. Creatinine, a waste product of muscle energy metabolism, is produced at a constant rate that is proportional to the muscle mass of the individual. Because the body does not recycle it, all of the creatinine filtered by the kidneys in a given amount of time is excreted in the urine, making creatinine clearance a very specific measurement of kidney function.The test is performed on a timed urine specimen--a cumulative sample collected over a two to twenty-four hour period. Determination of the blood creatinine level is also required to calculate the urine clearance.

Urea clearance test.
Urea is a waste product that is created by protein metabolism and excreted in the urine. The urea clearance test requires a blood sample to measure the amount of urea in the bloodstream and two urine specimens, collected one hour apart, to determine the amount of urea that is filtered, or cleared, by the kidneys into the urine.

Urine osmolality test.
Urine osmolality is a measurement of the number of dissolved particles in urine. It is a more precise measurement than specific gravity for evaluating the ability of the kidneys to concentrate or dilute the urine. Kidneys that are functioning normally will excrete more water into the urine as fluid intake is increased, diluting the urine. If fluid intake is decreased, the kidneys excrete less water and the urine becomes more concentrated. The test may be done on a urine sample collected first thing in the morning, on multiple timed samples, or on a cumulative sample collected over a twenty-four hour period. The patient will typically be prescribed a high-protein diet for several days before the test and asked to drink no fluids the night before the test.

Urine protein test.
Healthy kidneys filter all proteins from the bloodstream and then reabsorb them, allowing no protein, or only slight amounts of protein, into the urine. The persistent presence of significant amounts of protein in the urine, then, is an important indicator of kidney disease. A positive screening test for protein (included in a routine urinalysis) on a random urine sample is usually followed-up with a test on a 24-hour urine sample that more precisely measures the quantity of protein.



Abnormal results

Low clearance values for creatinine and urea indicate diminished ability of the kidneys to filter these waste products from the blood and excrete them in the urine. As clearance levels decrease, blood levels of creatinine and urea nitrogen increase. Since it can be affected by other factors, an elevated BUN, by itself, is suggestive, but not diagnostic, for kidney dysfunction. An abnormally elevated blood creatinine, a more specific and sensitive indicator of kidney disease than the BUN, is diagnostic of impaired kidney function.

Inability of the kidneys to concentrate the urine in response to restricted fluid intake, or to dilute the urine in response to increased fluid intake during osmolality testing may indicate decreased kidney function. Because the kidneys normally excrete almost no protein in the urine, its persistent presence, in amounts that exceed the normal 24-hour urine value, usually indicates some type of kidney disease as well.





Imaging tests (X-rays etc.)
A number of different kinds of test can be used to show the kidneys. These are some common examples.




Ultrasound is the most commonly used technique. It uses sound waves, not X-rays, and seems to be completely safe, even in pregnancy. The pictures look better during the examination than when 'stills' are shown.




CT - Computed tomography, the 'CAT scan', is widely used to show organs and structures.

MRI - Magnetic resonance imaging is another type of cross-sectional imaging like CT. It is sometimes useful for showing particular regions well, and it can sometimes be used to show blood vessels as an alternative to arteriography




IVU (or IVP) - intravenous urography (or pyelography). In this test an injection of a substance that is eliminated through the kidneys is given. This shows up on X-rays, and it can be followed travelling from the kidney, down the ureters into the bladder. It is useful for showing the ureters and for suspected kidney stones.





Arteriography (angiography) This is a way of showing the blood supply to the kidneys. It usually requires injection of contrast material into the artery that you are trying to see.



sources:

http://findarticles.com/p/articles/mi_g2601/is_0007/ai_2601000790
http://kidney.niddk.nih.gov/kudiseases/pubs/kidneytests/index.htm
http://renux.dmed.ed.ac.uk/edren/EdRenINFObits/NormalKidney.html


prepared by Chris Sim