Patient Care

12 Things Hospitalists Need to Know About Nephrology


 

One number alone should be enough for hospitalists to want to know everything they can about kidney disease: 26 million. It’s the number of Americans that the National Kidney Foundation estimates to have chronic kidney disease (CKD). That’s about the same number as the American Diabetes Association’s estimate for Americans battling diabetes.

And a lot of people who have CKD don’t even know they have it, kidney specialists warn, making it that much more important to be a knowledgeable watchdog looking out for people admitted to the hospital.

The Hospitalist talked to a half-dozen experts on kidney disease, requesting their words of wisdom for hospitalists. The following are 12 things the experts believe hospitalists should keep in mind as they care for patients with kidney disease.

1) Coordination is key, especially with regard to medications and dialysis after discharge.

A goal should be to develop a “tacit understanding of who does what and just trying to see each day that everyone’s working toward the same goal, so I’m not stopping fluids and then you’re starting fluids, or vice versa,” says Ted Shaikewitz, MD, attending nephrologist at Durham (N.C.) Regional Medical Center and a nephrologist at Durham Nephrology Associates.

A key component of hospitalist-nephrologist collaboration is examining and reconciling medications.

“If it looks like they’re on too many medications, then call the specialist, as opposed to each of you expecting the other one to do it,” he says. “Just pare things down and get rid of things that are unnecessary.”

Often, Dr. Shaikewitz says, the hospitalist and the nephrologist both are reluctant to stop or tweak a medication because someone else started the patient on it. He stresses that the more a medication regimen can be simplified, the better.

Coordination is especially important for dialysis patients who are being sent home, says Ruben Velez, MD, president of the Renal Physicians Association (RPA) and president of Dallas Nephrology Associates. If a nephrologist hasn’t been contacted at discharge, the nephrologist hasn’t contacted the patient’s dialysis center to arrange treatment after the hospitalization. And that treatment likely needs to be altered from what it was before the hospitalization, Dr. Velez explains.

The dialysis center needs to get a small discharge summary, so it’s important to get that ball rolling right away, he adds.

“It’s not uncommon for a nephrologist to round in the morning and suddenly realize that the patient was sent home last night,” he says. “We go, ‘Oops. Did somebody call the dialysis center?’ and we don’t know.”

Informing the nephrologist about discharge helps them do their jobs better, he says.

“My job and my clinical responsibility is, I need to contact the treating nephrologist. I need to contact the dialysis clinic,” he says. “I need to tell them, ‘Change your medications.’ I need to tell them there’s been added antibiotics or other things. I need to tell them what they came in with and what was done. And I need to tell them if there has been a change in their weight....The dialysis clinic has difficulty in dialyzing that patient unless they get this information.”

Hospitalists should provide a patient's dialysis center a small discharge summary, according to Dr. Velez.

Hospitalists should provide a patient’s dialysis center a small discharge summary, according to Dr. Velez.

2) Acknowledge the significance of small, early changes.

A jump in serum creatinine levels at the lower end of the range is far more serious than jumps when the creatinine already is at higher levels, says Lynda Szczech, MD, president of the National Kidney Foundation and medical director at Pharmaceutical Product Development.

“The amount of kidney function that’s described by a [serum creatinine] change of 0.1 when that 0.1” is between 1 and 2, “meaning going from 1.1 to 1.2 or 1.3 to 1.4, is huge compared to the amount of kidney function that is described by a change of 0.1 when you’re higher, when you’re going from 3.0 to 3.1,” Dr. Szczech says. “That’s important, because the earlier changes of going from 0.9 to 1.1 might not trigger a cause for concern, but they actually should be the biggest concern. When you go from a creatinine of 1 to 2, you’ve lost 50 percent of your kidney function. When you go from a creatinine of 3 to 4, you’ve probably lost about 10 percent.”

Hospitalists need to understand both the significance of the change and know “how to jump on something,” Dr. Szczech says. “That is probably the most important thing.”

3) Avoid NSAIDs in patients with advanced CKD and transplant patients.

“The nonsteroidal anti-inflammatory drugs can make your renal function much worse,” Dr. Velez says. “Those can finish your kidneys off, and you end up on dialysis.”

That concept is so simple that it’s commonly forgotten, he adds. Patients come to the hospital and are put on an NSAID and the kidneys are damaged.

“It’s horrible,” Dr. Velez says. “That’s one of the worst, and we want to avoid more damage to their kidney function.”

It’s such a common occurrence that the American Society of Nephrology (ASN) included it on their short list of suggestions for the American Board of Internal Medicine’s (ABIM) Choosing Wisely campaign, which aims to arm patients and providers with better information, promote evidence-based care, and reduce unnecessary testing and cost.

4) Don’t place PICC lines in advanced CKD and ESRD patients.

Placement of peripheral intravenous central catheter (PICC) lines in advanced CKD and end-stage renal disease (ESRD) patients is something hospitalists should “avoid as much as possible,” Dr. Velez says, “or forever.”

“PICC lines will destroy veins that we will need to use to create fistulas” needed for dialysis or potential dialysis, he explains.

This item also appears on the Choosing Wisely list.

What we hate to do is have [hospitalists] spend most of the day trying to manage a problem and then calling us late in the day or in the evening, especially if a procedure like dialysis would be needed at that point in time. It’s a lot harder to manage those troops, so to speak, once we let the day go. It’s a little bit more of a crash as opposed to a nice plan.


—Michael Shapiro, MD, MBA, FACP, CPE, president, Denver Nephrology

5) Take basic steps in cases of acute kidney injury (AKI), but be careful about ordering too many tests.

Dr. Shaikewitz says there is little point in hospitalists “ordering everything they can” before the nephrologist is even consulted. That said, certain basic steps—ultrasound, urinalysis, stopping NSAIDs, stopping angiotensin-converting enzyme inhibitors, and hydration—should be taken very early, he says.

But hydrating the patient really means achieving a “euvolemic state,” he explains.

“You don’t want to drown the patient,” Dr. Shaikewitz says. Once patients “clearly have enough fluid on board, then you can stop.”

Plus, while it might sound basic, looking back at old creatinine levels is crucial.

“Oftentimes, a lot of what is going on with a patient will become obvious, and the differential will become obvious, when you have more data,” he says.

He also says it’s important to keep in mind that “patients who are in flux with kidney issues often times can tolerate higher blood pressures,” and the goal should be to get it going in the right direction, not necessarily hitting a specific number.

6) Don’t wait for AKI to progress to needing dialysis before consulting the nephrologist.

As Michael Shapiro, MD, MBA, FACP, CPE, president of Denver Nephrology, puts it, “it doesn’t have to be a catastrophe or an emergency for us to be there within a very quick period of time.”

Nephrologists would rather help out earlier than later.

“What we hate to do is have [hospitalists] spend most of the day trying to manage a problem and then calling us late in the day or in the evening, especially if a procedure like dialysis would be needed at that point in time,” he says. “It’s a lot harder to manage those troops, so to speak, once we let the day go. It’s a little bit more of a crash as opposed to a nice plan.”

Hospitalists should adopt the “earlier is better” mantra for cases of electrolyte problems, such as hypokalemia, hyperkalemia, and significant hyponatremia, or low salt levels, he notes.

“We don’t mind being curb-sided,” Dr. Shapiro says. If the specialist gets a simple heads-up about a patient on the fourth floor—even if it doesn’t require immediate action—he can then pop in and check on the status of that patient when he’s there on his rounds, he says.

Dr. Shaikewitz admits that some kidney specialists prefer not to be called in very early; therefore, it’s important for hospitalists to develop relationships and understand individual preferences. But in his case, an early referral is favorable.

“When in doubt, refer a little bit on the early side,” he says. “It’s actually kind of a fun teamwork with the hospitalists, trying to manage the patient and doing everything as a group.”

The nonsteroidal anti-inflammatory drugs can make your renal function much worse. Those can finish your kidneys off and you end up on dialysis.


—Ruben Velez, MD, president, Renal Physicians Association, president, Dallas Nephrology Associates

7) Always call a nephrologist when a kidney transplant patient is admitted.

Robert Kossmann, MD, president-elect of the RPA, and other experts agree that it’s a good idea to at least call and inform a nephrologist that a transplant patient has been admitted. The call can go something like, “I have this patient coming in to the hospital, their kidney transplant function is fine, but they’re here with X, Y, or Z,” he says. “Is there something that we should be paying particular attention to or do you need to come see that patient?”

Dr. Kossmann says hospitalists don’t need to automatically consult a nephrologist every time, but “it’s probably a good idea to call and talk to the nephrologist every time.”

Dr. Velez says he’s seen a lot of unnecessary mistakes around transplant patients.

“There’s a lot of drug interactions with immunosuppressive drugs that these patients take that could have been prevented or avoided,” he says. “Even on patients that have fantastic renal function up to transplant … these patients can turn sour on a dime.”

8) Don’t forget the power of a simple urinalysis.

You can get a lot of diagnostic information from the urinalysis—“from a simple dipstick,” Dr. Szczech says. She points out the value of the specific gravity reading.

“A specific gravity of 1.010 in the setting of a rising creatinine [level] probably means you’ve got injury to the tubule,” she says.

The power of this simple tool can sometimes be overlooked, she says, as clinicians seek to understand how to use the newer biomarkers.

“In nephrology, we can make things quite complicated,” she adds. “We can’t forget about the low-tech stuff that we just take for granted.”

9) Simply looking at serum creatinine level is not enough.

It’s extremely important to calculate the glomerular filtration rate (GFR), says Katherine Tuttle, MD, clinical professor of medicine in the University of Washington’s division of nephrology. Some hospital labs will do this, but hospitalists need to “make sure they review the GFR values, not just the serum creatinine,” she says.

And those readings have important ripple effects.

“Everything from need for adjustment of drugs for low GFR to drug interactions to caution about, for example, using iodinated contrasts because of risk of acute kidney injury, increased risk of infection, increased risk of cardiovascular complications,” she says. “So it’s a very important part of the clinical assessment.”

10) Know the potential benefits of isolated ultrafiltration.

This dialysis-like procedure is becoming more widely recognized as helpful for patients with congestive heart failure who have recurrent readmissions.

“This is a very small group, but a very complicated group,” Dr. Kossmann says. “You can’t keep them out of the hospital.”

Isolated ultrafiltration can help “pull off quite a lot of fluid while they’re in the hospital or in a setting where you can do that,” he adds. “That’s something that I think hospitalists may be seeing more of as this unfolds into the future. It’s a small group of people, but there’s so much heart disease in this country that it winds up being a significant increase in number.”

11) Avoid using low-molecular-weight heparins, especially Lovenox, in advanced kidney disease and dialysis patients.

Don’t just follow the protocols for preventing thromboembolic events, says Dr. Velez, who adds it’s done “very frequently.”

“In this day and age of preventing thromboembolic [events], they have protocols where they just put them on it and they don’t realize they have advanced kidney disease or end-stage renal disease,” he says. “Heparin is fine. Lovenox should be avoided.”

Such mistakes are, in part, a product of operating within a protocol-driven environment.

“Dealing with a lot of protocols and algorithms and pressure from the hospital and you name it—and we’re all busy—we want to do the right thing,” Dr. Velez says. “But we don’t apply it to individual patients, and that’s a concern of having too many protocols and trying to treat everybody the same.”

Dr. Tuttle says the risk of “over-reliance” on protocols and guidelines is real.

“The problem with guidelines is people extrapolate them too far and they overinterpret them,” she says. “That happens in the hospital all the time.”

12) Take a moment and ask: Am I really comfortable handling this patient?

“It’s worth pausing at some point with yourself and sort of taking a self-assessment and saying—whether it’s nephrology, cardiology, or something else—‘Where do I feel confident and strong?’” Dr. Kossmann says. “Although it sounds overly basic, that’s an important starting point.”

He says he’s witnessed hospitalists with a wide range of comfort levels handle cases involving kidney dysfunction.

“There’s no one-size-fits-all,” he says. “Sometimes the question I get asked is, ‘Rob, what’s the general rule? When should a nephrologist be called for a consult?’ And that’s a terrible question, because it depends on the doctor who’s seeing the patient.”

Thomas Collins is a freelance writer in South Florida.

Bonus Tips: The Nitty-Gritty

When Dr. Velez, president of the Renal Physicians Association, sent out a blast email to 60 of his colleagues looking for tips for hospitalists, he says he got “tons of responses.”

Here are several tips of the nitty-gritty variety that he imparted, based partly on those responses, that didn’t make the top dozen but are nonetheless important.

  • Avoid using a dialysis catheter as an IV source unless it’s an emergency.
  • Don’t use IV gadolinium in MRIs in anybody with advanced chronic kidney disease or end-stage renal disease (ESRD): “This is common knowledge, but I want to bring it up,” he says. “It’s not a question of maybe.”
  • Avoid using Foley catheters in patients with ESRD who aren’t making urine. “And if we have to put one in, let’s take it out as soon as possible if patients aren’t making urine,” he says. “It’s just another source of infection.”
  • Adjust for glomerular filtration rate in patients on antibiotics.
  • Avoid using metformin in advanced CKD or ESRD. “It can cause a severe acidosis,” he says. Metformin also can be problematic in the event of a procedure requiring use of a contrast agent.
  • Don’t send patients to dialysis immediately after CT scans with contrast, contrary to common belief.
  • Don’t use phosphate- or magnesium-containing products to cleanse the colon in patients with advanced CKD or ESRD. “That’s general knowledge, but it still happens,” he says.

—Thomas R. Collins

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