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Discussion

What do Primary Care APNs Want to Know about Nephrology?

  • Expert

Hi everyone.

I've been tapped to give a presentation to primary care APNs regarding tips about how to care for end stage renal disease patients in the primary care setting. So far, this is what I've come up with:

1. Medication dosing of common meds:

antibiotics

anticoagulants

anti-hypertensives

diabetic agents

diuretics

2. Dialysis access issues

bleeding

3. End of life issues

4. Interpreting lab results related to ESRD and dialysis

timing of obtaining blood samples

being aware of lab parameters for ESRD pts regarding anemia

5. Coordination of care between PCP and nephrology providers

What else do you have questions/concerns about? What other topics would you like to see covered?

Thanks much for your time.

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    • Featured Replies

    I've been trying to get a straight answer from our local nephrologist about the use of coumadin for AF in ESRD patients on dialysis.

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    Diabetes is huge for me. So many medications that can't be used at various stages. I recently acquired a patient on actos who was stage 3-4 ESRD and I was dumbfounded nobody took him off much sooner.

  • Quote
    • Author
    • Expert
    I've been trying to get a straight answer from our local nephrologist about the use of coumadin for AF in ESRD patients on dialysis.

    Totally fine but metabolism is not consistent so need pt/inr weekly. If in dialysis they should manage

  • Quote
    Totally fine but metabolism is not consistent so need pt/inr weekly. If in dialysis they should manage

    So you keep your patients on it?

    This is my concern:

    Shah, M., Avgil Tsadok, M., Jackevicius, C. A., Essebag, V., Eisenberg, M. J., Rahme, E., ... & Pilote, L. (2014). Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis. Circulation, 129(11), 1196-1203.

    We are lucky if we can get cardiology to manage INR let alone nephrology!

  • Quote
    • Author
    • Expert

    Oh yeah have tons of pts on coumadin, a few on eliquis too. Multiple reasons but most commonly Afib so stroke prevention. However, I have some pts with mechanical valves and a few with coagulopathies

  • Quote

    Definitely, it is important to adderss medication dose adjustment. Many medications may be adjusted downward due to longer bioavailability.

    Dialysis modalities (Peritoneal, Hemodialysis, in-center or at home)

    Kidney friendly diet (low potassium, low phosphorus for most ESDR patients)

    Fluid restriction... how to spot hidden sources of fluids in food( apple, watermelon...).

    Adderess Calcium and the implications of mineral bone density disease (Hypo-parathyroidism of renal origin) You may need to include Phoaphate binders and Calcimimetics...

    Difficulties associated with complying with transplantation requirements...

    End Stage Renal Disease and Depression.

  • Quote

    Yes ESRD patients with A-Fib should stay on whatever blood thiner the cardiologist wants. Many nephrologists prefer the cardiologist to manage Coumadin due to liability.

    When I was working at a dialysis clinic, our nephrologist did not even want us to check PT/IRN because of the legal liability implications.

    Let's say the lab results come in Friday at 5 PM, and patient is not notified until the clinic opens back on Monday to hold the next Coumadin dose..... not good!!!!

    Each specialty should stay in their lane.. which I know sounds ackward for my friends who think holistic care....We believe in collaborative care, with professionals who focus on their different areas of expertise.

  • Quote
    • Author
    • Expert
    Yes ESRD patients with A-Fib should stay on whatever blood thiner the cardiologist wants. Many nephrologists prefer the cardiologist to manage Coumadin due to liability.

    When I was working at a dialysis clinic, our nephrologist did not even want us to check PT/IRN because of the legal liability implications.

    Let's say the lab results come in Friday at 5 PM, and patient is not notified until the clinic opens back on Monday to hold the next Coumadin dose..... not good!!!!

    Each specialty should stay in their lane.. which I know sounds ackward for my friends who think holistic care....We believe in collaborative care, with professionals who focus on their different areas of expertise.

    While there is certainly liability associated with coumadin dosing, its better that the dialysis units manage as they are accessing the central system. My experience with cards managing coumadin is that it doesn't get done. A couple of my pts have home monitoring systems as they are home hemo and they call in with their results. The end result is that it must be monitored weekly and no cardiologist in my rural areas will do so.

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    Trauma, I was actually working on a minor course for some of the primary care APNs that I work with too. Maybe we should work together on this.

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