12 Things Hospitalists Need to Know About Nephrology

The Hospitalist. 2012 December;2012(12):

December 1, 2012 | The Hospitalist

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