Annals for Educators - 20 February 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives20 February 2018Annals for Educators - 20 February 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201802200 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMid- and Long-Term Health Risks in Living Kidney Donors. A Systematic Review and Meta-analysisLiving kidney donation is the gold standard treatment of end-stage renal disease; more than 8000 living-donor kidney transplantations were done in 2013 in the United States, Brazil, and Japan alone. This systematic review of 52 observational studies details health risks for adults who donate kidneys.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what risks might accompany kidney donation. What did this systematic review and meta-analysis find?What medical and ethical issues must be considered and discussed with persons who are considering donating a kidney? How might the results of this review inform these discussions?What limitations in the available data were identified in this study? Why is the follow-up time so important?How should we counsel patients who inquire about donating a kidney? What questions do we need to ask? What do we need to tell them about the short- and long-term risks?The authors assessed whether the nondonor comparison groups were as healthy as the donors in the studies included in this meta-analysis. Why is that important? The authors found that most comparison groups were likely not as healthy as the kidney donors. How might that affect the findings and conclusions?Use the accompanying editorial to help frame your discussion of these questions, and invite a specialist in kidney transplantation to join your discussion. Chief Concern: “I'm Worried I Have Chronic Traumatic Encephalopathy”Chronic traumatic encephalopathy (CTE) has recently been the focus of extensive media attention. Are your learners prepared to address concerns that their patients might have? This commentary addresses diagnosis, prevention, treatment, and financial compensation for patients with a history of head trauma and their families.Use this paper to:Ask your learners what they know about CTE. How is it defined? Is it helpful to know about a disease entity that, at present, can only be diagnosed at autopsy? How?What symptoms and signs have been reported in patients with CTE? What is the differential diagnosis for each?Who is at risk for CTE? What is known (and not known) about the relationship between concussion and CTE?How would your learners respond to a patient who is concerned about CTE? How would they discuss the risks and benefits of participating in sports that might involve head trauma? What would they recommend patients (or parents whose children participate in sports) do?Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac SurgeryUncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. This substudy from a large multicenter trial examines benefits and harms of perioperative aspirin in patients with prior PCI undergoing noncardiac surgery.Use this study to:Ask your learners how they assess the risks for cardiac complications of noncardiac surgery. Who is at increased risk? Who requires testing, and how? Use In the Clinic: Preoperative Evaluation for Noncardiac Surgery to help prepare a teaching session. Review the results of this study. What are its strengths and limitations? Use the accompanying editorial to help frame your discussion. Why does it matter whether a study was prespecified by the investigators? Should your learners continue aspirin in noncardiac surgical patients who have had prior PCI?Who requires antiplatelet therapy after PCI? For how long? Watch The Consult Guys - An MI, a Stent, Bleeding, and Surgery! What Do I Do? with your learners for a relaxed way to review antiplatelet therapy after coronary stent placement. The ACC/AHA 2017 Hypertension Guidelines: Both Too Much and Not Enough of a Good Thing?The most notable recommendation in the 2017 hypertension guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) is the reduced threshold for the diagnosis of hypertension, from ≥140/90 mm Hg to ≥130/80 mm Hg in the general population. This commentary discusses the guidelines and why they create as many questions as they answer.Use this paper to:Ask your learners what threshold they use to diagnose hypertension. What do the guidelines from ACC/AHA and the American College of Physicians and American Academy of Family Physicians recommend? Why do they differ?How do blood pressure measurements obtained in your learners' practices differ from those obtained in the clinical trials whose results are used to formulate hypertension guidelines? What other important differences are there between a clinical trial and your learners' practices?The authors of this paper discuss how failure to recognize these differences might affect assessments of the quality of care provided by physicians. Do your learners think this is a problem? Can they suggest solutions?Humanism and ProfessionalismOn Being a Doctor: Politics and ProfessionalismDr. Sexauer writes that, “To many, [the 2016] election seemed to be as much a referendum on civility as it was about the political future of our country. Civility lost.” He asks how the medical profession should respond.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether differences in political opinions have affected their interactions with coworkers. What about with patients? How? Should we refrain from discussing political topics at work?Do your learners share the author's concern for civility in our society? What responsibilities does our profession have here?MKSAP 17 QuestionA 65-year-old woman is evaluated during a follow-up visit. She has end-stage kidney disease due to IgA nephropathy; she started peritoneal dialysis 3 months ago. She also has a 10-year history of hypertension. She has done well since starting dialysis, is without current complaints, and has recently resumed exercising regularly. She has three adult children who are encouraging her to explore kidney transplantation and are willing to be evaluated as kidney donors; however, the patient feels that she is “too old.” Medications are amlodipine, ramipril, calcitriol, epoetin alfa, and calcium acetate.On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 135/75 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. BMI is 27. The peritoneal dialysis catheter site is nontender without induration or exudate. Cardiac examination reveals normal heart sounds. The lungs are clear. The abdomen is nontender. There is no peripheral edema.Which of the following kidney replacement strategies is most likely to provide this patient with the best long-term survival?A. Change from peritoneal dialysis to hemodialysisB. Continue peritoneal dialysisC. Continue peritoneal dialysis and evaluate for transplant in 2 to 3 yearsD. Refer for transplant evaluation nowCorrect AnswerD. Refer for transplant evaluation nowEducational ObjectiveUnderstand the risks and benefits of kidney transplantation.CritiqueKidney transplantation would be the most likely strategy to provide this patient with the best long-term survival. Although there is an increase in short-term morbidity and mortality following transplantation, there is strong evidence that kidney transplantation decreases mortality and improves quality of life over the long term. Even though increased recipient age is also associated with reduced patient and allograft survival than younger patients after transplant, carefully selected older patients also benefit from kidney transplantation, and many centers therefore do not have an absolute age cutoff for transplant recipients. Moreover, this patient has family members who are willing to be evaluated as living kidney donors, and kidneys from living donors have superior outcomes compared with kidneys from deceased donors. Therefore, referral for possible kidney transplant in this otherwise healthy patient would be most likely to improve her long-term survival.There is no clinical indication for this patient to change from peritoneal dialysis to hemodialysis, and clinical outcomes, including mortality and quality of life, are approximately equivalent between these modalities. The choice between peritoneal dialysis and hemodialysis should therefore be driven by patient-specific factors and patient preference if dialysis is pursued.There is evidence that risk of graft loss and overall mortality are increased in patients who have been treated with dialysis prior to transplant, and that this risk of graft loss and overall mortality increase with the length of dialysis prior to transplant. Therefore, continuing dialysis and reevaluating for possible transplant in 2 to 3 years would not be an optimal management strategy in this otherwise good candidate for transplantation.Key PointKidney transplantation decreases long-term mortality and improves quality of life compared with dialysis.BibliographyTonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011 Oct;11(10):2093-109.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 20 February 2018Volume 168, Issue 4Page: ED4KeywordsHypertensionKidneysMedical dialysisMortalityPercutaneous coronary interventionPeritoneal dialysisRenal failureRenal transplantationSurgerySystematic reviews ePublished: 20 February 2018 Issue Published: 20 February 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...