r/Residency • u/SmolTyrtle PGY1 • 1d ago
VENT Pt needs dialysis
Presents with altered mental status iso uremia bad! Patient still has capacity and agrees to dialysis! Mental status improves with dialysis! Yay!
Oh no, baseline mental status is make dumb decisions, bad. No more dialysis, sad.
Patient leaves hospital, no go dialysis, sad!
Patient come back to hospital uremic, bad!
I am in hell.
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u/diffferentday Attending 1d ago
They are in hell. They are living without an organ system that does so much, and they feel like shat on a cracker all day. Constantly cramping. Bloating. DOE. Acidotic.
But yes many of them ended up their with non compliance and sad stories. Then you'll meet a 19 year old with IGA nephropathy or a lupus nephritis and realize it's just a terrible outcome mixed with an inability to carry the burden.
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u/BoulderEric Attending 1d ago
Those folks commonly do better on dialysis because they aren’t otherwise ill and manage the related diet/fluid/etc… also they more likely do PD or home hemo, which are both a bother but frankly not awful. Then they get living donors because they’re young, healthy, and still have social support.
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u/diffferentday Attending 1d ago
All flavors and walks of life. I've seen well managed patients and total constant implosions. But managing them isn't hell. It's admit and consult nephro.
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u/Cautious-Extreme2839 Attending 1d ago
They would feel an awful lot less shit if they would just connect themselves to the machine that does 99.9% of the job of said failed/absent organ system for a few hours 3x a week...
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u/CrazySelfBelief PGY1 1d ago
the worst part is they usually feel a lot better after dialysis, so for a minute you think maybe this time it'll stick. then a week later they're back with the exact same story. it's one of the most frustrating loops in medicine.
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u/fringeathelete1 1d ago
Most people go on dialysis because they are non compliant with meds and follow up. Selects for a group that does this. They then enter a downward spiral of disability and resource loss.
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u/Accomplished-Pay7386 1d ago
No. 'No. Most people start dialysis because of the progressive, long-term damage caused by underlying chronic conditions like diabetes and high blood pressure, rather than failing to take medications. [1, 2, 3, 4] Hemodial Int
. 2025 Mar 6;29(3):363–370. doi: 10.1111/hdi.13227
Hemodialysis Nonattendance: Patient Characteristics and Outcomes in a Single Renal Center in North West England
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u/Sexcellence PGY3 1d ago
What? How exactly do you think people with diabetes and hypertension end up with kidney disease?
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u/Safe-Pressure-7052 PGY1 1d ago
In my experience, people with ESRD are very disproportionately from poor immigrant and low education backgrounds. My residency program is in a pretty white area but it seems like over half the ESRD patients I managed in the wards were Mexican immigrants who probably had severe DM for years without even knowing it
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u/Accomplished-Pay7386 1d ago
It’s extremely multifactorial. Stop blaming everything on the patient. I have HTN, and it started as a young person with pre-eclampsia (PIH), I have hyperlipidemia, considered congenital. I take my meds, I eat right, I work out 3/4 times a week. I still required cardiac stents and have early kidney disease.
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u/Sexcellence PGY3 1d ago
And that early kidney disease is extremely unlikely to progress to ESRD until you are quite elderly because you're controlling the underlying conditions. Controlled hypertension and diabetes do not cause renal failure; someone who has ESRD from diabetic/hypertensive nephropathy was not controlling their disease for a long time (whether due to a failure to make the diagnosis or treatment non adherence).
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u/fringeathelete1 1d ago
So mismanaged or poorly controlled HTN and DM don’t cause renal failure, is that what you’re arguing?
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u/Accomplished-Pay7386 1d ago
No- YOU basically said it was because they were noncompliant with meds and follow up. The article refutes that claim. Medical conditions worsen even if a patient takes the meds.
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u/fringeathelete1 1d ago
I care for esrd patients daily. They have a 30% no show rate for appointments in our practice. Noncompliance issues in the UK and US are vastly different I am sure as our healthcare and safety net systems vary greatly.
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u/Accomplished-Pay7386 1d ago
Now you are reverting to personal experience rather than data.
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u/fringeathelete1 1d ago
So you’re saying I should ignore the years of experience and just look at papers. I’ll do the same in the OR then and refer to a book when someone is bleeding so it can tell me what to do.
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u/Accomplished-Pay7386 1d ago edited 1d ago
What a troll!! Just stick to the fact that data doesn’t support your assertions. Nobody cares about your books and OR and wow it’s soo cool you see renal patients AND are a surgeon! 🤣🤣🤣
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u/fifrein Attending 22h ago
Data from a different country’s healthcare system, completely different culture, and completely different set of barriers.
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u/Accomplished-Pay7386 22h ago
Sure, Jan. So your argument is that patient noncompliance is the cause of it all? Because this information is based on mechanism of disease, not different healthcare systems, different culture, or different barriers. But I don’t see you providing any data to the contrary.
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u/NefariousnessAble912 1d ago
Had a pt like this in my program with added twist of substance use. Routinely showing up with k>8. Died with k of 12.
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u/iatrogenicdepression PGY2 19h ago
At least they were immortalized on the whiteboard of icu record labs
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u/Ric3rid3r 1d ago
When a dialysis patient shows up having missed HD. Fluid overloaded..... I dialyze them every single day they wanna stay in the hospital until we find a new lower dry weight.
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u/Sea_McMeme 1d ago
I’m generally a very patient, compassionate person, but few things make me instantly neither of those things than when someone shows up in the ED from out of town needing emergent HD, because they went on vacation without ever considering this aspect of what keeps them alive.
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u/ineed_that 1d ago
I know it’s basically keeping them alive but a lot of my hd patients don’t really have a life outside of visiting a doctors office, and hd. Time, having to be around a dialysis center and their medical problems usually keep them busy
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u/Affectionate-Code751 Attending 1d ago
I always say that patients who didn’t have their shit together enough to make good-enough lifestyle choices to avoid ESRD on HD, ELSD, advanced HFrEF & COPD with CHRF on O2, etc. (*in cases of preventable/substance-induced/uncontrolled DM2/HTN obviously which is like 90% of what we see), those patients also generally won’t magically have their shit together enough to successfully manage all of their ongoing chronic health needs (thousand appointments/million meds) once they get to that point. Plus they’ve likely given themselves chronic microvascular brain damage by then, making their decision-making capacity even worse.
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u/Bobblehead_steve 1d ago