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.
—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.”