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Five-minute Practitioner: February 2007

Only got five minutes? Then just read these key points on: dialysis, renal stones, chronic kidney disease and peri-prosthetic joint infections

Only got five minutes? Then just read these key points on: dialysis, renal stones, chronic kidney disease and peri-prosthetic joint infections

?Dialysis

Peritoneal dialysis (PD) accounts for approximately 30 per cent of all dialysis in the UK.

It is managed by patients in their own homes after suitable training, and can offer high-quality dialysis for a number of years. It generally works best during the early stages of RRT, and can work well for one to five years. Common problems with PD that might be brought to the attention of GPs include peritonitis (an emergency), constipation, hernias, poor appetite, abdominal pain and contamination of the dialysis catheter.

All forms of dialysis require patients to have routine blood tests every month. These will guide therapies such as epoietin, vitamin D and phosphate binders, and technical decisions about the dialysis itself.

The initial cost of home dialysis has prevented some renal units from making full use of this option.

Patients could be managed in very small, GP-run units of two to five machines. A pilot study is under way in which dialysis machines have been set up in a GP surgery and patients are managed by the primary care team.

Renal stones

The overall lifetime risk of renal stone disease is estimated to be 8-10 per cent. The reported recurrence rate varies with the duration of follow-up, but is estimated to be at least 50 per cent. In the UK, about 75 per cent of renal stones are calcium-based.

The lifetime risk of symptomatic renal stone disease is at least twice as high for men compared with women.

The classic clinical presentation of renal stone disease is acute onset, loin-to-groin colicky pain, renal angle tenderness, and haematuria.

Copious fluid intake reduces the risk and time to recurrence of calcium-based stones. Increasing fluid intake to at least two litres in 24 hours is supported by randomised clinical trial evidence.

A substantial reduction in dietary salt intake can reduce calcium excretion from the hypercalciuric to the normocalciuric range. A normal calcium intake is recommended.

Chronic kidney disease

Most patients with established renal failure (ERF) have progressed through earlier stages of chronic kidney disease (CKD); however, most patients with earlier stages of CKD do not develop ERF.

Any degree of proteinuria, including persistent microalbuminuria not related to sepsis, is associated with an increased risk of cardiovascular disease and progressive kidney disease.

ACE inhibitors and/or ARBs can reduce and even reverse microalbuminuria, and can prevent progressive CKD in some patients.

The risk of premature death, particularly from cardiovascular disease, is greatly increased in patients with CKD. This is partly because of classical cardiovascular risk factors. Whether CKD itself is an independent risk factor, which accelerates the progression of atherosclerosis by the operation of novel CKD-specific risk factors, is uncertain.

CKD patients require integrated, community-based chronic disease management, with a well-defined system to ensure long-term follow-up.

Peri-prosthetic joint infections

Superficial wound infections usually occur within 30 days of the procedure and involve only the skin and subcutaneous tissues. You should assume that a superficial wound infection indicates a deep infection until proven otherwise.

Joint pain and a persistently elevated CRP may be the only features.

Culture of aspirated joint fluid, under strict asepsis, offers the best diagnostic approach. Antibiotics should be withheld until appropriate specimens are obtained.

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