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Okay. Any disease and, um, also chronic kidney disease. Um, So I think this is this is a topic which isn't always, um, explain very well in medical school. I think it's also quite I have a complicated, um, So hopefully by the end of my presentation, um, today, uh, you will be able Teo really understand it in the most simplest terms of trying to simplify things as much as possible. Um, most of my slides. You'll probably see you don't have, um, a lot of information on them. And that's because I'll be, uh, building on the small text that I've left foot. But also, it's just so that you can really grasp the idea rather than having to me through a waffle, Um, and then getting confused yourself, Sir, today we're gonna be talking about I can't get any injury and, uh, kind of kidney disease. Um, and you just want to set the objectives out before, uh, you know, get him get onto the the actual theory of things, And you know what things look like. I'm concerned that so I really want to focus on actually recognizing, um, you know that someone is pretend you having a kidney injury. Onda also the subtle kind of signs and symptoms that may may present, uh, which can try the eight to a diagnosis off of an A k i and CKD and then and then managing themselves from me. Um, we'll try and get you some some urine electrolytes interpretation. They'll be, um, a question on those so pleased. Attention seeking Get the most out of this. Um, and as always, I'll describe basic in the store. I'll describe the basics of the conditions. I mean, what causes the risk factors, things like that, and then and then last, the management of the said conditions. So, um, it is you can see that there is, um, there's two pictures here off the urinary tract. Um, and I think it's very important that we just discussed a little better, Um, and after me before, uh, before we get involved with the hardcore theory. So obviously the the urinary type is made up off to kidneys to ureters, which then connected Teo the bladder and the function of the urinary system is to filter blood, um, and then create urine as a weight spike product. Um, the the kidney um is responsible for the filtering out. A lot of liquid waste, more known is also known as urea on it. It's also responsible for keeping potassium sodium. And, uh, water in balance is Well, um, Andi, as you continue from from the images here, uh, this is the Guerrino cortex. Misses the medulla, the renal pelvis, which is where the urine is collected and filter is collected. Where then? Parsons to the pelvis. Um, the major purpose all the way down the ureters into the bladder to be treated with the urethra. Um, that's the basic anatomy done. So you might thinking, What is a guy? So take a I, um, Is the kidney injury Um, Andi, it is impaired renal function. Um, and it basically refers to a rapid IQ decrease in renal function. Um ah, it's a few hours or even a few days. Um, especially in kids. Um, and it's that that there's many different ways of category of cattle categorizing make a I miss nice. And, um, most of Europe tend to tend to basic on, uh, 1.5 times increase in crafting me. Um, we're also 25% or more decline in your EFR is well from from the normal baseline. Uh, but you might find in different countries that they're different. Uh, classifications. I'm mainly going to using the Kadian I g o uh, which is the basis for a lot of European guidelines. Especially new cases. Well, um, and another thing that's not mentioned here, but another way of defining a t i z Also, low urine output. Um, it's obviously a symptom on the sign. Um, but, uh, a definitely you can actually defined AKI, um, with no urine up in form of less than 0.5 mils per kilogram per hour is Well, um, there's different types of achy I or there's there's different etiologies You could say they feel so there's, um, previous causes a severe renal causes, which we're going to love it detail about, um, and also patient causes. Well, um, and just to put things into context in perspective, 50% off all hospital in patients, um, suffer from a k I onda. Out of those 15% you know, 25 to 30% will end up coming. Teo, kidney injuries. Um, just because the body is just not able to process the, uh, this year capacity of waste products and things like that. So one of the risk factors AKI so having, um, chronic kidney disease, Um, unfortunately, leaves you quite susceptible for having an acute kidney injury having organ failures. So that's good. Heart failure. Liver disease. Um, liver failure can also precipitate a k I, um, and and chronic diseases. Such is for diabetes. Uh, where the the glomerulus is being impacted by the like the like, the glycosylated in things like that, having an a k I, uh, previously were Also increase your risk. Um, unfortunately, if you're above the age of 65 that also predisposes you to having a chiari nephrotoxic drugs, which will also be discussing also taking your and radio contrast agents as well, such as i d. In another contrast, how does how does a k I present? So as I said before, um, okay, I will usually present in the form of reduced urine output. Um, so the way we define it is anything less than 0.5 mils a kilogram hour, um, is, by definition, acute kidney injury. Um, they may also be a demon around the body. Um on da dut, um, you're on or the edema around the body would be because of the kidneys not being able to filter on. Uh, subsequently, you would have a big backlog of fluid which would then start in cream the interstitial space on other other spaces as well. Uh, arrhythmias, uh, arrhythmias. A probably the most, um, catastrophic, um, presentation of acute in a k I, um So I can get anyone in the in the chat box or abstinence are you can open the chapels, Teo. Some suggestions for what? Types of origen years in particular, My present in a cage. The chart box should be open if if they're wants to take a guess, they could just write the answer them. And if you wouldn't mind, just telling me is Well, may I Just so I can just, like, continue very clearly. Yeah. Course you always. Okay. There's a couple suggestions of bs or F. Yeah, exactly. So if the, uh, pretty much anything, um any any form of tachycardia and also bradycardia, um can be caused by by AKI. And your problem is your pulmonary dealing with the potassium aspect of electrolytes hyperkal in your hypokalemia as well. In some cases of rare a k I can also precipitate one of these arrhythmias, um, pericarditis on da encephalopathy. Um, so these are more features of the your e me A. Really? So, um, obviously, we know that the normal ranges of the urine years between two and seven. So anything above seven, um, will could potentially cause, uh, symptoms of uremia. Pericarditis is something that's usually caused by it on. Then you have encephalopathy because the waste products into the brain on then also be quite a lot of puritis a swell. So, um, as as everyone knows that the new Monica off dialysis A I owe you, um, you is uremia. So in those cases, a lot of patients will need dialysis and the benefit you Now, now we're on teo, the actual types of renal failure. So pre renal failure is usually the most common. Um, off all of the a. K. I see, um, on it often needs to intrinsic AKI, which will be renal AKI if it's not correct and properly. Um, and it's usually, uh, we can be provoked by volume loss, so buy volume loss. This can be anything from really vomiting away togut nearest burns and things like a zealous hemorrhages. Um What? That's one in los on, then, in terms of the decreased real profusion. Um, you know, No, no rewards for guessing this, but your hyperbole, mia, um, or patients with heart failure or shock is Well, um, can thinking suffer from decreased renal profusion causing the AKI um and, ah, and the several medications as well, which can, unfortunately induce pre renal take a I mean, those are volume depleted. Anyway, um, so some of those drugs ace inhibitors is so basically drugs ending. And Prilosec, um, and also angiotensin receptor blockers. ARB. So we're talking certain here, Um, And there's also, um you know, like a sides. And, um uh uh also also NSAID, PSAs, wells so that they they usually tend to cause a lot of basic constriction. And when you already have hyperperfusion off the kidneys, they tend to excessive it. The condition more than anything, So can everyone see this is can everyone see? This is ah is a question then this are This will be the first question. Um, and if you wouldn't want sharing the pole, were telling me the majority of people that aren't so to read this out. So you're the one called Cetaphil Junior doctor and happy nasty review and incredibly healthy 18 on your female, uh, with low your urinary output. Oh, 420 mils in the past 24 hours. This by having two liters of IV fluids administered over eight hours. She was admitted with small bowel obstruction. Then, after examining her, you review her been missed. You You reviewed her admission investigations for the scans or the blood and also e p m e, which is, um, the platform. Years of prescribing medications and things on you Notice her potassium is six minimally the meter, and she has a credit me off. 346 micromoles bolena. It appears she was given some medications in accident emergency while she is being treated. Um, the general surgery, uh, without the weight being calculated. So what Medication? Um, could be causing the abnormal using these, um, and is there? Is there a possibility that all of these medications could potentially be damaging the kidneys? Well, so I'll leave that to all of you to try and answer on. Decide if you wouldn't mind turning in the general content. Is that great? Yeah. Basically reason there's an error coming up when I'm trying to learn the post. Can you give it a try and see if you can do it? Let me see. Well, you know. Yeah. Yeah, I was working. I'm more than happy. Teo. No, she was saying that we're not just on. They're saying that I'm not hosts. I can't do pose. You don't know. Yeah, I think it's working now. Yeah. There was also a question earlier, uh, regarding the pneumonic for dialysis. Ta. Oh, you Yeah, in the shop if you want. Um, maybe over the the indications for dialysis, uh, or the pneumonic for understanding the indications with dialysis. You, um and as you as you already know from me, um, the you is, um, full arena on DA The A I use are actually acidosis is electrolyte problems. They were talking hypercholesteremia here. Uh, potentially hyperness clean me? Yeah. And any electrolyte problem? The basic, you know, I should so could be. Could be anything from ethanol poisoning to have seasonal overdoses. Just quite rare. Usually, but it can still be, um oh is for overload. um, or over fluid. Um, and the years I said, Is this what you mean? Yeah. And as I can see from, um, the pole, a lot of people have. Yeah. Correctly answered the gentamicin. Um, can get anyone. Tell me why the gentamicin in the chart research. Even I don't know. I'm It's not that we use the poster that you might have to take control of the post, but that's all right. Yeah, I know. I'm now struggling together. Yeah, I got it. So people are saying is, um, you know, excited nephrotoxic Exactly. The nephrotoxic. Um and they need to be calculated based on, uh, weight age. Sex on height is, well, a Z the your craft on you as well. So this is something that happens quite often during hospitals, uh, in hospitals, rather because there's ah, big, um, impetus to crying treat. You know, potential sepsis is and then anything like that as rapidly as possible. Um, usually in in most hospitals these days and anything abdominal well, usually calls um, a bit of a mg amoxicillin metronidazole in gentamicin to be prescribed. Um, and it happens a lot that people do. You know, Um way the patient on day tend to go for a lot of, uh, prescribing errors in terms of put the gentamicin and also with gentamicin, you need to know that gentamicin can can be given over 24 hours, 40 hours and 72 hours is well, in some cases, depending on the kidney function. So in this case is the gentamicin. But I just want to point out that the paracetamol the are more friendly amoxin can also caused, um, kidney problems. So paracetamol would probably be the the third most potent immunoglobin. Sorry, the third most nephrotoxic choice in out of these four or um, or would be the second, but because, um, the dose of the arm office quite low. Um, I wouldn't really be too worried about the the morphine causing any kidney damage, but this is this question will now need you onto the the renal causes off of achy I. That's what said, um intrinsic AKI or renal causes of a K. I can convey reform, structural injuries to the tubular injuries or the way to interstitial injuries. I just got a question on this arm to this is well so to just to confirm is the dose of the dentist, Martin. Which means it, Yes, in this case, 400 mg. Um, in an 89 year old probably isn't the most, um, smartest or the most safest option. If it was a lower dose, then then for sure, there wouldn't be any problems. But just because of the high days on, likely, it's like it's been given a status is, well, love them over 24 hours of 40 hours can potentially become quite nephrotoxic. And it has, in her case, going back to this. So in terms of the structural injuries, we're talking about women. And the right is here, Um, and in the glomerular nephritis young. So you have, uh, pretty causes you have nephrotic causes a swell. So the most common causes for, um, renal injury in chlamydia and Fridays, usually rapidly progressive glomerular nephritis are PG N You're probably learned by the end of this electrolyte is on, um, a little short cuts and, uh, a previous a shins with things. I do apologize for a few. Do you struggle with them? Please Let me know. I'll explain them again. Um, good posture syndrome. Good posture syndrome is um is really a syndrome where you're having, uh, antibodies being formed. Um, against, you know, the the glomerulus on the basement membrane is Well, um, you have mpg in, which is a member nurse proliferative glomerulonephritis. You have P e i g n which is post infective the Maryland. If itis and this convenient, usually after staff, the caucus infections can be after any infection. Basic. See, What's that? VT. So, you know, venous thromboembolism. It doesn't just have to be a promise. It can be a number that it could be a number like potentially from there from the left side of the heart. Um, can also be vasculitis is Well, um, so with vasculitis, you obviously have large. So So you have large vessel disease of medium vessel disease and small vessel disease. Full, um, kidney disease is usually it's it's usually medium, uh, meeting better disease. They were talking granulomatous. Um good. So granulomatosis with pollen joint is, um we're also going to be discussing things like isn't a filaggrin um in granulomatosis polyangiitis or stoners Chug Strauss syndrome. And then potentially you could have microscopic, um, call me in. Giant is's Well, you also have a d i c so disseminated intravascular coagulation. Um, because you will obviously have clumping up off from buses, and those offices will become my coast on by And they could potentially, um, into the the systemic circulation and clog up one of the kidneys, um, hypertension, purely because of the destructive effect of scarring and things like that that has on the kidneys. Um, and I think it's also wise to mention cramps pond rejection a swell, because that will have, um, a bit of a water immune cascade response for for for kidney function. Um, something that I'm no mentioned here, which is also worth mentioning is any sorts of former to the kidney region can also cause, you know, failure. Obviously that that structural injury, the tubular injuries, um, these will most commonly be affected by wrapped in my license. Um, hum any any kind of muscle death as well, um, tumor lysis syndrome and those people suffering the tensor and then medications. Such a Z, a Munich like asides tracks eight antiviral. Such is a cycle of the CIS plate in, and also radiocontrast agents in this world. They can all do damage the tubules ascending and descending. And in the last woman, um, renal failure is interstitial injury. Uh, interstitial injury can also once again be caused by medications for infections and also systemic diseases. Such a Z, uh, Lupus, leukemia and lymphoma, actually, for that matter. And also struggling this disease. Um, that's kidney. Uh, well, there's a renal causes for renal failure. Any questions after this? Well, when we want to push for you, we'll take That isn't none. I think it's fairly simple up until this point. But if you do have any questions, please, please let me know it'll slow down a little bit. Explains Well, yes, sir. Are G n So that's rapidly progressive glomerular nephritis, um, on MPG and is a member nisp proliferative glomerulonephritis on P i g n is post infective Romeril in the right is, um that is I find that's the easiest way off remembering what's new critic and what's not partaking just in general. Um, what other diseases parts of those subtypes is. Well, that makes sense. Cem, come to the the post, renal. Um, so it's a pressure, you know? Ah, quite once again. Fairly logical. It's mainly because of obstruction. So in terms of obstruction. We're talking about mechanical obstruction here. And the mechanical obstruction of the urinary collecting system. Um, including, and the the UTIs bladder urethra. Acceptable. Acceptable. Um, can be caused by any of these following causes here. So it could be a stone disease strictures, tumors. So both intraluminally extra liminal on. Also, intramural is Well, let me do two clocks from basis is and hematoma is a swell from both surgical procedures. And also, uh, you know, potential blood disorders. Uh, and there's also the most systems. Well, so emotions will be probably, um you like to think more to do with pediatric neurology love than adult, um, adult nephrology, neurology. But it can sometimes affect, um, adults. Just a much Is his Children as well. So put for you, re trick obstruction steady. Simple stones, tumors. And Bruces, uh, one thing that I'm no mentioned here, which I just remembered. Um is the, um the possibility of Tradjenta injurious? Well, so by Tradjenta, I mean, we're causing the injury, So this is But even though it is quite common in general surgery, especially, and in Colorado, so general surgery that as you re trick injuries or the uterus. Accident like gated, Um, thinking it might be a vessel on. I can obviously cause post renal failure as well. Bladder obstruction. In terms of tumors, it can be anything from prostate carcinoma to the bladder tumors. Um, well, obviously the BPH on da neurogenic bladder as well in the potting as I said, which one which can sometimes be caused by surgical procedures like sisters Copy is well, and Botox injections into the bladder as well. For uncontrolled, For with the patients with with the incontinence is Well, so that's post renal. So right now we've discussed what different types of a K I exist. We've talked a little bit about the symptoms. Uh, we've talked a little bit about classifications, I think also, we haven't, um, we're going to be talking about No, um, but I'm trying to ask you guys, how do we How do we actually diagnose it? Um, so once again, no surprises for getting, but the way that we would diagnose an acute kidney and three with with problem with probably going to be initially it would be, uh, would maybe be due to using these. So, as you can see here um, the bottle that we need to use for collecting the blood would be would be the goal top of the yellow top. Um, for the using these and the electrolytes here and that kind of parameters of the knee in the the many to do with the sodium potassium ride bike. Obviously, credit me with this specific focus on the sodium potassium on the urea in the crediting as well. Um, And so, as I said before, nice guidelines recommend that we would. Then they suggest that we can use a variety of different kinds of white iria to make an official diagnosis. Um, of achy I so usually, um, it's a creatinine rise off more than 1.5, um, in in a short duration of time, usually within 48 hours. Um uh, And it can also be decreased EEG EFR 25% more, and also urine output falling to less than no 0.5 mils per kilogram per hours. I mentioned earlier. You may need diagnose 80. I, um, by a blood test. Um, however, if, um, if there's no, I didn't identifiable cause for the deterioration, um, or someone is a risk of potential post renal. Um, failure. They really ought to have a renal ultrasound within 24 hours. Just a rule out post renal obstruction. Um, and I'm not sure this is this is practiced a lot in hospitals, but in general, every patient has got suspected a k I should have. Your analysis is Well, um, just two without any of the, um, a college or etiology. So this is this is what we've been talking about. This is the achy I stages. Um, and I can see that there's 33 different stages. Um, I'm not going to go into this is I've mentioned this a lot of times. Now, um, another question is Well, eh? So how do you diagnose in a go without previous news in his results? That that's Ah, it's an interesting question, because, um, you wouldn't really be able to find out what the creatinine is doing if you didn't take blood. Um, it's not normal. Um, for any HIV patients be diagnosed with a car without having blood. Um, they did. It's imperative that they have blood. That the catheter. I said we can measure the urine output. Um, and in general, it goes hand in hand if you do cats right, Someone in the emerging that they have got less than, um, no 0.5 mils, um, kilogram per hour being do being excreted that they they need the bloods to check the creatinine Because depending on the stages of the a k I you may need to refer to a nephrologist a swell, um, Andi, you know, they might be a potential side of Ah, the dialysis indication needed a swell if things do you start worsening in the patient's deteriorate. Um, so have on to that question. Yeah. Once again, three stages. The first stage is an increase of serum creatinine 1.5 to 1.9 times. Um, on the baseline. Um, Stage two is by t tube. Fine times and be is three times a day. That's why I need you to remember if it really pressure as well. So it is the first time without fine, that's I just establishing baiting on. For example, the patient is present in particular that you would, um and you probably have to you have a suspicion of it. I, for example, they have a fluctuating G. Yes. Um, that their heart sounds excellent. Book it. The giving muffled You could have the classic sign of friction type rub when you're listening to the chest. Uh, so all of those things considered, um, it would have to be a suspicion. But once again, um, you could you'd have to do the bloods. And if this person is presenting for the first time, you'd have Teo, you'd have to kind of have the first admissions, but as the baseline and then go from there, Really, You'd have to treat them and then see if they improve. And if they don't, Then you know that that's something that makes any sense. Noise. Um, they have those are the three stages, um, on, But I one of you paying attention and you're remembering this because we have a We have a question. Now, um, did talk about stage is so 72 or sorry. A 70 year old gentleman, um, presents to the surgical eStick Also the same day emergency care unit, um, with the presenting complaint of not being able to urinate for the last nine hours despite having urge, um, he has a past medical history or type two diabetes and chronic back pain after a road traffic collision 50 years ago. Um, his regular medications are metformin fiber proof in, and he has adequate PPI cover with the ibuprofen, and he has no known drug allergies. Bloods today showed that his sodium is within normal reference is potassium is also within normal reference. Range is bicarb is all right. Greer's just mildly elevated, but the creatinine is 200 micromonospora nita, which is that you continue very, very elevated for from the normal reference range is so from all of the theory that we discussed what AKI stage would you guys put this gentleman okay, this poll. So hopefully you can answer the pole? No. 50 50 so far. Last few seconds. Bread one, too. To have a guess. Price, I think I think probably probably end the pole now. I think a lot of people have voted, so yeah, Most people have voted for, um, option one a k i won. A lot of people have waited for a care to you, and then a few people will say, Go on for a tweet. I'm going to guarantee the reasoning down everyone beyond everyone else's decision. But it is a k I one. Um so? Well, then if you guessed it, don't worry if he didn't, I'll not explain why it take your one. So as I mentioned to you before in this previous slide, um AKI one in the cage. I g o um, pacification is when our creatinine is between 1.5 to 1.9 times above baseline. Urine output is less than no 0.5 mils kilogram per hour for more than 66 to 12 hours here. So all of the clues are in the history. Um, so you would actually have, um, a bit of a suspicion there, Um, for for an a k. I stayed one especially. Yeah, I do apologize. You didn't have a baseline there. Um, but I think when you got such a bond or elevation in the creatinine, um, more often, now you be able to diagnose the AKI. Um however, if you if you said to this patient on discharge or GP will have to you after you're using these after two months or three months and you noticed that it was falling, then the problem probably be in a K I rather than a loved in a CKD situation is also had that makes sense. Um, but to explain why I take it at one. Um, well, first it it can't be a guy for so our option for is completely off the table because it doesn't exist. Um, and his his urine output has as well he's not had any urine output. Be 60. Um, so that kind of leaves you on two stage one on the urine output side of things on because his creatinine is, uh, you know, between 1.5 to 10, 82 times above the baseline, it would be in keeping with take a a stage one. Um, he has a risk factor, Um, in terms of his age as well. So he's 70 years old. Um, he unfortunately has diabetes. And he also uses and said's three ibuprofen. There's back pain, so that should also be quite should be ringing alarm bell inside your anti Do it between your ears as well. Um, achy I to just to just to go through again. They care. I two is when, um, you haven't increase in the serum creatinine, um, between 2 to 2.9 from baseline and the urine output is less then no 0.5 minutes. Pick killing a kilogram per hour for 12 hours and more. And then a k I come years. You're correct me more than three times. Um, And the urine output is complete. Reduced, um, or if not, is less than no 0.3 mils per kilogram per hour for your 24 hours or even longer. This was Ah, achy I interpretation. How do we know now that we've discussed the different types of a guy, we know what a k is. Um, you know how to diagnose it. How do you manage it? That's all right. Just got another question. Um, did you mean the normal range and not patient? Basically, Yeah. So in in a bundle case like that, you wouldn't really want to do a patient baseline. You want to just get on treating their ache? I, um you had tried to get the GP to assess the baseline, and then it would probably be up to the GP. Teo, uh, introduced a lot of medications to try and control that that corner kidney disease. If it is, or if not, it would be in a K I off this knee on having the urge to urinate. It means is the person course? Not always. Because in the elderly, uh, I haven't actually specified it very clearly there in the history. Um, but as you unfortunately, my a team with with your own grandparents, they tend to not be, um, the best with drinking water and keeping their fluids up. That's something that I see daily in inside hospitals. And I'm sure you might have experienced as well on placement and your interaction of the grand parents. So in this case, it would be dehydration as the core was off. Um, off the, uh, off the the AKI. Um, but you can still have the urge without without actually being able to urinate, because as you get older, you you start to lose function of your bladder. Um, so you have never explained that way? I have. No, I'm sorry. So, as I said, um, you discussed with a k r. I, um the only thing that we need to figure out is what to do when someone suffering communicate, and how do we manage it? Um so fluids, fluids, always a good shell, particularly if it's a pre renal cause, right? Because they would be fluid depleted in Sep. Test they have lots of babies or constriction, so they would need a lot of fluid. Teo, try and overcome all of the, uh, all of the, um no, or all of the the construction involved in it. But that'll be very, very careful with how many hours you prescribed foods for And also how many liters of fluid you prescribe because mgl be in the in the young as well. And in general, anyone, it doesn't take that long for someone to stop to feel overload in and actually start becoming a belated um so we should always treads with a lot of caution with prescribing fluids, we should stop any nephrotoxic drugs. If you know that the kidneys are completely butchered because they're using the ibuprofen's left and right, you should probably tell them to stop the ibuprofen. And you should stop that, um, same, uh, same reason for if someone has been created for that's biliary sepsis, and they're on amoxicillin, metronidazole and gentamicin. And you know, this is the kidney function is cooked. It's correlating with the starting off the gentamicin, and then you have to confirm that where you have to have the suspicion that the gentamicin is becoming to nephrotoxic for them on do you should stop it. You should also treat any electrolyte disbalance. So not every single hyperkalemic patient needs dialysis. Um, and so you should always try to treat them with the hyper. You know, particles of the the incident, like liquor is, um well, the razzmatazz basically involved. We're treating that, um, but queery consider loop diuretics, and that is it's very, uh, but I think it's you should consider it, But you shouldn't consider it because usually in an actual practice, you wouldn't consider it, um, unless someone was significantly fluid overloaded. Um, and you would only use it if they're significant. Include overloaded to try an artificially boost. Urine output. Um, so that's why you could consider it. But you'd only have to consider in a very small population of patients with significant new it overload. Um, and as I said in a k I to catch me, you should be You should start considering, um referring to a nephrologist. Proceed the patient then assess whether they can actually take fluids or, you know what? What did you next? Um, in dialysis is will be the last last resort. Really? For for a lot of these patients when they're not responding to the medical treatments. Um, and they have a lot of complications as well. Such as likely me, a pulmonary edema, um, acidosis. And also you're a genius. Well, that was that was a k I. Does anyone have any reflections about AKI before we continue with anyone, like, would would everyone like a a five minute break or anything like that? I don't know necessarily. Is that a king? We take a break in people like a break Or do you just continue? It's up to you. If people want a break. And, you know, we can take it with break. If everyone's happy to continue on it. If you're happy to see you, I was I would say we keep pressing. Um, you keep pressing forward just to see you guys get your geek in grass full of the the baby. Really quickly. Yeah, consensus is to continue. There's a question saying, When do you consider renal replacement there? You said by being over patient, do you mean, um, like a transplant will do you mean artificial renal replacement in the form of dialysis? So if it's in renal transplant, Um, that's That's something that's actually probably beyond my pay grade if I'm being honest. Um, but in general, you usually keep it the penal dialysis on. They probably need dialysis. I mean, numbness. A few. A few patients, unfortunately, may need to come in every day for renal dialysis. Some people may need Teo come every two weeks. Some may have to have it on a night, Um, just to maintain the function of the kidneys, depending on the stage. Um, but it's a renal transplant will probably be a very, very, very, very last resort if dialysis literally couldn't work, But then you'd have the problem or one kidney not functioning. Or you don't have one kidney functioning. Um, and that would that once again be quite problematic? And you need a form and you can How do you decide when diarrhetics are appropriate? Continue. Start. Since then, nephrotoxic, we'll know a lot. No. Every single diuretic, um, is nephrotoxic that you're very right in the sense of pr nephrotoxic. Um, I would say that that would be on specialist opinion. first e and then second. Me, if you could quite clearly see that this patient is Yeah, they got pitting edema. Um, they got dyspnea. They've got bilateral pleural effusion and a lot of complications. Now, off the kidney failure, that would probably be a good time to give them some. Sure, it's a mind, because it's not gonna harm them. Um, and in general, something that it's probably worthwhile noting for all of you, Um, if your creatinine and e J far does brought, um, first of mine is actually a very, very safe option for trying to artificially promote urine output. So I would say those would be the scenarios where you could consider your diuretics. Is that okay? Everyone. Does anyone have any other further questions? But we continue Awesome. So we've done a k I. We've done the acute condition. So let's now talk about the chronic conditions. We're going to stop talking the bit of a case study. I'm going to open the floor to you guys to, you know, to suggest what you think is going on. Basically. So a 57 year old gentleman with a past medical history of type two diabetes on hypertension presents to his GP with fatigue. Um, and weight gain over 4.5 kg in the last three months. On examination, there is bilateral pitting peripheral edema. Um, turn his legs on. He's got cotton or patches. When you when you shine the for endoscopy light into his eyes as well. It's observations and normal. Um, except for his BP, which is 150 over 92. Once again, it's not new to us. Um, So what do you think's going on here? Okay, yeah, I'm like, I'm like, everyone's for processes here. So we've got a lot of diabetic retinopathy. These but diabetic nephropathy, um, have uncontrolled diabetes along. All right. None of your wrong here. Unfortunately, what we have here, it's sounding a lot of, like, firstly, kidney disease. Um, because there's a demon. Okay, someone's put autonomic dysfunction. Someone whose book CKD on that is exactly what's going on. So we've got kidney dysfunction. Um, and we have got chronic kidney disease. Um, happening. And this is a textbook textbook, um, presentation of your fatigue. Weight gain. What can consult and tell me why they get any weight? Yeah, exactly. Fluid retention. Very bloated. Um, and can someone tell me what the best this is actually a PS a prescribing safety assessment question. If we were to give for a PSA mind in this patient, how would we know that the first in mind is working? Well, concern also on to that, please. Okay. Urine output, lot of urine outputs if you weight loss is Yeah. So the only way we find out whether the first mind is working would actually be by by by weight loss. Um, if anyone put weight loss if it is indeed weight loss, urine output is good. Um, and I would tend to agree with you, but anything can cause artificial urine out that lots of fluids IV can Also, it was a solid urine up it that we we did them to continuously start losing weight for us to know that the, um, that the first mind is working as I mentioned a lot of CKD going on in this, um, 57 year old gentleman. Um, and what we've got on what we've got going on here, you have the weight gain. So that's suggesting the overload, um, of the fluid you've got the fatigue. Why? Consulting me y fatigue off all of the symptoms. Why? Fatigue? Yeah, exactly. Got need me going on in sometime. What type of anemia is going on here? Is it, uh, microcytic is a normocytic or is a macrocytic? Yeah. You guys, you guys know it. So exactly is no Massetti sick? And it is indeed, um, enemy of corny diseases. Um, great. Great stuff. Um, so that's what's going on. There's a lot going on here. I'm going to talk about all the fatigue, weight gain and all those things in the following sides. But we'll say he's got type two diabetes. He's hypertensive. Well, so you have to think that there's also a lot of diabetic never happy, um, as well associative of this or that would be associated with those types of comorbidities. So that's what's going on in terms of, um Ah. Sorry. Can everyone see you just lost my screen here? Um, so we're chronic kidney disease. Ah, you have five stages. Um, rather than three. Really? You'll see in the following slides that five stages is actually six stages. I explain why in a second, um, but CKD often goes unrecognized until it's well advanced. So by well advanced, I'm cooking stage three basically, um, effects around 10% of people worldwide. You're thinking that's that's quite a large number. And it is, Um, but that's because we've got such a massive rise of conditions of diabetes and hypertension on every single corner of the world. Um, so that will attributes to it other causes of ckd a or so, um, the chronic pyelonephritis is well, so it's an effective cause on also, you can have genetic causes such a polycystic kidney disease, both adult form and also, um, the the pediatric formas. Well, after physiology, it is highly dependent on the cause. Because if you if you got diabetes, then you have a lot of, you know, like isolation. And a lot of the think lamere remember that sort of glomerular a membrane, um, effusion and a lot Those crescents and things like that going on pathologically um, in general, you would have, you know, an increase in integrin very low pressure. Uh, you'd have an increase in glomerular permeability, which would then it's then a lot of symptoms. Um, and all of this word lead Teo renal scarring and with being with scarring in a lot of fibrosis. And inevitably, you end up with progressive loss of function. Um, you'd start off with, you know, your kidneys working it, let's say 90% or the way down to your kidneys working at best than 15%. Um, so that is that is the big variety of the stages. You can have more than 90% for stage one. Um, and then you can have, you know, CKD stage five, which is end stage kidney disease. It was basically palliative, unfortunately, and that be less than 15. Um, your your GFI would be less than 15 risk factors. Diabetes, hypertension, Ms. Styne, Age above 15 years old. Um, obesity, along with smoking as well. Uh, unfortunately, some ethnicities have a higher predisposition to CKD, so people, Hispanic origin and people who are black, um, may have additional risk factors for developing CKD posted Family history of CKD is also suggestive. All, um, CKD diagnosis. If you mail a Z I mentioned before he have. Or if you've had childhood kidney disease, um, on dot so adult kidney disease or adult adult polycystic kidney disease, this world, they, um you're developing COPD. These were stages. Um, I said, there's there's really sick stages because three is a B stage one, um, of no kidney disease is your e J a pa. Great guarantee. I'm Stage Teo 16 89 and you guys condemnatory read what's going on here? And you can also, from the the image below the G f R section that the the amount of kidney damage that's happening progressively or this time is getting bigger and bigger. Um, some of you clever clothes, my figure that there's a crediting you both, um, concern. Tell me why we're not using creatinine. Just have a guess, guys. No, no, guess is a bad guess, But I'm saying, could be an acute phase protein. Ah, yeah, exactly. Use if has very quickly pointed out that creatinine is actually dependent on muscle mass. So tier, um, creatinine may not actually provide an accurate estimate or renal function due to differences and muscle. Um, and as a result, for this reason, that's why we have e g f 54. Um, Andi. Another thing that might also affect boats would be example if if someone is pregnant, the Jeff might be deranged or it might be different muscle mass, obviously, if you mentioned that also, um, for example, body been body build. Is that the eat a lot of meat have. I mean, if if you eat a lot of red meat prior to having the sample being taking your your your TFR, um would be with the skewed A Z well, and we're not be accurate, Okay? Someone saying why is it used to take a I then? Because that's a good question. Actually, um, the reason why I creatinine is, think used, um, getting drink a k I, um and, uh, no. Yeah. And, um, CKD is probably because creatinine is a very, very acute way of finding out. I think kidney clearance, in my opinion. So obviously you guys know about in your limbs and all those other kind of physiological, um, test that we can use to figure out kidney function. And your creatinine is the most accurate way of figuring on kidney function. If the creatinine is high, you know that that you're you're dehydrated and then they're getting some country where's in chronic disease. It's hard to figure out whether it's an accurate, um, it's an accurate parameter for diagnosis, if that makes sense. Yeah, giving on, um, these are five stages. Uh, how consecutive? Present. So CKD can present bit fatigue due to be in your aspect? A demon because of the overflow or the overloaded and everything not to fluid, restless legs. Um, restless Latest is really to do with the diabetic aspect off off the CKD desk near and orthopnea. A swell many dealing with the fluid part of things here and then So me, your toe cola colored urine. Um, osteo Malaysian osteoporosis is well, then you have nausea with without vomiting. Uh, protests and anorexia as well. Why? The fatigue's as you guys very correctly mentioned stupid, the anemia of chronic disease. So you need me or will cause reduced EPL levels. And, um, the reduced equal levels the most significant, um, that they're they're the most significant factor in in the fatigue. Uh, symptom. Um, and you also have reduced very through police is, uh, due to the uremia toxicity. Um, you'd obviously have reduced absorption of iron as well if your kidneys, um, they don't function is well, it's possible the, uh, the the urine. You would also cause the uh, generics and the, uh, nausea as well. Uh, another thing that I have not mentioned. Well, you obviously have a lot of blood loss, you teo fragility of the red blood cells. And you also probably have poor platelet function as well. Um, so how how how we treat the fatigue in this. So the first thing you do have to try and get the hemoglobin up. So you guys real clever. So you know what? The normal ranges of their hemoglobin alpha about male and female. Um, but in general, you should try and have anemia globin higher than 10 g per deciliter in there, in in the elderly, in some bone to flirt between 19, 100 sometimes even know. But it's fine if it's stable. And if they're not symptomatic, if they're symptomatic, then that's the cause for concern. And it should be elevated as soon as possible. You also have, um, good question. So what you get for, like, an acid? Uh, no. You wouldn't give folic acid and lists situation, because can someone toe walk in Someone try to explain where you wouldn't give the folic acid the phone a cast? It isn't really indicated because there's no signs of, you know, folic acid deficiency. This is purely because off the PPO being reduced. And you would probably find the more blood film off all of the other carrot in fibrillating all of those types of values from. So the main thing of doing it as a result, you need to have, um, referred. Police is stimulating agents. So, um, this is basically yes a, um and, you know, potentially If, uh, if if you're on hemodialysis, that might not be appropriate for you. Um, on you would need to have my the iron. Um, parental. Someone has been in the chat, if you want him, you know, dialysis. And then also, um, you may, you may need you dio, um, and as a last resort. Or that was a 3rd 3rd line option. Um, for getting your hemoglobin up. Why do you demon? So I think we will discuss this. Why the Adina? Um, if you guys would like to check more than welcome to Why the why the posterior Malaysia or the osteoporosis? So this is what this is because of, um, one alpha hydroxy nation usually occurring in the kittens on. If they're damage, naturally, you would have low vitamin D. If you have low vitamin D, it kind of goes hand in hand. You have low calcium. Um, and if you've got the low counts, um, then your body would prime compensate in such a way that it would try to increase it on. The only way the body knows how to try to increase our calcium levels and when they're low is by having the parathyroid gland work overtime. Basically, And as a result, you would have hyper parathyroidism and someone tell me whether this hypoparathyroidism will be primary or secondary. Exactly. Yeah. Secondly, we would have to be secondary because it's in response to the body. Rather then primary pathology. Um And so when the when the parathyroid glands that's working obviously try to rectify the low calcium. But what it does is it actually starts causing high prostate level's high prospect levels really need to be counted because they can cause some problems down the line. And the way that we tried Teo try to cut down on those is first thing that we tried to be for pretty much every single condition. Um, systemic is we try to have some some sort of diabetes control. We tried to, you know, modify our diet. So we tried to limit phosphate and take, um, on the 2nd, 2nd way we tried to to come back. This would be to use phosphate binders. So there's there's a few forced a finder's out there, but one that I think the only one that I really know I think that you guys should probably know is a drug called Savella Me. And basically, the phosphate binder is, um will bind to the dietary faster, and it will prevent its absorption. Um, it also has, uh, quite a good profile is it reduces the uric acid levels as well. So you kind of cut down on the potential effect of uremia Taking place is Well, that third line would be, um, you know, vitamin D. Um, substitute. So artificial causes artificial ways of supplementing vitamin D's. You have counseled trial alpha calcium. Iowa's well on. Do some cases. Parathyroidectomy, um can also help his Well, this is the Austin Malaysia. Um, we have a question, especially the chaplain. Also, um, is also a question here is Well, so um, a 62 year old lady with Stage three a CKD visits a GP to discuss the results of the annual EKG fr test the last two years. Her EDG huh has seen 59 51 on Day 35 respectively. What do you think is the most appropriate step in her management case? A lot of people are saying Refer to a nephrologist couple of people, same prescribe in a senior Byetta. All good suggestions, to be honest. Um, but unfortunately correct on to here is referred to a nephrologist on that is all in line with nice guideline. So the correct time to just do Rituxan it once again is you would have to refer to a nephrologist. And you have to refer to neurologist because in ninth guidelines explicitly stable. If the E jafar falls below 30 we'll progressively more than 15 in a year. You have to reflect in the college ist and in general, the nice guidelines for any sort of a nephrology special, um, specialist opinion. A zoo falling so ah, urinary, a CR between discussed a tone off 17 millimeters or more unless protein urea is known to be associated with the D m is being managed. Should be referred. Um, a sophomore in 30 with matter area after exclusion of new T. I was a renal. Colic has to be referred Uncontrollable hypertension on. Then also, you know, read read causes of CKD suspectedly know actress to no cysts. And also any complication or seek 80. So that would be any of these, uh, any of the symptoms that I mentioned that to stop. So, as I said, we were going to discuss, um, a C Also, you're thinking, what is a CIA? Um, and I'm going to get into that little bit. But I think what's important is you have protein urea, as we would have frothy. So you have probably. And foamy urine. Um, also potentially, uh, you know, kind of cover your anus. Well, um, and the reason why, um, we But well, the reason why, um, you know, protein urea is really important. It's something significant. That is because it's an important marker of the CKD, especially for the diabetic. Never path the side of things. Um, and the way that we try to investigate this is by performing a a cr. So a cr is, um Well, a CIA is actually, by definition, albumin and albumin creatinine ratio. It's preferred to PCR not PCR for covert or anything like that, but protein creatinine ratio and everything. How do you perform in a CR? Um so whether you performing a CR is by I collecting a spot sample, So spot sample, Um, basically, avoid the need to collect urine over, you know, 24 hour period. You just do it once, and that's the spot. Um, should be a first thing in the morning type specimen know during the day or night time, Um, and in terms off, analyzing it. Um, if the A CR is between three and 70 it needs to be verified. And by being verified, it needs to be repeated subsequent human in the next morning to confirm that there is protein urea if they're 70 if there's more than 70 many grams of minimal, never pee is needed because it's very bond or basically. So this is this is a small table. It's been lifted from past medicine. A CR is that mean? Um on. You know, between 13. 70 then you can see what the urinary protein excretion is like. Program. Um maybe 24 hours. Then the next night I'm gonna discuss more about the interpretation. So if the A CR is more than 3 mg from any more or more, um, is confirmed clinically important protein urea, and it's highly suggestive of diabetic, never, never happy on also chronic kidney disease. Nice guidelines once again say that if the urinary a CR is more than 70 on unless we know that protein you is already associate it with, um, the diabetes and it's being managed. You need Teo need to refer once again to a nephrologist. Um, and once again, I'm repeating myself here. But anything above 30 with battery of after excision of new try and really colic knee severe flat in the front. Just so basically, it might seem to you guys, you just always have to reflect an apologist on. That's not bad. Not a bad option, to be honest, but you should really going to consider a photo kidney doctor when the A CR is between three and 29 especially if someone has concomitant symptoms. Such a Z, um, assistant Hematuria's and they also have declining GFO on your cardiovascular diseases. Well, this is a CEO. This is a very nice diagram. Um, it doesn't always make a lot of sense. Definitely didn't make sense of me as well. Um, this is basically this This essentially is, um, is was how frequent. You should probably monitor you do your far, um, in terms of number of times a year. Uh, with that, that that the cumulative risk of someone developing CKD So if on the left you can see all of the different stages off off the off the CKD stating system and then on the y axis here. So this will be our X, and this will be a while. And why here? You've got, um, the A CR ratio her and you can see that if someone's GFI is quite good, um, and that the albumin creatinine ratio is is also be like three. Then it's I like the They don't have some kicking. They might not need monitoring. Is this frequent near someone? For example, with Egypt far less and 15 on the A C are more than 30. They would have very, very high likelihood, if not absolutely probability, that have CKD and they need to have regular monitoring. So those are Those are all of the symptoms in their house. Manage them how to interpret them. We should also try to manage the systemic disease Is a zoo well as we can. So we would We should try to manage the hypertension. Um, it's very difficult to to manage it. Um, in people with uncontrollable kidney disease, something So you would have you know, actually, you would have someone on the nation hitter, um, once again, any any drug ending in April. And then you also have a ARB going along beside it. The's days. They don't tend to make combinations off based on a, uh these they're usually separate. You have to have two different tablets, but you need a starting approval. I mean, you also might need ah, run in and attention system blocker. Or, for example, you won't need a rental agonist a z. Well, um, just to control the whole, um, chemo dynamics of things and the equilibrium as well as I said, furosemide is always, always something that you shouldn't you should consider. Especially when the G f. R is less than 45 mils. And when they're significant, you know, um, overload as well as I mentioned the best, because it cannot specially, um, promote urine output. Um, and it can tend to, um, significantly improved on the clinical picture of the patient. But anyone on CKD you'll see that there be be a prime textbook example of polypharmacy have a lot, lot of things that they take, um, to try and control it. The next thing is, you know, we have to you have to be a bit more effective with managing, uh, the nephropathy. So the way that you tried to manage the property is by having an effect of screening program on by effective screening program. Each patient should, ideally, the screened Emily using a C are on get, including that criteria would also be having regular fundoscopy. Um, and also probably monitoring their HBA. One C is is Well, uh huh. You know, with everything, as I said, try to modify the diet so you'd have to, um, encourage the patient. Also advice the patient to try and restrict the dietary protein intake. Um, you tried to control the BP as much as you can. You try to aim for the BP to be less than 130 systolic and 80 on diastolic on. Then you'd have to also control the this lipidemia with a form of statin, Um, as well. And, um, a lot of recent trials are actually showing that there's a lot of the benefit. Um, if you have, uh, that that there's a lot of benefit for combinations. So no combination with a lot of benefit for the individual. If they have a nascent a bitter on down and your attention to receptor blockers, a certain basic, the running concomitant news, Well, they do improve outcomes. There's also another, um, another pearl full of you listening. There's also another trial. I think going on the SGLT two inhibitors is, well, a very, very potent trying to control CKD on also SGLT SGLT two inhibitor is also being used right now for, like, over trials as well to try and come out the fluid overload of all of the pleural effusions as well. So we're kind of coming up to the Enbrel. Um, so I only have two questions left now. So everything you guys have got a really good picture of what's going on, uh, with acute kidney disease and also CKD, um, question for, um, is there a lot of questions? So what stages of CKD require dialysis? That's that's a very subjective question, and that's highly dependent on the clinical picture. So if that EEG E f r, for example, is really, really, really in the dumps on, they have started developing symptoms of uremia overload. Um, any diuretic is not working and things like that when they have to be a candidate for the Addison's. Because dialysis would be a life saving, that would be a life saving intervention. Basically, no, it's It's not just symptomatic relief. It's more, um, it's more controlling. Uh, we're trying to get a better control to stop the the inevitable rapid progression. If you do not control these things, it's a bit like Parkinson's. You can't reverse Parkinson's that you can control it, the level that you can function and with chronic kidney disease. More often than not, if it's uncontrollable, you will end up in end stage kidney disease where, um, your your kidneys and butchered and you started with today life unfortunately, and once you start the house is this is a long term thing, or it could be a one off treatment for? For some. For some people, it can be, um, one off treatment in cases of intoxication. Paracetamol over there or any other type of overdose can be, um, but more often than not, it's usually a long term. It's a long time activity, unfortunately, um, but the frequency, if it can, very depending on how well you control your symptoms. So you can start off with, you know, going to to dialysis machines or the nephrology unit of every hospital, maybe twice a week. And then you might find that one to start calling the systemic disease is better. You can maybe, um, frequent the hospital less, Um, if it's controllable, if that makes sense. Yeah. Yeah. Back to the question. Um, so you have a 65 year old man with type two diabetes? Um, he presents his GP for annual routine. Diabetic check ast part of the routine checkup. He needs to be tested for diabetic. Ah, nephropat. The, um he denies having any signs and symptoms of chronic kidney disease. Um, and his prior urine tests have bean be normal. Um, there's diabetes is is when well controlled by the metformin. So how best should the patient be screened for the diabetic bathroom is the option one when you measure the protein creatinine ratio PCR on a spot urine sample. If the results are normal, you repeat it in first thing in the morning. Or did we do the A CR way on? If it's abnormal, we need to repeat it again. Or do you just performing urine dipstick test? Uh, do you take blood involuntary? The HBA one C. What do you guys think? Just create the pole. You could use you probably good. Um, people have answered on and and that everyone has been listening because everyone has pretty much but be, um so that's good. And that's very right. You would have to measure the A C on that spot. Urine sample first. Um, and if it's between three and 70 uh, many grands propensity to, then they have to repeat it. And once again, if it's repeated and it's elevated, then that is confirmed for, um, for for protein urea and a zero result, the diabetic nephropathy and the CKD. I mean, you would you would be performing, um, you'd be taking regular blood and you'll be monitoring the HBA one c is well in general. Um, so that's not a wrong answer, but ideally, you'd have to do that. The albumin creatinine ratio first, um, and then repeat it to verify it on. Then you have to take it from there. Okay, that's question for the final question is, what are the differences between, ah, acute kidney injury versus chronic kidney disease? So I'm gonna leave this, uh, we'll leave it alone. You to put in the chat box. Um, what do you guys think? Um, the other differences. Yeah. I mean, everyone is pretty much hit a hammer on the head. So achy eyes more often than not reversible. Um, I can't actually reproduce that. The amount of a guys that progressive CKD by another is obviously a risk factor for having if you've had previous like I was, you are at risk of pregnancy, kiddies. Then people with CKD 10 also have a care if that makes sense. Um, but also, uh, yeah, the achy eyes reversible, as I just said, Um, the kidneys. Exactly. I'm glad someone pointed out the kidneys. So usually you would have, um a bit of a change in the appearance of the kidneys. um, and you probably have to do an ultrasound. Um, totally assess the kidneys. You probably expect for them to be reason these showed up on definitely a trophic chronic kidney disease been acute kidney disease that they had actually relatively normal. Then I would be more based on the glomerulus, um, or the glomerular disease Or the post renal aspect of things as well. Um, symptoms as well. Um, yeah, urine output. Acute me in a k I. And there's obviously kratie mean, which is ah, more acute. Marker off how the kidneys are filtering fluids. Um, someone has said that the three stages in a k I'm five stages in chronic kidney disease, so pretty much everyone is is right on the think you will be paying attention as well. Um, so yeah, that's That's really, really good to hear On C is well, so thank you very much. You get to the end of my legs, you know, um, actually, this isn't This is really useful tool of you. My references were being gay. Best practice. Um, past medicine textbooks, most of the question bank. Um, yeah. Okay. Like as I said, this was you're so full of you know is interactive. Thanks very much. If he doesn't want to leave that feedback mean count. I'd really appreciate it. You know what I did? Well, I did wrong. Well, also. Well, um, yeah. Thanks again, guys. Thanks. And Miss Argon Beam. Having me on a lot of really enjoyed being on. Thank you. Thank you, Stephen. This is very helpful. That's really informative. Went through a lot of tea, so I think everyone appreciate that to you guys about it. They're linked with feedback for in the chart on For those you can scan Yorker. There's a cure. Couldn't screen on both. Shared the slides and recording on Meadow. So I want to throw it out for free, but form you can get both in there if it doesn't really have any more questions for those couple. Yeah, and I have been taking questions. If you guys have any further questions you guys want. Now you get on you too, and last questions make it in for more if you want. Yeah, right. Doesn't seem that is any more questions, have you? I think it's odd. Um, I said I think everything that I wanted to see if I missed out on anything, I do apologize. I had to be as up today. It's possible with the guidelines, and it's all theory. But if you have any further questions, my email address is right. That brought him. You like to get in touch more than happy Teo, speak to anyone and everyone on, Uh, thank you once again that having me in this arm, um, thank you Have one for turning up paying attention. Uh, a great experience. Thank you. Thank you much dot Good evening. This pain guys take care.