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Hi guys, we're just gonna wait um a few more minutes just for some more people to join and then we will get started. Ok, I think we can start now as a few people have joined. Yeah. Um Hi guys. Um Welcome to our medical clerking webinar. Um There's just a few housekeeping things we've got to say sorry. Can you move to next slide, please? Yeah, thank you. Um So welcome to BB SSN. Um Basically, we are a organization that is aiming to offer guidance and support to students um just to help them navigate and be able to reintegrate into the NHS. Um We are mostly targeting students in Bulgaria and making it more accessible for students to reach the help and support they need. If you have any questions or suggestions about things, we can do initiatives um that can help students in your university, please feel free to reach out to either myself or on the Instagram page um that is linked on the screen. Um Our speaker today is Doctor Marcus who is an I NT three working in the NHS in Colchester. So, um over to Doctor Marcus. Thank you. Perfect. Thanks. So much, didn't she? And, um, just a reminder of why if you, um, wouldn't mind leaving us any questions or comments in the chat as we go and I'll do my best to get to know at the end. Uh, if that's all right, please. So today's talk is about nephrology and I've recently done a, a rotation within the renal department uh at my local hospital. Um, and I wanna share some, some tips and tricks about how best to clark patients who are coming into hospital with uh pathology concern in the kidneys. And the aim of this talk will be to, to a later year medical students or maybe final year graduates. Um and just a summary of what we're gonna talk about today. So firstly, acute kidney in kidney injury, AK I um chronic kidney disease and what to look out for when seeing patients with both. And then we got two cases about A A and C KD. And finally, we'll talk about renal failure. So what to do when medical management is insufficient. Um And when to start thinking about things like dialysis and, and calling intensive care and, and and things like that. So let's make a start. So we'll start off with uh our first case. Um This is a 60 years old male patient admitted after having four days of vomiting and then profuse diarrhea, also noted to have fevers and fatigue. Um the past medical history HD N. So hypertension and gout. The medication the patient is on is Ramipril. So an ace inhibitor and allopurinol which is controlling his gout and then always ask about social history. So we know this patient minimally drinks alcohol and is an ex smoker um with a 20 pack year history and he happens to work as a a lorry driver. So when you're seeing patients almost always, you'll have a recent set of blood tests or at least blood tests on the way. Um And here what we wanna show you is so his kidney function is eg fr his baseline. So in January 2021 it was 64 and today it was 32 his potassium is elevated to 6.4 normal range being as high as 5.5. His urea is 25 and his creatinine today is 206 when his normal creatinine when it was measured two years ago was just 97. So we'll start off with a quick question if you wouldn't mind popping some ideas into the chart. Um or at least thinking about the history and bloods, we've just seen, um, what do you think could be a cause of this gentleman's acute kidney injury? And we're thinking back about the very brief in information that you have. But you know, he's a past medical history of high BP. He's on some medication and he is admitting symptoms with diarrhea, fatigue and fevers. So, if we we refer you on to his case. So we've got a huge list of things it could be. Um but really simply almost always, this case is gonna be likely to the e exactly as someone's mentioned. Um the prerenal ak I secondary dehydration. Um Yeah, the the vomiting and diarrhea leading to dehydration are all typical of a a gastroenteritis pic picture as ahmed's mentioned. Um and someone else Taza said uh hypertensive meds. Um yeah, the Ramipril. So that's our differential number two. It can be nephrotoxic at times, although it's it is useful in kidney disease. It's not useful when someone could be slightly dehydrated and that then tips them over into an AK I or acute kidney injury. Um And then the other three are gonna be less likely given this patient's case, say it's always almost always gonna be um because of dehydration, but you could think about hype hypertensive nephropathy. Um And here, if you've got progressive kidney disease over some time, um his last blood test was in 2001, uh 2021. So really it could be uh what you're seeing is a presentation of uh progressive renal impairment because of the high BP and then other things to mention. So, gout in itself can cause kidney injury and allopurinol, the drug itself can cause it as well. And then finally, this patient being a smoker. Uh his age was around 60 years, I believe So, could he have um sort of smoking, accelerated renovascular disease, much like smoking is a risk factor for um strokes, heart disease. It's also true for kidney uh vascular disease as well. So even from such a small case, there's such a, a wide variety of possibilities. I'd say the most likely being that dehydration. So, reviewing our history once more. Yeah, it's a 60 years old male. Um he's got a few prescribed meds background history and then we know his social history as well. So we wanna identify what to what. So the prerenal ati um profuse diarrhea, it says and vomiting and losing, losing your volume status. Uh the Ramipril as a nephrotoxin allopurinol um mixed in with the, the gout and the, and the drug and the drug induced effect on the, on the kidneys itself. Um and the progressive nature of uh hypertensive nephropathy and one I've stuck in there is so NSAID induced ak I in talking to this patient, what I realized actually they were his prescribed medications which were only two, but then he told me that he was taking a lot of medicines over the counter and some herbal remedies and one of which was actually quite a significant dose of uh Ibuprofen Cos he had a chronic bad back, but that never made it into his, his medical history and his records. Um So NSAID induced kidney injury is a, is quite a common feature, particularly for people who are taking it at higher doses. And for a long time when I say long time in at least weeks to months, um that's when we can typically see um nsaids like aspirin um or Ibuprofen causing a, a poor effect on the kidney. So then how are we gonna treat these possibilities? So, let's say he had um just a simple prerenal dehydration linked kidney injury. First and foremost, this guy coming into the hospital, uh job, one is pres prescribed some fluids rehydrate him. Uh And if there's no history of heart failure, he's not super old, he's only 60. Um you can be quite aggressive with the fluids. The next would be to um change his nephrotoxin or just hold Ramipril, don't give it to him whilst his kidney function is worse than usual and just stop that for a few days and things usually improve uh progression of his hy hypertensive nephropathy if that was the case. Um What you'd need to do is prove that with get some observations, it's more likely to be the case if his BP is usually sky high. Um If he's quite well managed on his, on his um just his Ramipril and his blood pressure's only in the, let's say one forties or one fifties, it's probably less likely to be the case. Um If it was gout or allopurinol related gout, you can uh change the medication. So things like colchicine as an alternative rather than the allopurinol or you could just stop it altogether and see how his uh his joint disease progresses. And then if he's got any renovascular disease, uh has he had any past imaging that could ct scans are really good for not just looking at what you're trying to find out, but other things are typically the kidneys get imaged in all sorts of scans uh that may be done for other pathology like bowels, bowel obstructions and, and various things the patient may have come into the hospital for. And then, uh, yeah, the NSAID induced AK I so always asking about these over the counter otc medications. And then on the right of the screen, we've got um, further management options and these are true in, in all cases of AK I. So, fluid rehydration is one if there's ever high potassium, what you wanna do is the, the medical management of high potassium. And there'll be, uh, if you work in the NHS in the near future, there'll be a protocol exactly of how to prescribe calcium gluconate, which protects the heart from any changes in potassium. And then insulin dextrose, uh the insulin pushing the potassium into cells and the dextrose then to maintain an even uh blood glucose. The next uh is he becoming anuric? So you want a urine output, monitor this patient, um, whether or not it's just having him measure what he ps or using a catheter to more accurately assess things if the, if the situation, it determines the next I've got a VBG. So this is a, a venous blood gas. And the important thing here is you wanna be looking for how acidic his blood is naturally. The kidneys are filtering uh lots of products and removing hydrogen ion. So, acid and if there's kidney injury, you can have an acidosis and that's to find that out and, and correct it if need be uh with an E CG, you can rule out. Is there any uh changes on the E CG associated with high high potassium? And what you're gonna get is your tall tented T waves. Usually it's on, on all the leads, but certainly in the chest leads. So that's V one to V six. Um And if that's true, then it just means the situation needs to be looked at a little more carefully and a lot more closely and having a strict, um sort of medical management of the high high potassium. And finally, uh you won't get a result for an ultrasound so quickly, but an ultrasound of the kidneys, ureter and bladder. Uh So ultrasound K UB and that's to make sure there isn't any obstruction or dilation of the kidney. Um, although you, you think this is a prerenal, so dehydration related. AK I there's nothing to say that he could have two slightly different things going on at the same time. So it's confirming your, your primary diagnosis is one and ruling out other things is another. Um Even if you think it's a lot less likely it is still sometimes worth uh doing a test to find that out. So if you wouldn't mind feeding back into the pole, so we wanna rehydrate fluid, rehydrate this, this patient. Um If you wouldn't mind asking or answering the question, whether you, which fluid you would use, if you have an opinion as to which um whether you'd use Hartman's, which is a, a more balanced fluid or whether you'd use uh sodium chloride or normal saline or otherwise known as naught 0.9% N ACL or whatever you wanna call it. Um So let's see what people would, er, wouldn't wanna put, I'll just give you a few moments just to have a think about that and we've got fairly even split. Um So I just wanna talk about these two fluids slightly more. So probably you don't see it quite so well. At least not on my screen but um in Hartman's, although it's a balanced fluid, so it's got a little bit of chloride, it's got a more physiological amount of sodium. Um But in this case, it has five millimoles or millimoles per liter of potassium. Whereas of course, the normal saline has only naught 0.9% of uh sodium chloride, but pretty much is the only time or one of the few times where sodium chloride is the better option. And the reason is because of the potassium. Um We said that this chap had a potassium of, I think it was six point something. Um And although Hartmann's has a very small amount of potassium, in the first instance, you're probably gonna wanna prefer the sodium chloride. Um Although it's not a really physiological fluid, it's used a lot in the first instance for resuscitation and given large amounts very quickly. And then typically, what I do at least is give a few bags of sodium chloride and then prefer to give Hartmann's later on down the line. Um And the second reason for that is actually there's far too much chloride in sodium chloride as well. And that in itself can cause an acidosis and acidic blood. And although you've fixed the potassium issue, you then give yourself a acidosis problem. So, too much aviva is, is um disadvantageous but balancing it with sodium chloride to start and then thinking about Hartman's later on in uh maybe a day or so later, uh is probably uh the best way to go and certainly how I do things. And the next thing I wanna talk through is what we, our trust called a acute kidney injury bundle. And basically, it's like a pilot checklist, but for kidney injury and for medical doctors, so rather than thinking about what you should do or what you shouldn't do, it's all listed for you and you've just gotta go through and identify what's appropriate for, for the patient in front of you. So for instance, on there, it says about obstruction, um is there is history of bladder outflow obstruction. Um And with all the males, you can have uh enlarged prostate. So again, in male patients, I always, always take yes or possibly and then request an ultrasound K UB to make sure there's no obstruction. But uh various hospitals have checklists and care bundles like this for, for different pathologies, not only kidney injury, and I advise you to familiarize yourself with them whenever you settle into work and um find your, your possible of work because each trust and each hospital does things ever so slightly differently. Um But this is just for, for information only really. So we'll pause there just a moment and um, we'll have a think about case two. Ok. So we're gonna move on to chronic kidney disease and it's a 55 year old patient who is admitted with three days of cough fever, shortness of breath. S ob and a few weeks of general fatigue. Uh Importantly, we identified the n the, the negative important negative symptoms, there's no chest pain, there's no optic pain. Um and patient is passing just small amounts of urine. Uh I'm an exsmoker, uh they don't drink alcohol and this patient works as a taxi driver. So the background history, the C KD stage four and I'm just gonna make sure you guys can see our slides. Uh is everyone able to see s uh case two slide. Yeah. OK. So I think some people may be struggling. OK. Great, perfect. All right. So we'll crack on. Um we mentioned a background history as patients. So C KD stage four and when I say stage four, there's um the ke go list of how bad your eeg F I is. Um So stage four is anywhere from eg fr 30 to 15. Um In addition, I have high BP, type two diabetes, mellitis or TD, uh type two diabetes, Angina and PBD peripheral vascular disease um medication they're on. So beta blocker bisoprolol, Ramipril, Metformin, flusemide a diuretic uh atorvastatin for the cholesterol and then a small dose of aspirin. No doubt that's for the angina. And we go and examine this patient and what we find is crackles on the chest but not bilaterally, but only on the one side. The heart sounds, you have the S one S two and there's no additional murmur. Uh The capillary refill time is three seconds and you find that they're all mucosa dry and they look a bit dehydrated, converted. Oh, and quite paradoxically, they got pitting edema, lots of fluid on the legs. And when seeing edema or fluid, you wanna find out how far it goes up and on this patient, it's sort of mid shin area and the calves are soft and nontender. There's no sign of a DVT and the patient's perfectly awake and orientated and talking to you. So we run through the observations. They got elevated respiratory rate. The heart rate um is 98. So ever so slightly tachycardic, the saturations are the lowest it could be, it be normal. So that's 94% BP just about OK. 100 and 17/66 uh G CS 15. And they're just mildly febrile at the moment and the blood tests. So the important ones, I'll drag your attention to. So hemoglobin, it was always low, but now it's sl ever so slightly low. At 85 white cells are significantly elevated. The C RP is super high. So that's 250 and then the urea and the creatinine urea 15, creatinine 233 or 31 and baseline creatinine is 100 and 90. So showing that they have that KD and the EG FR has dropped, it was 21. It's now just 13. So looking back at that case, um how many diagnoses do you think you can make? So why is the pa think about why the patient has come to hospital? Um what's going on in the background and what the blood test can tell you. Um If we can start that pole, I'll just give you a few moments just to try and choose an option from the poll list. OK. So how many diagnoses in this case? Well, we had the C KD um and the patient was diabetic. So is just a, a diabetic nephropathy or again, the, the renovascular disease could be one and we had the impaired renal function. So this is an AK I again, but with the background of D and he was anemic. So if I take you back to the bloods, we had a, he was anemic to start with and he's ever so slightly more anemic today. So that's a sort of chronic anemia. Um And your job here as a as a medical doctor, seeing the patients who have been referred from A&E would be always asking yourself why, why things are the case? So treating it is, is one thing and stabilizing the patient and that's great. But also then you've got to try and find out a little bit more about why things are happening. So likely this is because of his anemia, his uh his renal disease. And we know urethro Perin is released from the kidneys. Um But you wanna, if you think in the background, maybe he's deficient of iron. So you could do some iron studies for this patient. And then the patient was febrile. Uh you auscultated the chest and there was unilateral crackles. So whether this is a a pneumonia or c community acquired pneumonia to be more specific. Um So that all the things at least I was thinking about when, when seeing this patient and what I wanna get across to you is how to sort of initially manage patients on the when you're seeing them coming into the hospital for the first time, an A&E of seeing the patient stabilize things and what should your plan and investigations be? And you'd use your AK I bundle if you have one in the hospital. So for this patient, the EGFR is really low. So it would be fair to, um, ask the nurses to put in a catheter for the patient to monitor their urine. You could get a chest x-ray cos they're presented with chest symptoms. Uh, fever, ecg is there any, although there's no chest pain, um it'll be important to have a look at any changes for uh hyperkalemia, blood cultures as there is infection. Um the ultrasound ku once more and then what's really useful is you can add on some blood tests to those that have already been taken and the lab usually stores the bloods for about 48 hours and you can just fill out a form to add on things in the past and that's iron studies B12 and your folate. Um just to try and have a look at that anemia and the results of that typically come back hopefully within 12 to 24 hours and then prescribing. So what could you prescribe to a patient? It'll be fluids, it'll be uh an antibiotic. Obviously respecting the allergies if there are any. And in this case with a, a pneumonia, a community acquired pneumonia, coamoxiclav one and Chloroin er our hospital asked us to prescribe both of those for suspected pneumonias. So what to consider when prescribing in, in renal impairment. Um, anyone will be a bit brave and thinking about what could be held or what you gotta prescribe or what you mustn't prescribe and feel free to pop it in the chat. But I wanna guide you and, and direct you some really important resources. So, one of which is the B NF, um which I just Google, the drug name and put B NF afterwards. And um it's really useful cos it tells you exactly uh what doses to use and which ones can be um dangerous in renal impairment. And then it's a little bit harder to get hold of. But the renal drug handbook um is a lot more accurate than the B NF and it's preferred by renal physicians. And it'll tell you exactly what to do, even if the patient is on dialysis or any other type of renal replacement, it'll tell you exactly what to do with which drug. Um The second thing is this med celc again, easily accessible just through Google. Um And here, if the eeg fr is a calculated number that the lab gives for every patient, but if your patients ever at the extreme of body weights are really obese or overly slim, uh it's really useful to calculate. Actually, the creatinine clearance is slightly more accurate than it takes into account the exact patient's body weight, uh age sex and then their creatinine and this gives you AAA far more accurate result. And then you can use that in conjunction with the renal drug handbook to dose the patient appropriately cos you don't wanna overdose the patient, but most certainly for infections and antibiotics, you definitely don't want to under dose them neither and hold a regular and nephrotoxic medications that the patient usually takes at home and then you can also hold any nonessential medications. Um just whilst the patient is acutely unwell and in the comments, we got evaluated flusemide. Yeah, perfect. So this is a drug that uh you don't really need an acute illness, especially if you're infected. If your, your BP was only in the hun let's say around 100 and 17 systolic flusemide in this case, is gonna do you any favors. Um and a similar train of thought. So medications like nephrotoxic uh are made perfect. So yeah, having a, you're thinking how on and making sure you're not adding to the problem. So, prescribing in chronic kidney disease. So for this patient with um eg fr that's now in the teens, um the correct dose is IV Coamoxiclav at least is, is 1.2 g, grams BD to twice daily and not three times daily. That is the usual dose for those with an EG fr above 30. Uh the clavicin actually orally is just fine. Uh the statin um you can't prescribe statin with uh a macrolide. So Claviformin. So nonetheless, it's a non-essential medicine whilst the patient's in hospital receiving IV antibiotics. So you could just hold out for a few days. Um And exactly as Taz said, holding the flusemide patients on Ramipril hold out risk of hypotension and it's uh nephrotoxic as well. And another one to mention was actually the Metformin. So if I tell you, it's completely contraindicated if the eg fr is less than 30 But this patient's eg fr in 2021 was actually 21. So really, they shouldn't have been on that to start with. So clerking patients in seeing them in hospital, you could be the f you know, the only doctor who's seen the patient for months or, or even years. And it's a good opportunity just to review their regular medicines uh and make any changes that you feel are appropriate. And with this patient ever so slightly dehydrated, but they got quite bad D and now on AK I on KD, you can't overload them with fluids. So we're encouraging them to drink orally or if you do give IV fluids, give it a little bit slower, be a little bit more cautious. Um When I say cautious, I mean, for instance, an eight hour bag of fluids or a liter over eight hours, um the old damage goes. So it's never killed anyone. So eight hour bag is absolutely fine for almost all people. And it's quite a good rule of thumb and then just to finish, um I'm gonna talk about renal failure. So when C KD is so bad that it gets termed renal failure. So that's end stage. Renal disease is another word and it's an eeg fr of less than 15 or even in the single figures. So, four key markers of renal failure, hyperkalemia, uh which is resistant to medical management, fluid overload. So the kidneys are that bad that they can't quite offload the fluid that they're drinking a metabolic acidosis. Again, we know kidneys are um managing the the protons and excreting bones. So then that's monitoring it with blood gasses. Um And then finally, uremia. So we have really high urea levels. You can get all sorts of uh end stage kidney disease complications. And I'm just going to vote four key features as a and giving you some details. So potassium significantly elevated and resistantly elevated above six acidosis. So that's recording the ph less than 3.7 0.35 on your blood gasses. You can medically manage that with bicarbonate. But that's more of a specialist intervention with the renal department or, or at least the consultants fluid overload. Um So we said this patient, the patient in the C KD case had pitting edema to the legs. But if they're centrally overloaded, they may have an optional requirement. They may have a wet sounding cough. Um an auscultation of the chest would give you bilateral crackles. Um in a dependent fashion. So, gravity taking its toll to both bases and then the uremia, um you don't really see uremic complications unless it's sky high and definitely nothing unless it were to be above 30. And what you can get is an encephalopathy, encephalopathy. You can have uremic jerks that almost seem like it almost seemed like someone's in control of flexing muscles, both arms and legs and then pericarditis. Uh you could see it on an E CG or it could be complaining of mild chest discomfort. So there are your key features of renal failure and when you might wanna be thinking about not just medical management, but do you need things like dialysis? Do you need intensive care? So we'll summarize there and I just wanna remind you of the sort of take home messages. So that's when to identify a AK I and C KD and be cla able to classify those as prerenal, intrarenal and postrenal. So, postrenal being obstruction, prerenal, being dehydration and intrarenal pretty much being anything else, the investigation of possible causes and then probable causes. So confirm your most likely diagnosis and rule out other diagnoses along the way, prescribe in accordance with the guidelines and you know how to look them up. So that's the B NF um and we have more detail, that's the real drug handbook, stop any regular meds. So de prescribe, it's not all about prescribing, but it's about stopping regular medicines as well. And then with those complications and those signs of renal failure, know when to refer to for HD hemodialysis or hemofiltration is a treatment that intensive care can give in the emergency setting. So I think we'll stop there. And I just wanna thank you all for your attention this evening. And if you wouldn't mind really kindly filling out a feedback form that really helps us at the P SSN to um direct our talks. So, thank you very much for listening this evening. Thank you. Um very much, Doctor Marcus. Um Now we're gonna move on to the Q and A si think some people have put some questions in the chat. Um OK. So the first question, can you explain the staging and sever um severity criteria for AK I and how that guides treatment decisions? Yeah. So uh staging for AK I is a CAL you always get a calculated number and that's given to you with the lab tests. Um It's about how your renal function and how your creatinine is shot up. Um And that's a lab based way of doing it. And the other way is how much urine you're producing per uh kilogram of po gra. So the lab will always give you a number where it's AK I stage 12 or three. And the details about can be found actually that on the KD go website KD IG O website and there's a really helpful table that'll show you um the staging and staging of both C KD and AK I Yeah, thank you. Um Another question we've got here is what are the immediate steps or interventions recommended for managing AK I in a in acute setting? Yeah. So acute setting AK I, I'll refer you back to the um the AK I bundle. So it gives you a lot of things to do. But the gist of it is um if dehydrated give fluids rarely, they're gonna be fluid, overloaded. U monitor the urine and the urine output. Um stop any offending drugs like Metformin like Ramipril. Um And the thing that kills people quickest is potassium. Um high potassium over 66 and over or anything with ECG changes is a medical emergency and that's when you need to be doing um your infusion of insulin and dextrose to move potassium from the blood into the cells and it sort of hides it away at least for a few hours. Um And that's the most important of all treatments when it comes to AK I um particularly those with high potassium, but not all patients will have high potassium. So, um you do need your blood test to confirm that. Um I think following up from that another, the question is, um, are there any like specific medications or treatments that should be initiated? Especially when they've got other comorbidities like diabetes um in the acute setting? No, it's just uh management as we said. But then once they get a little bit more well and well, they may have had an AK I, they're not necessarily gonna go back to their normal kidney function. Um, it unfortunately may never return to normal. So then if they've got like diabetes and kidney disease, when they're, well, they would benefit from uh an ace inhibitor like Ramipril. Um, and it's about managing or stopping things getting worse. So, for instance, with high BP, it's optimizing that whether that's with medication or advising patients on lifestyle choices. So it stopping smoking or smoking cessation um promoting so good health like with weight loss, if they're overweight and minimizing alcohol or reducing alcohol if it's at dangerous consumption levels. So it's that sort of advice in the long term um that you'll be giving. Mm I think the last question we've got here is um since the patient is D four, would they be recommended for dialysis? When and how is this in indicated in our role? Or is this specifically a speciality driven task? Yeah, very much a speciality driven task. And patients with like KD stage four, their GP should be referring them to the kidney doctors in the outpatient clinic. So hopefully they're known to the kidney team anyway. Um and it's very much bare decision about whether dialysis is appropriate for that patient and you only tend to start dialysis when you reach any of these features of renal failure. Um So having a low G fr into itself isn't really the defining factor. It's whether if you've got your fluid overloaded and you're coming in and out of hospital needing big, big doses of diuretics, then, well, the on balance, it may be worth you starting dialysis at that point. Or if you've got hy hyperkalemia that bring you into hospital or any other features of metabolic acidosis or uremia, then that's when you really need to be thinking about dialysis. And it's so it's very uh specialist driven. So your job really would be to identify these patients who need the attention of the renal physician or the renal consultant. Um and what's more starting dialysis. So you need access to the patient's blood. So, ideally, this is done through a fistula, but that takes at least months, sometimes as much as a year to get organized and the surgeons need to do the work and then it needs to mature. So that's a long process. You have a way you can get access for, for dialysis is in the emergency setting. You can put really big cannulas into the um jugular veins and that's the way that we do dialysis urgently for patients who come in quite unexpectedly. Um But this is very much a senior led um decision and it won't be exactly your job. I think actually, you've got a follow up again from that. So in this, in a situation where the patient isn't suitable for dialysis, maybe like due to comorbidities. What is the next line for this patient? What is the next line, I guess. Um next line is medical optimization, knowing that it's the second best treatment option. So, yeah, quite right. If the KD four or even then C KD five, but they're extremely frail, maybe they have a, a life limiting diagnosis like a metastatic cancer starting dialysis where you'd have to come to the dialysis unit in the hospital. Um for about four hours, three times a week means that you'll be tied to that geographical area. You'd have to be well enough actually to come in and out of the hospital. It's definitely not appropriate for every, every patient. And that's a really good point. Next in line is uh managing it as best as you can. So, fluid overload, you'll be given big, big doses of diuretics, um hyperkalemia, you'll be advising the patient of a low potassium diet. So avoiding things like tomatoes and bananas and you may also prescribe a potassium binding drug that only it, you take it orally, it stays in the gut and it tends to bind potassium in the gut. Um stopping you from absorbing most of that the metabolic acidosis. There's not so much you can do but, but for giving um bicarbonate that balances out um balances out the acidosis. So that can be a tablet. Um But in the hospital, we often give it IV and then Uremia. Um there's not too much you can do for it. So, if any of that is problematic and you can't solve the problem or at least, um, manage the patient to any acceptable level. That's when, unfortunately you'll be thinking more about, well, you can't make this patient better. Their renal failure would be, um, really their, their, their cause of death and you'll be thinking about palliative care and symptomatic care as best you can. Um, and unfortunately that does happen. Mhm. Thank you. Um I think that's all the questions in the chat. Doctor Mattis. Thank you again for this talk. Um, just to remind everyone if you could please fill out the feedback form, I think the link should be in the chat now. Yeah. Thank you everyone. Thank you, Doctor Marcus. Ok. Thank you very much. Well, uh we'll see you again soon. Bye bye bye.