विवरण
The evaluation of a patient with altered mental status begins with a detailed history. Because the patient may be unable to offer a history, it will be required to seek additional information from family, friends, or the primary medical team. The first step is to ascertain the timing of the mental status change and the circumstances surrounding it, such as medication/drug usage or trauma. An acute change in mental state is a medical emergency that necessitates an immediate, systematic evaluation. Airway, breathing, and circulation ("ABC's") should be evaluated in conjunction with an updated set of full vital signs and finger-stick blood glucose. Tachycardia may indicate a systemic infection, pulmonary embolism, or atrial fibrillation with high ventricular rate.
सारांश
- Anemia is a common complication in kidney disease, primarily due to inadequate erythropoietin (EPO) synthesis and is exacerbated by chronic inflammation, impaired iron absorption, and blood loss. Diabetic patients often develop anemia earlier. Anemia in CKD can lead to serious complications such as coronary artery disease, left ventricular hypertrophy, and increased mortality. Landmark trials have helped guide the treatment and management of anemia in CKD patients.
- Symptoms of anemia include fatigue, dizziness, and reduced exercise tolerance. Diagnosis involves checking hemoglobin levels and iron status, and the KDIGO guidelines recommend regular monitoring based on CKD stage. The target hemoglobin range in CKD patients is generally 11 to 11.5 g/dL, lower than the normal healthy adult range to avoid cardiovascular risks associated with overcorrection.
- Iron treatment is crucial, aiming to reduce blood transfusion requirements, improve symptoms, and enhance quality of life. The KDIGO guidelines recommend specific targets for transferrin saturation and ferritin levels. Both oral and intravenous iron preparations are available, with intravenous iron often preferred for dialysis patients due to poor oral absorption. Iron dextran requires a test dose due to the risk of anaphylactic reactions.
- Erythropoiesis-stimulating agents (ESAs) are used in conjunction with iron therapy to manage anemia. ESAs should be used judiciously at the lowest effective dose to minimize side effects. Newer oral HIF-PHI agents like roxadustat are promising but require further study. The approach to treating anemia in dialysis patients has evolved, with blood transfusions now rarely needed due to advancements in iron and ESA therapies.
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