Annals for Educators - 20 February 2018,Annals of Internal Medicine

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Annals for Educators - 20 February 2018
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2018-02-20 , DOI: 10.7326/afed201802200
Darren B. Taichman

Clinical Practice Points

Mid- and Long-Term Health Risks in Living Kidney Donors. A Systematic Review and Meta-analysis

Living kidney donation is the gold standard treatment of end-stage renal disease; more than 8000 living-donor kidney transplantations were done in 2013 in the United States, Brazil, and Japan alone. This systematic review of 52 observational studies details health risks for adults who donate kidneys.

Use this study to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners what risks might accompany kidney donation. What did this systematic review and meta-analysis find?
What medical and ethical issues must be considered and discussed with persons who are considering donating a kidney? How might the results of this review inform these discussions?
What limitations in the available data were identified in this study? Why is the follow-up time so important?
How should we counsel patients who inquire about donating a kidney? What questions do we need to ask? What do we need to tell them about the short- and long-term risks?
The authors assessed whether the nondonor comparison groups were as healthy as the donors in the studies included in this meta-analysis. Why is that important? The authors found that most comparison groups were likely not as healthy as the kidney donors. How might that affect the findings and conclusions?
Use the accompanying editorial to help frame your discussion of these questions, and invite a specialist in kidney transplantation to join your discussion.

Chief Concern: “I'm Worried I Have Chronic Traumatic Encephalopathy”

Chronic traumatic encephalopathy (CTE) has recently been the focus of extensive media attention. Are your learners prepared to address concerns that their patients might have? This commentary addresses diagnosis, prevention, treatment, and financial compensation for patients with a history of head trauma and their families.

Use this paper to:

Ask your learners what they know about CTE. How is it defined? Is it helpful to know about a disease entity that, at present, can only be diagnosed at autopsy? How?
What symptoms and signs have been reported in patients with CTE? What is the differential diagnosis for each?
Who is at risk for CTE? What is known (and not known) about the relationship between concussion and CTE?
How would your learners respond to a patient who is concerned about CTE? How would they discuss the risks and benefits of participating in sports that might involve head trauma? What would they recommend patients (or parents whose children participate in sports) do?

Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery

Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. This substudy from a large multicenter trial examines benefits and harms of perioperative aspirin in patients with prior PCI undergoing noncardiac surgery.

Use this study to:

Ask your learners how they assess the risks for cardiac complications of noncardiac surgery. Who is at increased risk? Who requires testing, and how? Use In the Clinic: Preoperative Evaluation for Noncardiac Surgery to help prepare a teaching session.
Review the results of this study. What are its strengths and limitations? Use the accompanying editorial to help frame your discussion. Why does it matter whether a study was prespecified by the investigators?
Should your learners continue aspirin in noncardiac surgical patients who have had prior PCI?
Who requires antiplatelet therapy after PCI? For how long? Watch The Consult Guys - An MI, a Stent, Bleeding, and Surgery! What Do I Do? with your learners for a relaxed way to review antiplatelet therapy after coronary stent placement.

The ACC/AHA 2017 Hypertension Guidelines: Both Too Much and Not Enough of a Good Thing?

The most notable recommendation in the 2017 hypertension guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) is the reduced threshold for the diagnosis of hypertension, from ≥140/90 mm Hg to ≥130/80 mm Hg in the general population. This commentary discusses the guidelines and why they create as many questions as they answer.

Use this paper to:

Ask your learners what threshold they use to diagnose hypertension. What do the guidelines from ACC/AHA and the American College of Physicians and American Academy of Family Physicians recommend? Why do they differ?
How do blood pressure measurements obtained in your learners' practices differ from those obtained in the clinical trials whose results are used to formulate hypertension guidelines? What other important differences are there between a clinical trial and your learners' practices?
The authors of this paper discuss how failure to recognize these differences might affect assessments of the quality of care provided by physicians. Do your learners think this is a problem? Can they suggest solutions?

Humanism and Professionalism

On Being a Doctor: Politics and Professionalism

Dr. Sexauer writes that, “To many, [the 2016] election seemed to be as much a referendum on civility as it was about the political future of our country. Civility lost.” He asks how the medical profession should respond.

Use this essay to:

Listen to an audio recording, read by Dr. Virginia Hood.
Ask your learners whether differences in political opinions have affected their interactions with coworkers. What about with patients? How? Should we refrain from discussing political topics at work?
Do your learners share the author's concern for civility in our society? What responsibilities does our profession have here?

MKSAP 17 Question

A 65-year-old woman is evaluated during a follow-up visit. She has end-stage kidney disease due to IgA nephropathy; she started peritoneal dialysis 3 months ago. She also has a 10-year history of hypertension. She has done well since starting dialysis, is without current complaints, and has recently resumed exercising regularly. She has three adult children who are encouraging her to explore kidney transplantation and are willing to be evaluated as kidney donors; however, the patient feels that she is “too old.” Medications are amlodipine, ramipril, calcitriol, epoetin alfa, and calcium acetate.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 135/75 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. BMI is 27. The peritoneal dialysis catheter site is nontender without induration or exudate. Cardiac examination reveals normal heart sounds. The lungs are clear. The abdomen is nontender. There is no peripheral edema.

Which of the following kidney replacement strategies is most likely to provide this patient with the best long-term survival?

A. Change from peritoneal dialysis to hemodialysis

B. Continue peritoneal dialysis

C. Continue peritoneal dialysis and evaluate for transplant in 2 to 3 years

D. Refer for transplant evaluation now

Correct Answer

D. Refer for transplant evaluation now

Educational Objective

Understand the risks and benefits of kidney transplantation.

Critique

Kidney transplantation would be the most likely strategy to provide this patient with the best long-term survival. Although there is an increase in short-term morbidity and mortality following transplantation, there is strong evidence that kidney transplantation decreases mortality and improves quality of life over the long term. Even though increased recipient age is also associated with reduced patient and allograft survival than younger patients after transplant, carefully selected older patients also benefit from kidney transplantation, and many centers therefore do not have an absolute age cutoff for transplant recipients. Moreover, this patient has family members who are willing to be evaluated as living kidney donors, and kidneys from living donors have superior outcomes compared with kidneys from deceased donors. Therefore, referral for possible kidney transplant in this otherwise healthy patient would be most likely to improve her long-term survival.

There is no clinical indication for this patient to change from peritoneal dialysis to hemodialysis, and clinical outcomes, including mortality and quality of life, are approximately equivalent between these modalities. The choice between peritoneal dialysis and hemodialysis should therefore be driven by patient-specific factors and patient preference if dialysis is pursued.

There is evidence that risk of graft loss and overall mortality are increased in patients who have been treated with dialysis prior to transplant, and that this risk of graft loss and overall mortality increase with the length of dialysis prior to transplant. Therefore, continuing dialysis and reevaluating for possible transplant in 2 to 3 years would not be an optimal management strategy in this otherwise good candidate for transplantation.

Key Point

Kidney transplantation decreases long-term mortality and improves quality of life compared with dialysis.

Bibliography

Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011 Oct;11(10):2093-109.

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中文翻译：

教育家年鉴-2018年2月20日

临床实践要点

活体肾脏捐献者的中长期健康风险。系统评价和荟萃分析

活体肾脏捐赠是终末期肾脏疾病的金标准治疗；仅在美国，巴西和日本，2013年就进行了8000多次活体供肾移植。这项对52项观察性研究的系统回顾详细介绍了献肾的成年人的健康风险。

使用此研究可以：

从选择题开始教学。我们在下面提供了一个！
询问您的学习者肾脏捐赠可能会带来哪些风险。该系统评价和荟萃分析发现了什么？
必须与正在考虑捐献肾脏的人一起考虑和讨论哪些医学和伦理问题？审查的结果如何为这些讨论提供信息？
这项研究确定了可用数据中的哪些局限性？为什么随访时间如此重要？
我们应该如何建议询问肾脏捐赠的患者？我们需要问什么问题？关于短期和长期风险，我们需要告诉他们什么？
作者评估了非供体比较组是否与本荟萃分析中所研究的供体一样健康。为什么这么重要？作者发现，大多数对照组的健康状况可能不及肾脏供体。这将如何影响发现和结论？
使用随附的社论帮助您对这些问题进行讨论，并邀请肾脏移植专家参加您的讨论。

首要问题：“我担心自己患有慢性创伤性脑病”

慢性创伤性脑病（CTE）最近已成为广泛媒体关注的焦点。您的学习者是否准备好应对患者可能存在的担忧？该评论论述了具有头部外伤史的患者及其家属的诊断，预防，治疗和经济补偿。

使用本文可以：

询问您的学习者他们对CTE的了解。它是如何定义的？了解当前只能在尸检中诊断的疾病实体是否有帮助？如何？
CTE患者已报告了哪些症状和体征？每种的鉴别诊断是什么？
谁有遭受CTE的风险？关于脑震荡与CTE之间关系的已知（未知）信息？
您的学习者会对关心CTE的患者有何反应？他们将如何讨论参加可能涉及头部创伤的运动的风险和收益？他们会推荐患者（或有孩子参加运动的父母）做什么？

非心脏手术前经皮冠状动脉介入治疗患者中的阿司匹林

对于事先进行过非心脏手术的经皮冠状动脉介入治疗（PCI）的患者，阿司匹林的疗效尚不确定。这项来自大型多中心试验的子研究检查了围手术期阿司匹林对先前接受过非心脏手术的PCI患者的围手术期利弊。

使用此研究可以：

询问您的学习者他们如何评估非心脏手术的心脏并发症风险。谁的风险增加？谁需要测试，如何测试？在临床上的使用：非心脏手术的术前评估，以帮助准备教学课程。
查看本研究的结果。它的优势和局限性是什么？使用随附的社论来帮助您进行讨论。研究人员是否预先进行了研究为什么重要？
您的学习者是否应该在曾接受过PCI的非心脏手术患者中继续使用阿司匹林？
谁在PCI后需要抗血小板治疗？多长时间？观看咨询专家-心肌梗死，支架，出血和手术！我该怎么办？与您的学习者一起轻松地评估放置冠状动脉支架后的抗血小板治疗。

ACC / AHA 2017年高血压指南：太多和不足？

美国心脏病学会（ACC）和美国心脏协会（AHA）在2017年高血压指南中最值得注意的建议是将高血压的诊断阈值从≥140/ 90 mm Hg降低到≥130/ 80 mm Hg在普通人群中。这篇评论讨论了准则以及它们为什么会创造出尽可能多的问题。

使用本文可以：

询问您的学习者他们用来诊断高血压的阈值是多少。ACC / AHA和美国内科医师学会以及美国家庭内科医师学会的指南有何建议？他们为什么不同？
在您的学习者实践中获得的血压测量值与在临床试验中获得的血压测量结果有何不同，临床试验的结果用于制定高血压指南？临床试验与您的学习者的实践之间还有哪些其他重要区别？
本文的作者讨论了未能认识到这些差异如何可能会影响对医生提供的护理质量的评估。您的学习者是否认为这是一个问题？他们可以提出解决方案吗？

人文主义和专业精神

关于当医生：政治与专业精神

Sexauer博士写道：“对许多人来说，[2016年]选举似乎既是关于公民政治的全民公决，也是关于我们国家政治前途的全民公决。文明失落了。” 他问医学界应该如何应对。

通过这篇文章可以：

收听录音，由弗吉尼亚·胡德博士（Virginia Hood）朗读。
询问您的学习者，政治观点的差异是否影响了他们与同事的互动。病人呢？如何？我们应该避免讨论工作中的政治话题吗？
您的学习者是否分享作者对我们社会文明的关注？我们的职业在这里负有什么责任？

MKSAP 17问题

在随访期间对一名65岁的女性进行了评估。由于IgA肾病，她患有晚期肾脏疾病；她在3个月前开始进行腹膜透析。她也有10年的高血压病史。自开始透析以来，她做得很好，没有目前的不适，最近又恢复了定期锻炼。她有三个成年子女，他们鼓励她探索肾脏移植，并愿意被评估为肾脏捐赠者。但是，患者觉得她“太老了”。药物是氨氯地平，雷米普利，骨化三醇，依泊汀α和乙酸钙。

身体检查时，温度为37.0°C（98.6°F），血压为135/75 mm Hg，脉搏频率为72 / min，呼吸频率为14 / min。BMI为27。腹膜透析导管部位不嫩，无硬结或渗出。心脏检查显示心脏正常。肺是透明的。腹部不嫩。没有周围水肿。

以下哪种肾脏替代治疗策略最有可能为该患者提供最佳的长期生存？

A.从腹膜透析到血液透析的转变

B.继续腹膜透析

C.继续进行腹膜透析，并在2至3年内评估移植情况

D.立即进行移植评估

正确答案

D.立即进行移植评估

教育目标

了解肾脏移植的风险和益处。

批判

肾脏移植将是为该患者提供最佳长期生存的最可能策略。尽管移植后短期发病率和死亡率增加，但是有强有力的证据表明，肾脏移植可以长期降低死亡率并改善生活质量。尽管移植后接受者年龄的增加也比年轻患者降低了患者和同种异体移植物的存活率，但精心选择的老年患者也受益于肾脏移植，因此许多中心没有为移植接受者确定绝对的年龄界限。此外，该患者有愿意被评估为活体肾脏供体的家庭成员，与来自已故供体的肾脏相比，来自活体供体的肾脏具有更好的预后。所以，

没有临床迹象表明该患者从腹膜透析改变为血液透析，并且这些模式之间的临床结果（包括死亡率和生活质量）大致相当。因此，腹膜透析和血液透析之间的选择应由患者的具体因素和患者（如果进行透析）的偏好来决定。

有证据表明，在移植前接受过透析治疗的患者中，移植物丢失和总体死亡率的风险会增加，并且这种移植物丢失和总体死亡率的风险会随着移植前透析时间的延长而增加。因此，在这种原本可以移植的好候选者中，继续透析并在2至3年内重新评估可能的移植将不是最佳的治疗策略。

重点

与透析相比，肾脏移植可降低长期死亡率，并改善生活质量。

参考书目

Tonelli M，Wiebe N，Knoll G等。系统评价：在临床相关结局中，肾移植与透析相比。我是J移植。2011年10月; 11（10）：2093-109。

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更新日期：2018-02-21

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