Metabolic Flashcards
Outline the guidance for preventing AKI in patients currently admitted in hospital
- identify those at risk by monitoring NEWS score.
- recognise and respond to oliguria in those at risk.
- measure U&Es in those at risk.
- record weight daily to determine fluid balance in those at risk.
Outline the guidance for preventing AKI in adults having iodine-based contrast media
- encourage oral hydration before and after procedure.
- IV volume expansion with isotonic sodium bicarbonate or 0.9% sodium chloride in high risk inpatients.
- temporarily stop ACEi and ARBs in adults with CKD eGFR < 40.
- discuss with nephrology team before.
Outline the guidance for preventing AKI in people at high risk/preventing deterioration
- electronic clinical decision support systems (CDSS) to support decision making and prescribing.
- seek advice from pharmacists about optimising medicines and drug dosing.
- temporarily stop ACEi or ARBs in patients with D+V or sepsis.
Describe the impact of haemodialysis on a patient’s physical/social well-being and psychological health
- the time the patient has to go for dialysis will restrict their activities and social interaction.
- reduces flexibility in a patient’s schedule e.g. going abroad or working.
- patient might find fluid restriction tedious and negatively impact on mental health and social life.
- AV fistula might make patients self-conscious and have a negative impact on body image.
- home dialysis/self-care is more flexible and empowering.
Describe the impact of peritoneal dialysis on a patient’s physical/social well-being and psychological health
- patient might find fluid restriction tedious and negatively impact on mental health and social life.
- PD tube might impact negatively on body image.
- risk of peritonitis.
- more flexibility on when to dialyse, improves patient’s social and work life. Can dialyse at night.
- treatment everyday rather than 3x per week.
What is the role of the Human Tissue Act (2004)?
To regulate the removal, storage and use of human tissue, to ensure its safe and ethical use.
What is the main change that came about in the Human Tissue Act (2004)?
It replaced the Human Tissue Act 1961, the Anatomy Act 1984 and the Human Organ Transplants Act 1989. The main change was focused around consent for the removal, storage and use of human tissue from living or deceased donors. It established the Human Tissue Authority (HTA).
Describe the offences under the Human Tissue Act (2004)
- Removing, storing or using human tissue for Scheduled Purposes without appropriate consent.
- Storing or using human tissue donated for a Scheduled Purpose for another purpose.
- Trafficking in human tissue for transplantation purposes.
- Carrying out licensable activities without holding a licence from the HTA.
- Having human tissue, including hair, nail, and gametes, with the intention of its DNA being analysed without the consent of the person from whom the tissue came or of those close to them if they have died.
Considering the 4 principles of medical ethics, which does the Human Tissue Act (2004) aim to uphold?
Non-maleficence: not harming human tissue, ensuring it’s safety.
Justice: fair and ethical use of human tissue.
What has been the implication of the Human Tissue Act for Organ Transplantation?
It requires that every living transplant donor and recipient is assessed by a formally trained and HTA‐accredited third party. The HTA will then pass judgment on the potential donation.
What is the role of the Human Tissue Authority (HTA)?
Regulatory body under the Human Tissue Act (2004) that regulates the removal, storage and use of human bodies, organs and tissue from the deceased and the storage and use of human organs and tissue (excluding gametes and embryos) from the living. It is also responsible for assessing applications for organ donation from living people.
Describe the role of the independent assessor (IA) for organ donation
All donors and recipients see an IA who is trained and accredited by the HTA to ensure that the donor has given valid consent, without coercion, and that reward is not a factor for the donation. They also ensure the donor has the capacity to make an informed decision. Donors and recipients must bring prof of their identity and relationship. IA then approves living donation.
Whose responsibility is it to seek consent for the removal of organs, for the purpose of transplantation?
It is the responsibility of the treating clinician.
What are the two kinds of risks that an individual should be aware of before agreeing to donate organs?
Generic risk - any reasonable person or all donors would attach significance.
Individual risk - the person consenting to donation would attach significance (specific to the donor).
Before giving approval for organ donation, which 3 key conditions are required by the HTA?
- No reward has been, or will be, given.
- Consent to removal, for the purpose of transplantation as been given.
- An independent assessor has conducted separate interviews with the donor and recipient and submitted a report of their assessment to the HTA. A joint interview with donor and recipient is also required (except with non-directed altruistic donors).
If the organ donor is a child, how is the decision of whether transplantation proceeds made?
Made by a HTA panel of at least 3 members in all cases where there is perceived to be a higher regulatory risk e.g. if the organ donor is a child.
“The HTA also requires the living donor to specify how they wish their donated organ or part organ to be used should it not be possible to transplant it into the intended recipient”. What are the different options available to the donor? When is this decision usually made?
- Donor is ask to consent to either: implantation into another recipient, re-implantation back into the donor, research, or disposal of the organ.
- Consent for this is taken during discussion with the surgeon.
What does the Human Tissue (Scotland) Act 2006 suggest with regards to the use of human tissue?
- Provision for activities involving human tissue in the context of transplantation, research and education, its removal, retention and use following post-mortem examinations.
- Provisions are based on authorisation rather than appropriate consent.
How does altruism relate back to living donor transplantation?
Reinforces the philosophy of voluntary and unpaid donation and solidarity between donor and recipient.
How does autonomy relate back to living donor transplantation?
Entitlement to control our own body and to the right of self-determination. Therefore valid consent must be given by the living donor before an organ can be removed, which must be made freely and autonomously. Donor has the right to make the decision to donate their organs.
How does beneficence relate back to living donor transplantation?
Donation must be in the patient’s best interests.
How does dignity relate back to living donor transplantation?
Any form of financial payment or commodification of bodies or body parts violates human dignity (honour/respect).
How does non-maleficence relate back to living donor transplantation?
Transplantation should not involve harm to the donor or recipient.
How does reciprocity relate back to living donor transplantation?
It refers to providing benefits or services to another as part of mutual exchange, for example in paired/pooled donation.
Describe the possible ethical dilemmas that may arise for the recipient
- Living donor transplant is the preferred option rather than deceased donation as the survival rates are better, however this might not always be available (justice).
- Living donation can only be justified if the interests of the donor are given priority, regardless of recipient benefit.
Describe the possible ethical dilemmas that may arise for the donor
- Even though there are overall benefits for the individual donor and wider society, living donor still entails risk, including a small risk of death. Is it fair to risk the life of the donor to save the life of the recipient?
- Removal of kidney may cause physical harm on health and well-being. This conflicts with non-maleficence.
- Questionable whether informed consent for organ donation can truly be given, with all the risk of donation (does the donor listen?).
- The only person who can know that consent is ‘freely given’ (voluntary) is the living donor. Subtle pressures from family members may not be revealed and remain undetected. Overt pressure or coercion is easier to identify.
- Difficult to establish that consent is both informed and voluntary.
Describe the possible ethical dilemmas that may arise for the transplant team
- If MDT has concerns about suitability of a potential donor and that it may be inappropriate (e.g. too risky), they are under no obligation to proceed, even if the donor wishes to proceed. Conflicts with donor autonomy.
- When is it appropriate to remove patients from national transplant list for deceased donor kidney if they have a potential living donor undergoing assessment? Balance the needs of the recipient, potential donor and the ‘greater good’ to the pool of patients waiting for a kidney (justice).
When did the opt-out organ donation system come into place and what does it mean?
- 20th May 2020.
- All individuals over the age of 18 are considered as organ and tissue donors unless they have opted out, have appointed a representative to decide for them after death or are in one of the excluded groups (<18, ordinarily resident in England for <12 months before their death, or lack mental capacity for a significant period before their death).
Describe the arguments for the opt-out organ donation system
- Increases the number of donors as there was a shortage of available organs in England.
- Reduces mortality rates in those waiting for a transplant.
- Makes the waiting list time shorter.
- Still respects patient autonomy.
Describe the arguments against the opt-out organ donation system
- People might not be aware of the law change, so might donate organs against their wishes when they are deceased.
- People might not know which organs are routinely transplanted and might only allow certain organs to be donated. Therefore people may wish to opt-out of certain body parts.
- Some individuals might not have access to the electronic opt-out system. Hard-to-reach groups might not engage with the system to express their wishes.
- Consent is an active process and cannot be ‘presumed’ because no objection is known.
What circumstances is the opt-out law not valid?
Novel or rare transplants (the law only applies to routine transplants).
Outline the role of the MDT in managing the process of organ donation and transplantation
- MDT responsible for planning the approach and discussing organ donation with those close to the patient.
- MDT includes: medical and nursing staff who care for the patient, specialist nurse for organ donation, local faith representative where relevant.
- Continuity of care.
- Provide support and accurate information about organ donation to the patient.
Summarise the cost-effectiveness of renal transplantation as opposed to dialysis
- Cost of dialysis is greater than benefits compared to renal transplantation, taking into account QoL (e.g. dietary restrictions, social limitations), emotional/mental effects, long-term financial costs, risk of death, adverse effects.
- Therefore transplantation is the most cost-effective renal replacement modality.
