Drug eruption associated with empagliflozin Yau, Kevin; Poon, Stephanie; Auguste, Bourne L
Canadian Medical Association journal (CMAJ),
12/2022, Letnik:
194, Številka:
48
Journal Article
Recenzirano
Odprti dostop
A 61-year-old man with a history of congestive heart failure, atrial fibrillation, chronic kidney disease and hypothyroidism was presented to clinic with a painful, bilateral, nonblanching, lower ...extremity rash 2 weeks after starting empagliflozin (5 mg/d). One month after starting the drug, they increased the dosage to 10 mg/d for ongoing heart failure management; his rash then worsened. Laboratory investigations showed that the patient was positive for antinuclear antibodies, with no extractable nuclear antigen antibody. Test results for hepatitis B and C serology, antineutrophil cytoplasmic antibodies, cryoglobulins and rheumatoid factor were negative. Eosinonegative for blood with trace protein. The patient was started on 0.05% clobetasol cream, but was subsequently admitted to hospital owing to progression of the rash. The differential diagnosis for the patient's rash included vasculitis, cellulitis, contact dermatitis, venous stasis and a cutaneous drug reaction.
Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is ...contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of ‘Your Questions Answered’, we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.
As the global prevalence of peritoneal dialysis (PD) continues to grow, practitioners must be equipped with prescribing strategies that focus on the needs and preferences of patients. PD is an ...effective form of kidney replacement therapy that offers numerous benefits to patients, including more flexibility in schedules compared with in-center hemodialysis (HD). Additional benefits of PD include salt and water removal without significant changes in patient hemodynamics. This continuous yet gentle removal of solutes and fluid is associated with better-preserved residual kidney function. Unfortunately, sometimes these advantages are overlooked at the expense of an emphasis on achieving small solute clearance targets. A more patient-centered approach emphasizes the importance of individualized treatment, particularly when considering incremental PD and other prescriptions that align with lifestyle preferences. In shifting the focus from small solute clearance targets to patient needs and clinical goals, PD remains an attractive, patient-centered form of kidney replacement therapy.
Volume overload in peritoneal dialysis (PD) is common and associated with significant morbidity and mortality. If left untreated, it can result in premature technique failure in patients receiving ...PD. Practitioners should be aware of common causes and formulate a stepwise approach in the management of volume overload.
Patients have varied learning styles and this has implications for home haemodialysis (HHD). Assessment tools directed toward understanding these styles remains understudied. As a consequence, this ...may lead to substandard retention rates or adverse events in HHD programs. As part of a continuous quality improvement initiative we have aimed to improve our understanding of patient learning styles and consequently tailor home dialysis training to individuals. To objectively determine knowledge translation and comprehension, irrespective of learning styles, we have introduced an objective structured clinical examination (OSCE). This assessment tool allows for further refinement of educational priorities by highlighting both deficiencies and strengths. Thereafter, an exit OSCE ensures patients attain an acceptable standard to complete home haemodialysis independently. We hope this tool will help shape future training criteria for HHD programs and consequently reduce adverse event rates.
SUMMARY AT A GLANCE
Patients have individualized learning styles and home dialysis training should be personalized.
Home modalities improve clinical endpoints and are more cost effective than in‐center treatment.
Early education, determination of health literacy, and use of educational assessment tools such as VARK should improve training success.
Personalized training should improve attrition and retention rates.
Standardized patient OSCE's can be used for knowledge assurance of theoretical and practical domains.
Adverse home dialysis event rate may be reduced using individualized training and patient OSCE's.
Coping with the transition from end‐stage kidney disease to dialysis can be challenging for patients and their care partners. Introducing incident dialysis patients to incremental forms of dialysis ...is associated with better quality of life and reduced cost. Incremental hemodialysis (HD) has generated significant interest over the last decade with treatments that focus on clinical criteria rather than prespecified Kt/Vurea targets. Incremental peritoneal dialysis (PD) has traditionally focused on the sum of residual renal and peritoneal clearances to achieve a specific Kt/Vurea value. Gradual increases in the PD dose were prescribed as the residual kidney function declined. Adopting a new approach to incremental PD similar to what has been done for incremental HD would obviate the need for Kt/Vurea and focus exclusively on clinical criteria. New incremental PD may be considered less disruptive to incident dialysis patients, and may be more likely to be accepted as treatment. It will also reduce our obsession with small solute kinetics and enhance encounters with patients by focusing instead on the holisitc clinical assessment.
Vitamin D toxicity is rare, but clinicians must be aware of the risks of vitamin D use to limit complications related to hypercalcemia. Calcium levels may get worse before getting better in patients ...even after cessation of supplements, as vitamin D is fat soluble. Observational data and expert opinion suggest that glucocorticoids, ketoconazole and hydroxychloroquine are reasonable options to treat hypercalcemia related to vitamin D toxicity by decreasing the "active" 1, 25 dihydroxyvitamin D3 levels.
Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the ...most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.
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