Kidneys Inc.

medicine and nephrology updates and interesting cases by a practicing nephrologist in USA

Archive for the month “December, 2011”

The nocturnal dip

There is a strong link between kidney disease and BP variations both in normal and hypertensive individuals that leads to the chicken or the egg conundrum of which came first when we manage our hypertensive patients. It is not very often that we stress on when the BP medications had to be taken to be most effective. The focus is on lowering the BP to expected goals hopefully through out the day and night. One of my previous posts was about an article that focused on a circadian clock and rhythm in the kidneys causing diurnal variations in the BP. Given the evidence that early stages of hypertension, there is a loss of the nocturnal dip, the 10-20% drop in the BP at night time, and it’s association with increased cardiovascular risk, it only makes sense to restore this nocturnal dip in order to decrease the risk. Recently saw this article. neat study, although it is open labeled with relatively small sample size, it is a prospective randomized open-label blinded end-point study, larger sample size than in any other trial to study this effect.

It is a general consensus that bringing the blood pressure to normal is more important than how it is done, in terms of what specific medications are used. But now it seems that it is not only important what medications we choose but also when we choose to give them


n = 661 332 awake group & 329 night time group (at least one medication at night time)

48h ambulatory BP monitoring

Follow up 5.4 years

Primary endpoint: adjusted risk for CV events was three times higher in the awake -group. Adjusted hazard ratio 0.31 p < 0.001

secondary endpoint: adjusted risk for composite outcome (MI, CV death, CVA) was three times higher in awake-group Hazard ratio 0.28 p <0.001

The night-time group had

lower asleep systolic BP mean p < 0.003

lesser proportion of patients with non dipping pattern 41% vs 71% p <0.001

higher proportion with controled BP 56 vs 45% p<0.003

awake BP similar in both groups p= 0.41

The difference in the cardiovascular risk was mainly due to restoration of the nocturnal dipping pattern. There was also a decrease in the albuminuria in the night time medication group.

An octogenarian perspective

I had picked up Emily’s patient to help her out, since one of mine was a ‘no-show’. The patient, Mr. Martin was in the infusion room getting an IV infusion . Not wanting to waste time waiting for him to finish, I decided to see him in the infusion room. Luckily, there were no other patients in the room and a computer to access his medical records was right on the table next to his chair. The conversation turned out to be one that I would remember for long. Within a few minutes, Mr. Martin had vented enough to give me glimpses of  his toughened mind, tempered thoughts, emotional vulnerabilities.He had pulled me into his world briefly by revealing some of the victories and losses of his life’s battles.

As I logged in to access his records, I introduced myself and hoping to start up a conversation, asked him how old he was.

Mr Martin belonged to the healthy looking octogenarian kind, even though he had dealt with his fair share of health problems. He actually looked younger than his stated age, not only going by his vigour and confidence, but also by physical appearance. He was neatly dressed, had maintained a good physique despite his physical disabilities.

Confidently he said, “Oh yeah, I want live for another 10 years, atleast. Not that I have any major project like building an empire or something but I now have a reason to live which I did not have before. You know, I am a capitalist..” And he looked at me for a reaction as if it was my turn to tell him what I was..

Me: Well, I am not quite sure what I am. I have conflicts in my mind when I see huge discrepancies in wealth. I feel deeply empathetic towards people who struggle for even basic necessities, while others enjoy an exuberant lifestyle

Him: “I am empathetic too, but if I become a socialist all I do is give away everything and nothing will be left for me. And they won’t even be helped. You need to strike a balance while being aware of the discrepancies & maintaining your empathy. You need to cut a path for yourself” I couldn’t tell if he was trying to change my opinion or was trying to defend his..

Me: Yes may be you are right. Because if you don’t have wealth, you can’t hope to get it from other “empathetic” people.

Now his eyes gleamed, happy that I got his point. “Exactly. I am not wealthy or anything but I have worked hard for what I have”

Me: I think you should stop taking the Magnesium tablet

Him: “Well that is good. Are you a doctor?”

I smiled, Why? are you having doubts? (I remembered that just a couple of days prior to this, another patient had mentioned his difficulty in identifying people in hospitals, since doctors, nurses, nurse practitioners, PAs all dress & look the same)

Him: “No, I can tell people easily. I was just checking if you are a pharmacist since you are adjusting my medications”  he then spoke to me in Spanish

Me: I can’t have a conversation in Spanish, I barely know a few words.

Him: “Well, I can talk to you in French then”. he smiled. for me it meant that he was looking for someone he could talk to. (needless to say, he lived alone)

Me: I am sorry I don’t know French either. I can speak hindi if you want to (note to self, my fall project is (has been forever) to learn Spanish or French)

Him: “No I don’t know hindi, I haven’t been that far yet. I have gone up to turkey, I have flown over india, not in a plane but a bomber. He looked at me with pride as he mentioned bomber.

I was busy gathering data to make my assessment and he probably wanted me to stop it & listen to him.

I can take care of Pakistan in a minute for you, if you wanted. Prrp! , (he snapped his fingers) in a second!” with a delightful expression on his face.

by now I had realized this was going to be a long conversation.

Me: oh no, I wouldn’t want that.

He probably noticed I am not freely entering into a dialogue. and sternly said, “I only have thirty minutes because I have to leave for another appointment” implying he doesn’t have time for me either.

Me: Looking at his infusion, told him that it was unlikely he would be able to get out on time, but I would try my best to finish up my part as quickly as possible.

I was being drawn into this converstation already and I did not mind at all, since I had time & also some interest in listening to this man who seemed enterprising

Yes I know that too, he grinned. “I feel better already. I probably take too many of those water pills. (which I found out was true) he was taking it more frequently than prescribed).

He continued, “I once saw an Indian movie in Paris that my wife took me to. She looks more Indian than any of the Indians that I know of. It was a totally new experience. The only other thing remember about that day was that the Egyptian movie was terrible.

Even while I was grazing through his chart, I could notice a sad tone in his voice when he said, “I don’t remember many thing s from the past but this one I remember very well”

I tried to perk him up a bit,

Me: I am glad you enjoyed the Indian movie, do you remember the name of the movie or the actors

Him: No, I only remember the costumes and the intensity of those scenes. He lifted his arms trying to probably describe a scene or something… but he couldn’t. aah yeah, and those actors can’t kiss. It was evident he remembered those moments somewhat vividly, though he did not remember any details of the movie

Me: Has anyone talked about dialysis to you?

Him: Yeah, they were talking about getting me a tube osmosis or something

Me: Sorry could you please repeat that again?

Him: You see, I am not trained in medical field but I am a well educated person, you know. I understand somethings well. If there is a membrane, I guess the exchange has to be osmosis.

I wasn’t sure if he was annoyed or offended by me asking him to repeat.

with a discontent tone, he continued, “We all are stuck here. We should not even be going to places where we are not supposed to be. Do you know our blood boils when we go to 50,000 feet? we have only 40 secs to live if that happens. Now you will think I am a crazy old man”

Me: No not at all. I would be happy if my brain works like yours when (&if) I am your age.

Him: I know. With a brain like mine, I sometimes cannot handle it myself. I get up in the night & start talking to myself. I become restless.  I have been to great heights, there is no sky and it is definitely not blue, it is just dark, black. I have seen the curve of the earth’s horizon. He was showing it with one hand as a plane and with another the curvature of earth’s horizon.

Me: Wow! That must have been a nice experience. I have only seen it on videos.

Him: Not entirely. You have a pressure helmet and you are under stress, but it gives you a different perspective

I was juggling between this conversation and my assessment and documentation. I had managed to squeeze in a physical exam while asking him a few more questions. Everytime, I tried to pull him back into a ‘medical’ conversation, he would pull me back to his side, so to speak…

Me: How long have you been on this medication?

Calculated & told me the duration,..

Him: When I moved here, I got my wife’s ashes and my medications in the front seat of my car. When I checked the next day, the medication was gone. I mean, somebody so slick?! What would they even do with that? Stealing other people’s stuff. Goddamn people. Oh god, I don’t even know what religion means anymore. he was sad again, actually sadder it seemed as his words dissipated into an angry mumble.

Now I had to stop typing and had to take a pause, since I noticed he was getting intensely emotional, remembering his wife

I tried to distract him, after hesitating for a second, since it was a delicate situation

Me: Hmm, are you a non religious person?

He had already rcovered, I thought

Him: yes. I do believe in god but I am too educated to believe in rituals and customs if that is what you mean. And I believe in god only to the extent that I think that is the only way I will ever see my wife again. Oh well, whatever… People can do all sorts of things if that helps them get peace. I don’t have an objection to that. May be it will help their stress & “hypertension”. He raised his eyebrows skeptically.

I asked him about one of his malignant medical condition.

Him: They put me on hormone injections so I don’t have testosterone in my body. Now I am a woman. I have breasts, I have a belly, I shave only once a week. I don’t know what I am anymore. I cannot control my emotions sometimes. you know, I cry like a baby sometimes. You probably have more testosterone than I do.

wanted to say that it is ok to cry and that everyone cries, but I kept it to myself

My colleague Tanya entered, wanting some info. She respectfully nodded her head as he looked at her, trying to make an assessment in his own mind.. he seemed to like her

Him: “You are pretty”.

She giggled “Oh! no one has ever said that to me”

Me: “Oh come on, that can’t be true

Colleague leaves after a brief exchange of some information with me

Him: See how easy it is to connect with someone? Well, She was actually pretty. If you can breathe, you are pretty.

Me: hehe, yeah may be you are right, I nodded as I continued with my work, trying to finish it up.

Me: So you had an infection in your bloodstream in the past? There was too much past medical history for me to browse through

Him: Oh yes. Can you believe I am still living after going through all of that crap? btw Do you know Ms Leena? she works at the regional hospital where I was admitted

Me: No

Him: She was ‘one of a kind’ person. She is a doll. She is young. well, everyone is young to me at 80 y of age. She is gay. She does not have a sex (gender) she is just a good person. You would have loved to meet with her.

Me: I see.

Me: OK I have made some changes to your medications. And ordered some labs before your next visit. Do you have any questions for me?

Him: Thanks for getting rid of some of those medications. So, are you going to help me live another 10 yrs?

Me: Oh sure, I will try my best. why 10? may be 15…

Him: Who knows, I had less than 30 minutes to live about ½ h ago. (pt was hypotensive and had received  some fluids in the clinic)

Me: I enjoyed the conversation with you. Could I please get your permission to post this on my blog?

The nurse had disconnected the IV lines by now.

We shook hands and then as he got up, he said,

“Sure, anything you want to do. You know, I don’t talk with everyone like this. I felt a positive feedback from you. It was a pleasure talking to you. How do I pronounce your name? how do you spell it?

Me: M as in Mary…, A as in apple…

he wrote it in a small book and he walked out with a sluggish & fragile gait with the help of his walker, dragging his tall statured, weathered self. He must have been a robust and handsome man in his prime days, I said to myself

I get to meet with many old lonely people during my day’s work. This one caught my attention today, mainly because of his resilient attitude which was incongruent with his weakened body, cold & random at times, yet wise & thoughtful, all while trying to deal with his loneliness and shortcomings. At 80 he seemed to have almost come to an agreement and had made peace with a disconsecrate view of the world he is living in.

I have written this from what I remember of all the relevant (or should I say irrelevant?) parts of our conversation

Names, patient information have been changed to protect privacy

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