AVF, severe comorbidities

Gabrielle Morris

39yo male for formation L RCF next week

Background:

  • ESRD
    • Diabetic nephropathy exacerbated by an AKI
    • Currently dialysed through permacath. Some blockages (resolved) but nil infections.
    • Secondary anaemia – EPO, Hb 109
  • T1DM
  • Smoker 10/d and cannabis ++
  • Malnourished, dry weight 54kg

Issues

  • Difficult phone consultation
    • Patient extremely difficult to engage in conversation, became agitated with attempts to clarify information.
    • Unable to ascertain functional capacity
  • Poor diabetes control
    • Multiple admissions to ICU with DKA
    • Fasting sugars 10-15. HbA1c unknown
    • Ultra-long acting/mixed insulin at midday. How to manage this perioperatively?
    • Potential for optimisation?
  • Undifferentiated HFrEF
    • Sestamibi as part of transplant workup showed EF 30%, asymptomatic (as far as could be ascertained). New development.
    • Awaiting TTE (although pt unaware of this), no current booking, should we pursue this?

Discussion

  • HFrEF
    • In absence of F2F review, preop TTE may be helpful and is a necessary step for him, it is unlikely to change management.
    • Point-of-care TTEs from ICU unable to be located
    • Could this be uraemic cardiomyopathy?
      • Classically that would present as diastolic dysfunction with hypertrophy and fibrosis, although chronic severe hypertrophy may lead to cardiomyocyte death and systolic failure.
      • Fibrosis may lead to dysrhythmias and sudden cardiac death.
      • Thought due to pressure and volume overload (HTN and anaemia), fibroblastic growth factors, chronic inflammation, systemic oxidant stress, RAA activation, insulin resistance, abnormal mineral metabolism and endogenous cardiotonic steroids.
      • Response to traditional therapies is limited.
  • Endocrinologist says they have worked extremely hard to achieve the once daily ultra-long-acting insulin and no further optimisation possible.
  • Profoundly depressed or cognitively impaired?
    • Services available within renal or transplant spheres?

Plan

  • W/H ultralong acting insulin DOS and use insulin infusion while in hospital. Resume normal insulin with normal diet.
  • Attempt to obtain TTE but don’t delay surgery if not possible preop.
  • Line up a procedural anaesthetist who will confidently do the procedure under regional anaesthesia only.