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<title>Acute Renal Failure</title></titleStmt>

<publicationStmt><distributor>BASE and Oxford Text Archive</distributor>


<availability><p>The British Academic Spoken English (BASE) corpus was developed at the

Universities of Warwick and Reading, under the directorship of Hilary Nesi

(Centre for English Language Teacher Education, Warwick) and Paul Thompson

(Department of Applied Linguistics, Reading), with funding from BALEAP,

EURALEX, the British Academy and the Arts and Humanities Research Board. The

original recordings are held at the Universities of Warwick and Reading, and

at the Oxford Text Archive and may be consulted by bona fide researchers

upon written application to any of the holding bodies.

The BASE corpus is freely available to researchers who agree to the

following conditions:</p>

<p>1. The recordings and transcriptions should not be modified in any


<p>2. The recordings and transcriptions should be used for research purposes

only; they should not be reproduced in teaching materials</p>

<p>3. The recordings and transcriptions should not be reproduced in full for

a wider audience/readership, although researchers are free to quote short

passages of text (up to 200 running words from any given speech event)</p>

<p>4. The corpus developers should be informed of all presentations or

publications arising from analysis of the corpus</p><p>

Researchers should acknowledge their use of the corpus using the following

form of words:

The recordings and transcriptions used in this study come from the British

Academic Spoken English (BASE) corpus, which was developed at the

Universities of Warwick and Reading under the directorship of Hilary Nesi

(Warwick) and Paul Thompson (Reading). Corpus development was assisted by

funding from the Universities of Warwick and Reading, BALEAP, EURALEX, the

British Academy and the Arts and Humanities Research Board. </p></availability>




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<respStmt><name>BASE team</name>



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<item n="speechevent">Lecture</item>

<item n="acaddept">Medicine</item>

<item n="acaddiv">ls</item>

<item n="partlevel">UG2/PG</item>

<item n="module">Urinary System</item>




<u who="nm0504"> right <pause dur="0.2"/> # <pause dur="0.5"/> the subject this morning is an important one <pause dur="0.2"/> # <pause dur="0.6"/> i'm sure all lecturers tell you that <pause dur="0.5"/> # acute renal failure <pause dur="0.6"/> # i'm timetabled to have two sessions <pause dur="0.4"/> # <pause dur="0.3"/> but # <pause dur="0.2"/> unless you particularly want a break <pause dur="0.5"/> i was thinking of just merging it into one <pause dur="0.7"/> # <pause dur="0.4"/> see if you can concentrate for an hour and a half <pause dur="0.7"/> # <vocal desc="clears throat" iterated="n"/> acute renal failure <pause dur="0.4"/> before we talk about acute renal failure <pause dur="0.4"/> tell me what # <pause dur="0.3"/> tell me what medicine's all about <pause dur="2.1"/> what's medicine all about <pause dur="3.1"/> what's the point of being a doctor <pause dur="1.4"/> remember if you don't <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> answer and <pause dur="0.2"/> i start picking on people </u><pause dur="0.2"/> <u who="sm0505" trans="pause"> relief of symptoms </u><pause dur="0.4"/> <u who="nm0504" trans="pause"> relief of symptoms yeah <pause dur="0.2"/> yep <pause dur="0.3"/> anybody else <pause dur="2.4"/> lady yawning here <kinesic desc="indicates member of audience" iterated="n"/><pause dur="1.0"/> what's medicine all about </u><u who="sf0506" trans="latching"> that's a vague question </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> it is <vocal desc="clears throat" iterated="n"/> it is in fact <vocal desc="laughter" iterated="y" n="ss" dur="3"/> very good <unclear>in fact</unclear> it's a vague question <pause dur="0.5"/> all right <pause dur="0.3"/> what i would say that # medicine is about biscuits <pause dur="0.4"/><kinesic desc="holds up biscuits" iterated="n"/> # <pause dur="0.4"/> why is

medicine about biscuits <pause dur="3.8"/> what happens when you make people better <pause dur="2.9"/> are they happy or sad <pause dur="1.6"/> speak up </u><pause dur="0.8"/> <u who="sm0507" trans="pause"> happy </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> happy </u><u who="sf0508" trans="latching"> depends on their quality of life </u><u who="nm0504" trans="latching"> sorry </u><pause dur="0.8"/> <u who="sf0508" trans="pause"> depends on their quality of life </u><u who="nm0504" trans="latching"> depends on their <trunc>quali</trunc> <unclear>that's a</unclear> that's a good answer <unclear>to do with</unclear> their quality of life isn't it i mean a <trunc>m</trunc> <pause dur="0.4"/> you know if they <pause dur="0.3"/> tried to die of an overdose <pause dur="0.5"/> and you saved them <pause dur="0.4"/> they may not be very happy with you # i was on medical <gap reason="inaudible" extent="1 sec"/> yesterday and <pause dur="0.5"/> # <pause dur="0.9"/> eight o'clock and get the violins out now violas whatever you like <pause dur="0.3"/> i was at the <gap reason="name" extent="1 word"/> Hospital trying to save the life of a <pause dur="0.2"/> an eighty-two year old man <pause dur="0.3"/> who came in with a G-I bleed <pause dur="0.5"/> # aspiration pneumonia <pause dur="0.3"/> and was dying <pause dur="0.2"/> basically <pause dur="0.3"/> and he'd probably taken an overdose which is very sad at eighty-two <pause dur="0.4"/> and # <pause dur="0.2"/> i think he'd almost <vocal desc="cough" iterated="n" n="sf0509"/><gap reason="inaudible due to noise from audience" extent="1 sec"/> dead by this morning <pause dur="0.4"/> but # partly 'cause we allowed him to die <pause dur="0.5"/> and # <pause dur="1.1"/> that is quite sad actually you know

why do eighty-two year olds take overdoses his wife said there were financial problems the business had gone bankrupt <pause dur="0.4"/> and you know i'm sure if he goes to I-T-U <pause dur="0.5"/> and <pause dur="0.7"/> stays there for a couple of weeks and survives he won't be very happy with us <pause dur="0.2"/> because # i'm pretty sure he wanted to die he <pause dur="0.3"/> he took # an overdose three years ago <pause dur="0.5"/> and i don't know why i'm telling you this <pause dur="0.3"/> but biscuits yeah <pause dur="0.2"/> so if you make people better <pause dur="0.6"/> they buy you biscuits <pause dur="0.4"/> and that's why i brought some along this morning just to # remind you what medicine was all about in my opinion it's about <pause dur="0.4"/> biscuits <pause dur="0.4"/> # biscuits because <pause dur="0.2"/> people are generally happy when they make you better <pause dur="0.9"/> # very important when you're looking after a patient to specify what type of biscuits you want <pause dur="0.5"/> otherwise you just get bog standard old rubbish from <pause dur="0.4"/> <trunc>s</trunc> <pause dur="0.4"/> ASDA or somewhere like that <vocal desc="laughter" iterated="y" n="ss" dur="1"/> so you must specify at the start <unclear>when you go and see</unclear> exactly what biscuits you want <pause dur="0.5"/> Marks and Spencer's <pause dur="0.2"/> every time <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay <pause dur="0.2"/> so # <pause dur="0.9"/> it's not just about biscuits though # <pause dur="0.3"/> it's actually quite good <pause dur="0.4"/> making people

better and # <pause dur="0.3"/> you're wondering what on earth this has got to do with acute renal failure well i'm <pause dur="0.2"/> getting round to it in my long and convoluted way <pause dur="0.5"/> # <pause dur="0.4"/> making people better is good <pause dur="0.2"/> # <pause dur="0.6"/> i've been doing it for nearly twenty years and it still gives me a buzz when you <pause dur="0.4"/> leave the hospital at <unclear>like</unclear> <pause dur="0.3"/> eight ten o'clock <pause dur="0.3"/> whenever you leave the hospital <pause dur="0.4"/> # <pause dur="0.3"/> you do know it's not a nine to five job don't you <pause dur="0.4"/> you do know that you are aware of that <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> and # <pause dur="0.5"/> just to get that imprinted in your brains at an early stage <pause dur="0.3"/> and # your careers will not progress <pause dur="0.7"/> if you consider it a nine to five job <pause dur="0.7"/> #<pause dur="0.9"/> don't think that has changed either <pause dur="0.4"/> but when you leave the hospital at eight ten o'clock at night and <pause dur="0.6"/> a patient or <pause dur="0.4"/> more often the relative of a patient grabs your hand <pause dur="0.3"/> and says thank you doctor you saved <pause dur="0.3"/> my life or my husband's life or my wife's life <pause dur="0.4"/> that still gives you a kick even twenty years later <pause dur="0.5"/> and # <pause dur="0.7"/> one of the ways in which kidney doctors get a

kick <pause dur="0.6"/> is <pause dur="0.5"/> the handshake when you've <pause dur="0.3"/> got somebody through acute renal failure <pause dur="0.6"/> # <pause dur="0.8"/> i think it's possibly because <pause dur="0.6"/> from the patient's perspective acute renal failure's a bit like a dream <pause dur="0.4"/> and # they know they're ill they don't know how ill they are <pause dur="0.2"/> they usually nearly meet their maker <pause dur="0.4"/> # <pause dur="0.3"/> and if they get better <pause dur="0.2"/> they don't quite know what's happened but they know something very bad has happened and in fact most <pause dur="0.2"/> body systems failure <pause dur="0.5"/> patients don't remember they're that ill whether it's respiratory failure cardiac failure or renal failure <pause dur="0.4"/> obviously my specialty's kidneys <pause dur="0.5"/> acute renal failure <pause dur="0.4"/> # like most failures is very bad for you <pause dur="0.4"/> # <pause dur="0.7"/> it's probably got a near hundred per cent mortality if you do nothing <pause dur="0.9"/> and you'll notice on on the handout have you all got a handout <pause dur="2.0"/> there is a handout <pause dur="0.3"/> anybody <pause dur="0.3"/> put your hands up if you haven't got a handout okay <pause dur="0.6"/> you'll see <pause dur="0.2"/> # fact number one at the top of your handout is kidney failure's very bad for you <pause dur="0.5"/> # <pause dur="0.3"/> even in two-thousand-and-three

fifty per cent of people died <pause dur="0.4"/> # <pause dur="0.3"/> and that hasn't really improved since the nineteen-sixties <pause dur="1.5"/> so <pause dur="0.7"/> hundred per cent or nearly hundred per cent die if you do nothing fifty per cent die if you do something so there's not a great strike rate <pause dur="0.4"/> # there aren't too many handshakes and there aren't that many biscuits but you must specify on your biscuits <pause dur="0.7"/> # <pause dur="1.4"/> just let's talk a little bit <pause dur="0.3"/> # about <pause dur="0.3"/> a few words and and the word failure <pause dur="0.6"/> # <pause dur="0.5"/> traditionally in in talks such as this you don't start with outcomes you start with definitions and <pause dur="0.3"/> standard things like that but i thought <pause dur="0.9"/> the outcome of acute renal failure is so bad i thought you'd better know it is so bad <pause dur="0.5"/> because a lot of people <pause dur="0.2"/> think oh it's all right have a bit of dialysis they all get better <pause dur="0.2"/> and that that really isn't true even with dialysis the <pause dur="0.5"/> mortality's fifty per cent <pause dur="0.4"/> so the word failure let's have the lady in <kinesic desc="indicates member of audience" iterated="n"/> pink at the back there <pause dur="0.6"/> tell me

about the the word failure and what do you think the patients <pause dur="0.2"/> what's your <pause dur="0.6"/> <trunc>me</trunc> <pause dur="0.2"/> what's your understanding of the word and and what do you think the patient's perception is </u><pause dur="0.4"/> <u who="sf0510" trans="pause"> that it's not working any more </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> yeah <pause dur="0.2"/> and <pause dur="0.2"/> how much is it not working </u><pause dur="0.6"/> <u who="sf0510" trans="pause"> quite a bit </u><pause dur="0.4"/> <u who="nm0504" trans="pause"> quite a bit <pause dur="0.3"/> and patients normally perceive the word failure to mean complete failure <pause dur="0.3"/> you know <pause dur="0.2"/> if you say your car has failed that means it doesn't drive <pause dur="0.7"/> or <pause dur="0.2"/> the <pause dur="0.2"/> washing machine has failed it means it doesn't work and you can't put your clothes in the washer any more <pause dur="0.3"/> and if you use the word failure <pause dur="0.5"/> and if you think about it i think you've probably already started to use the word failure has anybody <pause dur="0.5"/> seen a patient yet and those that the F word come out has anybody said <pause dur="0.3"/> heart failure <pause dur="0.5"/> congestive cardiac failure <pause dur="0.3"/> and <trunc>ha</trunc> has anybody said that in front of a patient <pause dur="0.7"/> lady in pink <kinesic desc="indicates member of audience" iterated="n"/><kinesic desc="nods head" iterated="n" n="sf0571"/> nodding there anybody else <pause dur="0.3"/> said the word failure <pause dur="0.5"/> with a patient around them <pause dur="2.0"/> read in the notes said oh i

see you've got heart failure oh <unclear>bloody hell</unclear> <pause dur="1.2"/><kinesic desc="nod heads" iterated="n" n="ss"/> bit of nodding okay <pause dur="0.5"/> # <pause dur="1.7"/> i'd avoid the word failure i think that's what i <pause dur="0.2"/> i'm getting at in my long and convoluted way <pause dur="0.5"/> it implies absolute failure <pause dur="0.6"/> okay if there is absolute failure use it <pause dur="0.3"/> but if there isn't absolute failure <pause dur="0.2"/> don't use it <pause dur="0.5"/> diabetes is not absolute failure of the <pause dur="0.3"/> pancreas and we don't call it pancreatic failure <pause dur="0.4"/> it's partial pancreatic failure <pause dur="0.4"/> if you think about it if you have complete failure of any major <pause dur="0.2"/> body system you're dead <pause dur="0.7"/> you can't live very long with complete liver failure complete heart failure complete pancreas failure complete et cetera et cetera <pause dur="0.4"/> and <trunc>k</trunc> the kidneys are no different <pause dur="0.7"/> and <pause dur="0.3"/> absolute complete <pause dur="0.3"/> anuric <pause dur="0.2"/> zero <pause dur="0.8"/> kidney failure <pause dur="0.3"/> is almost unheard of <pause dur="0.7"/> now <pause dur="0.2"/> i say almost unheard of because as you know i'm sure you've heard this <pause dur="0.4"/> old maxim by now <pause dur="0.2"/> always and never <pause dur="0.2"/> are words a good doctor never uses <pause dur="0.2"/> ha ha <pause dur="0.4"/> # but that there is some truth to that <pause dur="0.2"/> there is no always and never in medicine there's no always and never <pause dur="0.2"/> in nature

there's no always and never in life these are <pause dur="0.2"/> not words <pause dur="0.3"/> that we are familiar with in medicine and if you find yourself using them you probably don't understand what you're talking about <pause dur="0.9"/> # <pause dur="0.8"/> so try to <trunc>avu</trunc> <pause dur="0.2"/> avoid the word failure so lady in the pink <kinesic desc="indicates member of audience" iterated="n"/> doing well <pause dur="0.2"/> so if you're not going to <unclear>talk</unclear> about failure to a patient what what can you say </u><pause dur="0.6"/> <u who="sf0510" trans="pause"> impairment </u><pause dur="0.4"/> <u who="nm0504" trans="pause"> impairment <pause dur="2.1"/> Guardian all right </u><pause dur="0.6"/> <u who="sm0511" trans="pause"> dysfunction </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> dysfunction ooh yeah <pause dur="0.2"/> New Scientist <pause dur="0.4"/> bit <pause dur="0.3"/> no <pause dur="1.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> you know <pause dur="0.4"/> man on a <pause dur="0.6"/> on the bus you know <pause dur="0.3"/> they don't understand <shift feature="voice" new="mimicking American accent"/> dysfunction <pause dur="1.2"/> dysfunctional families <shift feature="voice" new="normal"/> but but # <pause dur="0.9"/> what's what's another way of talking to a patient <trunc>a</trunc> about <pause dur="0.8"/> a bit of them that doesn't work <pause dur="0.7"/> what <trunc>l</trunc> what language can we use <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> gentleman there </u><pause dur="1.0"/> <u who="sm0512" trans="pause">

can you explain that it isn't working <pause dur="0.2"/> as well as it could be </u><u who="nm0504" trans="latching"> mm <pause dur="0.6"/> just use simple words it's not working as well as it could be okay <pause dur="0.7"/> # <pause dur="0.8"/> you can give a percentage if you like and it's made up <pause dur="0.2"/> seventy-five per cent <pause dur="0.3"/> dysfunction <pause dur="0.6"/> but # <pause dur="0.5"/> what's the problem with percentages <pause dur="0.7"/> lady here <kinesic desc="indicates member of audience" iterated="n"/> </u><pause dur="0.5"/> <u who="sf0513" trans="pause"> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.7"/> <u who="nm0504" trans="pause"> they're not <pause dur="0.2"/> that accurate i mean they're but we we made up some of the numbers i mean <pause dur="0.6"/> deeper level they don't exist but <pause dur="1.5"/> what else is wrong with percentages <pause dur="1.1"/> i mean we talk in percentages all the time don't we </u><pause dur="1.3"/> <u who="sf0514" trans="pause"> they don't mean much to patients </u><u who="nm0504" trans="overlap"> they don't mean much to the patient why don't they mean much to the patient </u><u who="sf0514" trans="latching"> it's giving <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0504" trans="latching"> yeah exactly <pause dur="0.3"/> and you know most of the older generation i don't know what that is <pause dur="0.3"/> don't understand percentages what do they what do they understand </u><pause dur="1.0"/> <u who="sm0515" trans="pause"> fractions </u><u who="nm0504" trans="latching"> fractions yeah <pause dur="0.2"/> try to talk in fractions if you want to talk in numbers you know <pause dur="1.6"/> or talk <pause dur="0.3"/>

what's another way of expressing a fraction in in common language <pause dur="3.7"/> you're obviously a very clean-living lot never put a bet on </u><pause dur="1.0"/> <u who="ss" trans="pause"> odds </u><u who="nm0504" trans="latching"> odds yeah <pause dur="0.2"/> two to one three to one <pause dur="0.3"/> and that's the type of language people understand <pause dur="0.4"/> they don't <pause dur="0.2"/> okay you understand percentages and you can expect an educated person of your age <pause dur="0.2"/> but a less educated person of your age won't understand percentages <pause dur="0.2"/> they understand football league tables <pause dur="0.3"/> and they understand <pause dur="0.4"/> fractions and they understand odds but they don't necessarily understand percentages <pause dur="0.8"/> # <pause dur="0.2"/> so be careful if you talk about dysfunction and seventy-three per cent dysfunction <pause dur="0.3"/> doesn't mean <trunc>r</trunc> mean very much to most patients <pause dur="1.1"/> now <pause dur="0.5"/> the reason i'm <pause dur="0.3"/> emphasizing this point <pause dur="0.3"/> # <trunc>i</trunc> is that you can cause a lot of <pause dur="0.3"/> mental pain <pause dur="0.2"/> just by talking about failure and talking about percentages and and you know they don't understand it <pause dur="0.4"/> # <pause dur="0.7"/> and then you've got to be careful <pause dur="0.2"/> so <pause dur="0.7"/> as the

gentleman said there no <pause dur="0.2"/> you know your kidneys don't work and they'll say well how bad are they and you can say well <pause dur="0.6"/> very bad or <pause dur="0.3"/> bad or quite bad use words they understand <pause dur="0.2"/> if they want some data <pause dur="0.2"/> try and give it to them in language they'll understand <pause dur="0.2"/> and it may be that if they're a <pause dur="0.5"/> University of <gap reason="name" extent="1 word"/> <pause dur="0.4"/> professor of economics you can say seventy-four per cent function or dysfunction or whatever <pause dur="0.7"/> # <pause dur="0.6"/> what's the other problem with the word failure apart from the fact that they <pause dur="0.2"/> assume that means complete failure <pause dur="4.6"/> when a thing has failed completely <pause dur="0.3"/> it may not </u><u who="sm0516" trans="latching"> work again </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> work again okay <pause dur="0.3"/> so it always implies that but <pause dur="0.2"/> but we know <pause dur="0.3"/> many body systems can recover the liver is a classic organ that recovers of its own accord i wish the kidney did <pause dur="0.5"/> but <pause dur="0.3"/> # so <pause dur="0.6"/> when a patient's in heart failure it may not be permanent heart they may just had an M-I last night <pause dur="0.5"/> a tachyarrhythmia and they may be fine by the morning with a bit of frusemide and a bit of digoxin so <pause dur="0.3"/> it also implies

that <pause dur="0.6"/> you could never going to work again <pause dur="0.5"/> and when somebody's fighting for their life <pause dur="0.3"/> you mustn't <trunc>r</trunc> remove all hope from them because <pause dur="0.3"/> it's hope that's keeping them alive <pause dur="0.3"/> so if somebody's had an M-I and they've gone into heart failure and they're panting away and feeling awful and sweating and everything <pause dur="0.5"/> and they're about to have an arrest and you're going to shock them and then they'll come back <pause dur="0.4"/> but at that point they don't know that's going to happen <pause dur="0.5"/> and if you say to them <pause dur="0.4"/> <shift feature="voice" new="mimicking an other's voice"/> i'm terribly sorry Mr Jenkins you've got complete heart failure <shift feature="voice" new="normal"/> <pause dur="0.6"/> # <pause dur="0.7"/> they'll think bloody hell <pause dur="0.3"/> <unclear>bloody hell</unclear> <trunc>f</trunc> that's bad isn't it and my heart doesn't work <pause dur="0.8"/> it's never going to get better <pause dur="0.2"/> so i might as well pop my clogs <pause dur="0.4"/> and <pause dur="0.3"/> you you must never remove a patient's hope and in the acute situation <pause dur="0.3"/> language is important <pause dur="1.5"/> okay <pause dur="0.6"/> so i don't have # a word or a phrase for you invent your own one you know <pause dur="0.2"/> talk in language <pause dur="0.3"/> the patients understand <pause dur="0.6"/> and <pause dur="0.2"/> hopefully that that you

understand <pause dur="0.5"/> okay <pause dur="0.5"/> so <pause dur="0.5"/> we haven't got very far we're still on point <pause dur="0.4"/> point <shift feature="voice" new="laugh"/> one outcome <shift feature="voice" new="normal"/><pause dur="0.8"/> with drugs drugs drugs drugs drugs you'll notice that a theme of this talk is going to be drugs <pause dur="0.3"/> # drugs are very important <pause dur="0.4"/> both recreational and non-recreational <pause dur="0.6"/> # <pause dur="0.3"/> drugs are very important in terms of renal disease because they are a cause in part of <pause dur="0.2"/> up to thirty per cent of people <pause dur="0.3"/> with acute renal failure <pause dur="1.5"/> and rather worryingly # this is a little maxim that # an intensivist taught me when i was at an S-R at at King's in London <pause dur="0.6"/> if you're on I-T-U and you're on a ventilator and your kidneys go down <pause dur="0.8"/> you have eighty per cent mortality you're on a very low chance of leaving that I-T-U <pause dur="0.2"/> if you develop one more body system failure up you're up to ninety <pause dur="0.2"/> one more <pause dur="0.3"/> and you're bust a hundred per cent mortality <pause dur="0.6"/> so having kidney failure on an I-T-U is a very very bad sign <pause dur="1.5"/> # we don't quite know why there's been a lot of research in the last few years of of of why <pause dur="0.5"/> kidney failure on in the I-T-U

setting is such high mortality <pause dur="0.2"/> and it may be very simple you know if you've been smashed to bits in a road traffic accident you've got five fractures and a ruptured spleen your head's come off and <pause dur="0.3"/> you've got no arms <pause dur="0.3"/> you know the <pause dur="0.5"/> <trunc>i</trunc> <pause dur="0.2"/> it is bad for you it's bad for the health to be involved in that road traffic accident but <pause dur="0.5"/> but <pause dur="0.4"/> we don't really know why <unclear>you read in</unclear> whatever <unclear>you read in</unclear> these is such a bad thing <pause dur="0.8"/> but that's quite a useful maxim if you ever go on to an I-T-U and you're trying to <pause dur="0.4"/> # <pause dur="0.2"/> talk to a patient or <pause dur="0.2"/> probably not to the patient but talk to the family about <pause dur="0.4"/> are they going to live doc <pause dur="0.4"/> and and i start adding up the failures in my head when i start talking about <pause dur="1.1"/> little chance of survival but there is <trunc>s</trunc> some hope <pause dur="0.6"/> or <pause dur="0.4"/> a <pause dur="0.2"/> small chance of survival and if they ask what the percentages are i'll give it to them <pause dur="1.5"/> okay <pause dur="0.4"/> so <trunc>def</trunc> definitions definitions i think you know by now i'm not very keen on definitions <kinesic desc="writes on board" iterated="y" dur="8"/> and most

things are <pause dur="0.3"/> indefinable <pause dur="0.5"/> # <pause dur="1.1"/> and <pause dur="0.8"/> before you read the definition on that handout <pause dur="1.4"/> what would you have guessed <pause dur="0.3"/> might have been in the # gentleman on the end <kinesic desc="indicates member of audience" iterated="n"/> there <pause dur="1.3"/> what might you have guessed <pause dur="0.6"/> # as the definition of acute renal failure </u><pause dur="1.1"/> <u who="sm0517" trans="pause"> # an inability for the kidney to function </u><pause dur="0.5"/> <u who="nm0504" trans="pause"> yeah i mean that's probably <pause dur="0.2"/> as good as any <pause dur="0.4"/> # <pause dur="0.4"/> i'm sure you might want to slip the creatinine into your definition wouldn't you </u><pause dur="0.2"/> <u who="sm0517" trans="pause"> yeah </u><pause dur="0.4"/> <u who="nm0504" trans="pause"> you probably would <pause dur="0.5"/> # <pause dur="0.9"/> don't <pause dur="0.5"/> is the go home message # <pause dur="0.8"/> the creatinine and the urine output have nothing to do with the <trunc>desh</trunc> definition of of acute renal failure certainly when i was a student i <pause dur="0.3"/> i always was pestering them okay well what was bad you know what what's normal what's bad and what's failure <pause dur="0.5"/> # <pause dur="0.8"/> there's no such thing because remember as i talked about before how we get normal ranges <pause dur="0.4"/> you know we <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="3"/> measure creatinine in a lot of

people and we stick everybody <pause dur="0.2"/> within two standard deviations the mean within that normal range <pause dur="0.2"/> so perfectly normal people <pause dur="0.2"/> have a creatinine of a hundred-and-thirty remember the magic number up up to a hundred-and-twenty <pause dur="0.3"/> it's just voodoo <pause dur="0.4"/> hundred-and-twenty creatinine hundred-and-twenty <pause dur="0.4"/> # G-F-R <pause dur="0.3"/> it's the only number you need to remember to be a kidney doctor or know anything about the kidney <pause dur="0.3"/> and <pause dur="0.3"/> that voodoo is not there in the States and other countries where they use other units but it the voodoo is there the hundred-and-twenty number <pause dur="0.6"/> so <pause dur="0.2"/> it is almost impossible to define <pause dur="0.9"/> because <pause dur="0.2"/> people's baseline creatinine <pause dur="0.5"/> is variable and what does the creatinine your baseline creatinine depend on <kinesic desc="indicates member of audience" iterated="n"/> </u><pause dur="0.6"/> <u who="sm0518" trans="pause"> # <pause dur="0.4"/> the muscle bulk </u><u who="nm0504" trans="latching"> yeah your muscle bulk mainly your muscle bulk so age sex <pause dur="0.3"/> mass <pause dur="0.3"/> muscle bulk use of muscles <pause dur="0.5"/> so i'm sure Jonah Lomu before he got kidney failure had a normal creatinine of a hundred-and-thirty <pause dur="0.4"/> and that could either have been a hundred-and-thirty because it's <pause dur="0.7"/> within statistical error or it could

be genuinely a hundred-and-thirty <pause dur="0.3"/> because <pause dur="0.2"/> he's a big bloke and has big muscles how on earth he <shift feature="voice" new="laugh"/>plays <shift feature="voice" new="normal"/> <pause dur="0.4"/> top class rugby i've got no idea on dialysis <pause dur="0.5"/> but he does seem to <pause dur="0.7"/> # <pause dur="0.7"/> so <pause dur="0.4"/> it's very difficult to define according to a certain number and it's more important <pause dur="0.9"/> whatever your baseline is and movement from the baseline that if if you want a number <pause dur="0.3"/> i've copied a definition out of a book there <pause dur="0.2"/> for those of you who who cannot leave this room without some form of number in their head <pause dur="0.5"/> # <pause dur="0.2"/> a recent <pause dur="0.5"/> rise <pause dur="0.3"/> of fifty micromoles per litre of creatinine <pause dur="0.4"/> # if the baseline is less than three-hundred over hundred it's over over three-hundred <pause dur="0.5"/> you can <unclear>learn</unclear> that if you like i took it out of a book <pause dur="0.2"/> i'd forget it <pause dur="0.4"/> just <pause dur="0.4"/> remember that it's indefinable and movement away from the baseline is the important thing <pause dur="0.8"/> why does <pause dur="0.2"/> oliguria <pause dur="0.2"/> let's have this <kinesic desc="indicates member of audience" iterated="n"/> gentleman here why does that play no part in

the definition of of acute renal failure </u><pause dur="1.6"/> <u who="sm0519" trans="pause"> # <pause dur="2.7"/> well you <pause dur="1.4"/> well <pause dur="0.5"/> i don't know # <pause dur="1.2"/> well you you hope that your kidneys are <pause dur="0.5"/> # <pause dur="0.6"/> filtrating </u><pause dur="1.1"/> <u who="nm0504" trans="pause"> yeah okay you're getting there so <pause dur="0.8"/> how do you know <pause dur="0.2"/> that that nice glass of red wine there <pause dur="0.5"/> is a good glass of wine </u><pause dur="0.9"/> <u who="sm0518" trans="pause"> # <pause dur="0.4"/> the colour and # <pause dur="0.5"/> the smell </u><u who="nm0504" trans="overlap"> and what do you need to do </u><pause dur="0.2"/> <u who="sm0518" trans="pause"> taste it </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> you need to taste it don't you <pause dur="0.2"/> it may look all right <pause dur="0.3"/> and urine may look all right i'm not advocating you drink urine <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> but but you <pause dur="0.3"/> but you've got to taste it haven't you <pause dur="0.4"/> and and <pause dur="0.5"/> what urine is like wine it's all about quality <pause dur="0.3"/> and so you could be passing ten litres a day and if it's it's of low quality if it's not getting rid of urea creatinine phosphate potassium all the rest of it <pause dur="0.3"/> then it's not good urine so <pause dur="0.2"/> you have to know what's in it <pause dur="0.3"/> and that's why oliguria and there are plenty of people with non-oliguric <pause dur="0.3"/> or even

polyuric acute renal failure <pause dur="1.5"/> okay <pause dur="0.6"/> # so we're saying it's indefinable we're saying <pause dur="0.3"/> that # <pause dur="0.7"/> movement from the baseline is important but that does mean that a little old lady <pause dur="0.8"/> with no muscle bulk <pause dur="0.2"/> if we're taking the normal range <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="4"/> to be sixty <pause dur="0.2"/> a hundred-and-twenty for example <pause dur="0.2"/> a little old lady may have <pause dur="0.4"/> a creatinine of baseline creatinine of forty partly out of statistical error or partly because she genuinely does <pause dur="0.4"/> because she's a little old lady who doesn't have very big muscles and doesn't use them <pause dur="0.9"/> # <pause dur="0.6"/> and that's why it's always important to look back through the notes if <pause dur="0.2"/> the patient's <pause dur="0.5"/> had bloods done <pause dur="0.2"/> ten years ago twenty years ago <pause dur="0.4"/> # then seek them out in the notes they won't be on the computer system <pause dur="1.7"/> right epidemiology we mentioned a lot about epidemiology # <pause dur="1.8"/> if you want to make yourself famous do a PhD on epidemiology of acute renal failure nobody's ever done one <pause dur="0.2"/>

<shift feature="voice" new="laugh"/> # <shift feature="voice" new="normal"/><pause dur="0.4"/> i think it's the only major body system failure where nobody's ever looked into it in <trunc>an</trunc> any great detail i don't know why <pause dur="0.4"/> # <pause dur="0.4"/> perhaps because it's a relatively rare diagnosis <pause dur="0.4"/> actually it isn't that rare <pause dur="0.4"/> about thirty per cent of people entering hospital <pause dur="0.2"/> on a medical or surgical take have a raised creatinine i'm not saying they've got kidney failure <pause dur="0.5"/> they may have renal impairment for a period of time <pause dur="0.3"/> before you give them normal <gap reason="inaudible" extent="1 sec"/> and before the creatinine is normal and it fails <pause dur="0.3"/> and a raised creatinine on admission to hospital is extremely common <pause dur="0.6"/> and surgeons don't ring us every time <pause dur="0.6"/> somebody has a raised somebody has a raised creatinine level they'd be ringing us all day long every day <pause dur="0.8"/> <gap reason="inaudible" extent="1 sec"/> <pause dur="0.2"/> they note the creatinine's really abnormal on the first day they give the patient fluids <pause dur="0.3"/> give the creatinine <gap reason="inaudible" extent="1 sec"/> the next day and if it's come down fine if it's not come down give us a ring although they should give us a ring <pause dur="1.2"/> so we know very little about the epidemiology of acute renal failure # i've listed some

risk factors there and if you look down those risk factors they're the sort of standard risk factors that <pause dur="0.2"/> you know <pause dur="0.3"/> of anything really aren't they diabetes old you know pre-existing failure <pause dur="0.6"/> # <pause dur="1.0"/> and <pause dur="0.4"/> the the one theme that comes through those risk factors i think is atheroma <pause dur="0.4"/> <trunc>w</trunc> why why is it atheroma's important <pause dur="0.5"/> let's have this lady here <kinesic desc="indicates member of audience" iterated="n"/><pause dur="0.6"/> why do you think atheroma's important </u><pause dur="0.7"/> <u who="sf0520" trans="pause"> # <pause dur="1.2"/> in acute renal failure </u><u who="nm0504" trans="overlap"> yeah or predisposing to acute renal failure </u><pause dur="1.2"/> <u who="sf0520" trans="pause"> well <pause dur="0.2"/> blood flowing into the kidney is going to be hindered </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> yeah very good so you know <pause dur="0.2"/> if somebody has <pause dur="0.2"/> pre-existing renal vascular disease <pause dur="0.4"/> then they may already have partial blood flow to the kidney and then <pause dur="0.2"/> if another event happens if another insult happens they're more likely to get acute renal failure <pause dur="0.6"/> # <pause dur="0.3"/> and there are some worrying

statistics i've put down for you there <pause dur="0.4"/> # there have been studies done of <pause dur="0.4"/> angiography <pause dur="0.3"/> both of <pause dur="0.2"/> angiography of the legs <pause dur="0.2"/> and angiography of the heart <pause dur="0.5"/> and if you look hard enough if you do a cardiac angiogram or a leg angiogram <pause dur="0.3"/> for no kidney reason <pause dur="0.4"/> and you happen to squirt some dye down the kidneys <pause dur="0.2"/> about fifty per cent of people will have <pause dur="0.2"/> radiologically significant renal vascular disease <pause dur="0.4"/> so # and not know it they may have a normal creatinine <pause dur="1.3"/> # but it is there <pause dur="0.2"/> and so most of the patients out there in the ether <pause dur="0.2"/> the type of patient you're looking after are sitters <pause dur="0.3"/> for <pause dur="0.2"/> acute renal failure or more commonly acute onchronic renal failure <pause dur="0.3"/> which is sometimes <pause dur="0.3"/> # written as A-<pause dur="0.4"/>C-R-F rather than A-R-F <pause dur="1.8"/> okay <pause dur="0.3"/> # trauma <pause dur="0.2"/> why does trauma cause kidney failure let's have the <kinesic desc="indicates member of audience" iterated="n"/> gentleman right at the back there <pause dur="0.4"/> why does trauma </u><pause dur="1.0"/> <u who="sm0521" trans="pause"> # <pause dur="0.8"/> direct damage to the blood vessels <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0504" trans="overlap">

# <pause dur="0.2"/> yeah no good point actually yeah possibly <pause dur="0.3"/> # i mean yeah if if you avulse your <pause dur="0.4"/> # <pause dur="0.5"/> renovascular bed <pause dur="0.4"/> then that's not very good for you and that can happen <pause dur="0.2"/> it's quite hard to damage the kidneys as you know they're <kinesic desc="indicates kidneys" iterated="n"/> behind the ribs there <pause dur="0.4"/> and you have to really try hard to <pause dur="0.4"/> damage somebody's kidneys <pause dur="0.3"/> they are sometimes damaged in road traffic accidents but not very commonly 'cause they're at the back <pause dur="0.3"/> you're more likely to cause trauma to the front <pause dur="1.0"/> # <pause dur="0.6"/> you know some violent sports you're get punched or kicked or <pause dur="0.9"/> baseball batted in the in in the kidneys <pause dur="0.4"/> but # apart apart from that any any any other ways in which <kinesic desc="indicates member of audience" iterated="n"/> trauma can cause <pause dur="0.5"/> acute renal failure </u><pause dur="0.3"/> <u who="sm0522" trans="pause"> <gap reason="inaudible" extent="2 secs"/> </u><u who="nm0504" trans="latching"> speak up anybody else </u><u who="sm0523" trans="latching"> <gap reason="inaudible" extent="1 sec"/> </u><u who="sf0524" trans="overlap"> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> # yeah good yeah yeah yeah yeah </u><pause dur="0.6"/> <u who="sm0525" trans="pause"> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.5"/> <u who="nm0504" trans="pause">

yeah very good rhabdomyolysis <pause dur="0.4"/> # <pause dur="0.3"/> and <pause dur="0.2"/> # <pause dur="0.2"/> the study of acute renal failure in war has led us to <pause dur="0.3"/> # a much <pause dur="0.5"/> greater understanding of the pathophysiology we still don't understand it <pause dur="0.4"/> but a lot of important research came out of the Vietnam War <pause dur="0.3"/> # in terms of acute renal failure <pause dur="0.4"/> and there's nothing like a good war to improve <pause dur="0.3"/> doctors' understanding of disease <pause dur="0.6"/> # <pause dur="0.8"/> and rhabdomyolysis <pause dur="0.3"/> which can come on secondary to any form of of muscle trauma <pause dur="0.5"/> # whether it be <pause dur="0.2"/> spontaneous muscle trauma alcoholics <pause dur="0.2"/> for example <unclear>drugs</unclear> can spontaneously <pause dur="0.3"/> develop what's called compartment syndrome <pause dur="0.4"/> and <pause dur="0.6"/> from that develop rhabdomyolysis and that <unclear>go</unclear> acute renal failure or you can non-spontaneously you know <pause dur="0.3"/> a bus hits you <pause dur="0.2"/> you played rugby et cetera et cetera <pause dur="0.3"/> and you damage your muscles in some way <pause dur="1.2"/> # <pause dur="2.2"/> pregnancy pregnancy <vocal desc="sigh" iterated="n"/> <pause dur="0.8"/> the only interesting thing in from my perspective about pregnancy is the fact that they <pause dur="0.5"/> get kidney failure <pause dur="0.3"/> # <pause dur="2.3"/> when do they get

kidney failure why <pause dur="1.0"/> gentleman <kinesic desc="indicates member of audience" iterated="n"/> there on the right <pause dur="0.5"/> when do pregnant women get kidney failure </u><pause dur="1.3"/> <u who="sm0526" trans="pause"> # <pause dur="0.6"/> during hypertension </u><pause dur="0.6"/> <u who="nm0504" trans="pause"> yeah yeah <pause dur="0.3"/> <trunc>d</trunc> is it hypo or hyper </u><pause dur="0.3"/> <u who="sm0526" trans="pause"> hyper </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> hyper yeah i mean <pause dur="0.4"/> why do they get hypertensive </u><pause dur="0.8"/> <u who="sm0526" trans="pause"> it's a a complication of pregnancy </u><u who="nm0504" trans="latching"> yeah <pause dur="0.2"/> very good <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay <pause dur="0.7"/> it is a complication of pregnancy <pause dur="0.5"/> # <pause dur="0.2"/> particularly <pause dur="0.2"/> # the last trimester <pause dur="0.3"/> # <pause dur="0.4"/> pre-eclampsia or eclampsia these are these are names we call for a specific syndrome which incorporates <pause dur="0.5"/> kidney problems and hypertension <pause dur="0.4"/> # <pause dur="0.3"/> bleeding <pause dur="0.2"/> you know <pause dur="0.3"/> <trunc>ab</trunc> <trunc>ab</trunc> you haven't done your obs and gynae yet have you </u><pause dur="0.4"/> <u who="sm0527" trans="pause"> no </u><u who="nm0504" trans="overlap"> no <pause dur="0.7"/> you will <pause dur="0.2"/> do obs and gynae you will go to deliveries it's very messy there's blood everywhere <pause dur="0.4"/> # it's very exciting <pause dur="0.3"/> yes i cried at my first delivery yes most of you will all those hard men <pause dur="0.6"/> though you'll

all cry too it is an amazing experience seeing a baby born <pause dur="0.4"/> but # it's very bloody <pause dur="0.8"/> # and there is blood loss even with a a normal delivery <pause dur="0.8"/> # <pause dur="0.2"/> so there are a lot of reasons that a woman can go into acute renal failure <pause dur="0.2"/> pre-eclampsia <pause dur="0.2"/> eclampsia blood loss <pause dur="0.3"/> but there's also a specific syndrome <pause dur="0.4"/> # it goes by a variety of names <pause dur="0.3"/> pregnancy-related acute renal failure <pause dur="0.4"/> there's a load of other names for it some people say it doesn't really exist and it's actually just <pause dur="0.4"/> a variant of pre-eclampsia but there certainly <pause dur="0.3"/> is a syndrome it can come on even after delivery <pause dur="0.5"/> # of acute renal failure the aetiology of it is not really understood <pause dur="0.3"/> it's something to do with pre-eclampsia it's something to do with <pause dur="0.3"/> microangiopathic haemolytic anaemia it's something to do with low platelets it's something to do with kidney failure <pause dur="0.4"/> and this triad <pause dur="0.2"/> of haemolytic anaemia <pause dur="0.3"/> acute renal failure low platelets <pause dur="0.3"/> you'll see in many bits of medicine <pause dur="0.2"/> # <pause dur="0.4"/> dermatologists will <pause dur="0.3"/> stand here and talk about scleroderma causing <trunc>i</trunc> an

intensivist <pause dur="0.2"/> D-I-C <pause dur="0.3"/> a blood pressure doctor malignant hypertension a pregnancy doctor <pause dur="0.4"/> # <pause dur="0.6"/> pregnancy-related or <pause dur="0.6"/> acute renal failure <pause dur="0.2"/> HELP syndrome to a <trunc>ler</trunc> liver doctor <pause dur="0.3"/> if you think about it these things are all the same <pause dur="0.3"/> or they're <pause dur="0.2"/> they're probably a final common pathway from from endothelial damage <pause dur="1.2"/> fascinating subject <pause dur="0.2"/> can't go into it today i'm afraid <pause dur="0.7"/> # i hope somebody else will <pause dur="1.3"/> okay # <pause dur="0.2"/> so <pause dur="0.8"/> there are certain patients that we know get kidney failure they're sitters for it <pause dur="0.5"/> pregnant women <pause dur="0.4"/> people who've had road traffic accidents trauma old people et cetera et cetera <pause dur="1.7"/> it is however traditional to talk about the causes <pause dur="0.4"/> of acute renal failure <pause dur="0.8"/> and <pause dur="0.3"/> # <pause dur="1.1"/> i'm going to try to present this in a in a different way or hopefully a different way <pause dur="0.2"/> but can you <pause dur="0.2"/> could you read that at the back <pause dur="0.7"/> my writing okay <pause dur="0.5"/> # <pause dur="6.7"/> tubes you remember <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="8"/> what i said the kidney was it's a tube <pause dur="1.9"/> with <pause dur="0.2"/> a sieve in the middle <pause dur="1.7"/> and a way

of <pause dur="0.3"/> sending the blood back <pause dur="0.4"/> # if you think about it <pause dur="0.2"/> that's actually <pause dur="0.2"/> also <pause dur="0.5"/> what a liver is <pause dur="0.2"/> and what a heart is what's a heart oh well <kinesic desc="writes on board" iterated="y" dur="5"/> it's a sort of a pump thing isn't it with a few chambers <pause dur="0.4"/> and blood goes into it and blood comes out oh yeah <pause dur="0.7"/> <kinesic desc="writes on board" iterated="y" dur="4"/> that's actually what a liver is isn't it but there's two <pause dur="0.3"/> sources of blood and then blood comes out of it <pause dur="0.5"/> they're all tubes i mean <pause dur="0.2"/> there are embryological reasons why they're tubes they started off as tubes <pause dur="0.6"/> # and they've become other things <pause dur="0.8"/> and <pause dur="3.2"/> rather than think of the kidney <pause dur="0.2"/> in the <kinesic desc="writes on board" iterated="y" dur="5"/> traditional way of being <pause dur="0.2"/> a kidney-shaped thing with blood going to it and from it <pause dur="1.0"/> and <pause dur="0.5"/> i'd like to try <pause dur="0.2"/> to change your mental image by <pause dur="0.3"/> unravelling that in your head and thinking about it as a tube <pause dur="1.6"/> having said that because i think then you'll understand <pause dur="0.3"/> the physiology and the pathophysiology more <pause dur="1.0"/> if you are going to

think about the causes of acute renal failure sometimes <pause dur="0.4"/> a good old-fashioned diagram such as this is still useful <pause dur="0.9"/> because traditionally <kinesic desc="writes on board" iterated="y" dur="9"/> we talk about the causes as being pre <pause dur="0.5"/> as being renal <pause dur="0.7"/> and being <pause dur="0.2"/> post-renal <pause dur="2.6"/> but equally <pause dur="0.6"/> you could get rid of that <pause dur="0.8"/> and <kinesic desc="writes on board" iterated="y" dur="2"/> draw a tube <pause dur="1.5"/> and draw your sieve <pause dur="0.4"/> and talk about prerenal renal and post-renal <pause dur="0.3"/> you could also get rid of that <pause dur="1.9"/> and talk about a liver <pause dur="1.0"/> <kinesic desc="writes on board" iterated="y" dur="3"/> not a very good liver <pause dur="1.3"/> and talk about a tube as well <pause dur="0.7"/> how <pause dur="0.3"/> can the liver be extended to this analogy <pause dur="0.5"/> in terms of liver failure <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> that lady at the front there <pause dur="0.6"/> we're going to in a minute we're going to talk about kidney failure but let's just <pause dur="0.3"/> go a bit left field <pause dur="0.5"/> field <pause dur="1.1"/> <trunc>ho</trunc> how can <pause dur="0.2"/> the traditional way of

describing <pause dur="0.4"/> kidney failure be extended to another tube the liver <pause dur="0.9"/> speak up <pause dur="1.1"/> in other words <pause dur="2.4"/><kinesic desc="writes on board" iterated="y" dur="3"/> what three groups of causes of liver failure do you know <pause dur="3.9"/> it's not a trick question <pause dur="0.3"/> not a Dr <gap reason="name" extent="1 word"/> trick one it's a simple question <pause dur="0.8"/> so <pause dur="0.3"/> the liver's a thing where there's two sources of blood to it there's one source away <pause dur="2.4"/> on <gap reason="inaudible" extent="1 sec"/> </u><pause dur="2.9"/> <u who="sm0528" trans="pause"> <unclear><trunc>pre</trunc></unclear> prehepatic hepatic and <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="nm0504" trans="overlap"> yeah so we talk about it in the same way <pause dur="0.6"/> so we talk so what's an example of a prehepatic cause of <pause dur="1.7"/> <kinesic desc="writes on board" iterated="y" dur="2"/> liver failure </u><pause dur="0.5"/> <u who="sm0529" trans="pause"> haemolytic anaemia </u><u who="nm0504" trans="latching"> haemolytic anaemia okay <pause dur="0.4"/><kinesic desc="writes on board" iterated="y" dur="1"/> hepatic </u><pause dur="0.5"/> <u who="sf0530" trans="pause"> hepatic </u><pause dur="0.5"/> <u who="nm0504" trans="pause"> speak up </u><u who="ss" trans="latching"> <gap reason="inaudible, multiple speakers" extent="2 secs"/> </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> cirrhosis did somebody say </u><u who="sm0531" trans="overlap"> yeah </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> okay so there's something wrong with the liver itself <pause dur="0.3"/> post-hepatic </u><pause dur="0.3"/> <u who="ss" trans="pause"> <gap reason="inaudible, multiple speakers" extent="1 sec"/> </u><u who="nm0504" trans="overlap">

<gap reason="inaudible" extent="1 sec"/> <pause dur="0.3"/><kinesic desc="writes on board" iterated="y" dur="2"/> okay <pause dur="0.7"/> i mean yes it is a bit more complicated <gap reason="inaudible" extent="1 sec"/> syndrome there are other ways of thinking about obstruction of the liver <pause dur="0.4"/> but the analogy <pause dur="0.2"/> runs for a liver and it runs for a heart <pause dur="0.3"/> and it runs for a kidney <pause dur="1.0"/> and <pause dur="1.1"/> although the topic of today's talk is <pause dur="1.1"/> <kinesic desc="writes on board" iterated="y" dur="3"/> kidneys so we'll go back to the kidney <pause dur="0.6"/> # <pause dur="0.6"/> and <pause dur="0.5"/> the <pause dur="0.3"/> classical way <pause dur="0.3"/> and i think it's still useful <pause dur="0.2"/> of dividing up the causes of kidney failure into <pause dur="0.2"/> pre <pause dur="0.4"/> renal and post-renal so <pause dur="1.0"/> rather than take a big book and look at the lists of causes of <pause dur="0.2"/> renal failure the lists of causes of liver failure <pause dur="0.3"/> try to work it out conceptually in your head and you won't have to learn the lists <pause dur="0.3"/> and also if if you find you've got to learn a list <pause dur="0.4"/> then you're going to forget it anyway the next day or you can just remember it for the exam so it's not a good way of learning learning lists <pause dur="0.5"/> okay <pause dur="0.5"/> so i've listed there <pause dur="0.5"/> three types <pause dur="0.5"/> of <kinesic desc="writes on board" iterated="y" dur="15"/>

prerenal failure <pause dur="2.2"/> one <pause dur="0.3"/> true volume depletion <pause dur="0.8"/> two generalized ischaemia <pause dur="0.5"/> three local ischaemia <pause dur="1.7"/> so <pause dur="1.2"/> i'm doing a bit too much talking <pause dur="0.2"/> let's have the <kinesic desc="indicates member of audience" iterated="n"/> gentleman at the back there with the black top on on the right <pause dur="0.4"/> tell me about <pause dur="0.3"/> # volume depletion what do i mean by that and and what are some examples </u><pause dur="1.1"/> <u who="sm0532" trans="pause"> well <pause dur="0.4"/> <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0504" trans="overlap"> speak up so we can hear </u><pause dur="0.8"/> <u who="sm0532" trans="pause"> it's just a depletion of the circulating <pause dur="0.5"/> extra <gap reason="inaudible" extent="1 sec"/> <trunc>ex</trunc> <pause dur="0.2"/> circulating round <gap reason="inaudible due to overlap" extent="1 sec"/></u><u who="nm0504" trans="overlap"> yeah okay and and and what can cause volume depletion </u><pause dur="0.6"/> <u who="sm0532" trans="pause"> cardiac failure <pause dur="0.4"/> # sorry <pause dur="0.5"/> cardiac <unclear>heart failure</unclear> </u><u who="nm0504" trans="overlap"> you speak up yeah </u><u who="sm0532" trans="overlap"> heart failure </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> yeah yeah very good i mean <trunc>har</trunc> i'm glad you said that i mean <pause dur="0.3"/> i'm glad you didn't say that <pause dur="0.6"/> what you would normally say which is bleeding i mean bleeding yes perhaps is the most common and the most one of the most simple to understand but heart failure isn't <pause dur="0.4"/> but it's actually

it's the same thing <pause dur="0.2"/> in some ways <pause dur="0.2"/> and the body's pathophysiological reaction to heart failure is the same as bleeding <pause dur="1.1"/> and i'll come back to that <pause dur="0.8"/> so <pause dur="0.6"/> you can become volume deplete <pause dur="0.5"/><kinesic desc="writes on board" iterated="y" dur="4"/> if you lack fluid in the body <pause dur="0.7"/> you may lack blood if you're <pause dur="0.2"/> bleeding <pause dur="0.8"/> as the gentleman at the back <pause dur="0.2"/> said <pause dur="0.2"/> you may lack <pause dur="0.5"/> fluid of other types such as extracellular fluid such as <pause dur="0.5"/> # <pause dur="0.9"/> # interstitial fluid in in various failures such as heart failure <pause dur="0.5"/><kinesic desc="writes on board" iterated="y" dur="1"/> oh pen's running out <pause dur="0.9"/> # <pause dur="5.5"/><event desc="changes pen" iterated="n"/> break for a new pen <pause dur="1.4"/> make sure that works yeah <pause dur="0.5"/> # <pause dur="1.0"/> or you may lack <pause dur="0.6"/> plasma or <trunc>o</trunc> other substances <pause dur="0.6"/> and the treatment of volume depletion <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="1"/> depends on what you lack <pause dur="0.3"/> so if you're bleeding <pause dur="0.2"/><kinesic desc="writes on board" iterated="y" dur="1"/> you treat the patient with blood <pause dur="0.5"/> if you've got heart failure <pause dur="1.6"/><kinesic desc="writes on board" iterated="y" dur="2"/> are they truly volume deplete well they are <pause dur="1.2"/> in terms of how the body perceives the problem but the treatment is not to <kinesic desc="writes on board" iterated="y" dur="2"/> give them fluids <pause dur="0.7"/> but if they are volume deplete

because of <kinesic desc="writes on board" iterated="y" dur="3"/> pancreatitis <pause dur="0.8"/> or a burn <pause dur="0.7"/> pancreatitis or so-called <pause dur="0.3"/> intra-abdominal burn <pause dur="0.5"/> then you may want to <kinesic desc="writes on board" iterated="y" dur="2"/> give them what they lack which is plasma <pause dur="0.4"/> but either way <pause dur="0.3"/> in all <pause dur="0.5"/> # four of these examples the patient is <pause dur="2.6"/><event desc="wipes board" iterated="y" dur="1"/> i knew this would happen i had a nice pen <pause dur="2.5"/><event desc="changes pen" iterated="n"/> <vocal desc="sigh" iterated="n"/><pause dur="6.1"/><event desc="wipes board" iterated="y" dur="8"/> oh i've ruined the board forever <pause dur="4.8"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> okay <pause dur="0.5"/> we'll ignore that bit <pause dur="1.0"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="2.4"/><event desc="wipes board" iterated="y" dur="2"/> so <pause dur="0.8"/> let's talk a bit more about <trunc>th</trunc> this whole idea of of volume depletion <pause dur="0.3"/> # <pause dur="0.2"/> it certainly was something i i didn't understand as a medical student and i think i'm only just starting to understand it now <pause dur="0.9"/> # <pause dur="1.3"/> true <pause dur="0.7"/> volume depletion <pause dur="0.2"/> or what <pause dur="0.2"/> we normally consider true volume depletion <pause dur="0.3"/> is <pause dur="0.7"/> typified by something like bleeding <pause dur="0.3"/> or diarrhoea <pause dur="0.4"/> or polyuria where you are genuinely losing fluid <pause dur="0.2"/>

outside your body <pause dur="1.1"/> and <pause dur="1.2"/> <kinesic desc="writes on board" iterated="y" dur="2"/> that's why i've written on your handout there is a concept of true volume depletion <pause dur="1.7"/> now a more important concept <pause dur="0.7"/> <kinesic desc="writes on board" iterated="y" dur="5"/> is relative <pause dur="0.7"/> volume depletion <pause dur="1.8"/> relative volume depletion is a bit harder to understand but is a <trunc>nic</trunc> <pause dur="0.3"/> an example of it is heart failure as the gentleman said at the back <pause dur="0.8"/> and by relative volume depletion what i mean <pause dur="0.3"/> is fluid in the wrong compartment <pause dur="0.4"/> and heart failure is a classic example <pause dur="0.2"/> you've got fluid around your ankles <pause dur="0.2"/> you've got low blood pressure your heart doesn't work <pause dur="0.2"/> you can't pump <pause dur="0.5"/> blood or plasma or anything round your body <pause dur="0.5"/> and you are <pause dur="0.2"/> intravascularly dry you are volume deplete <pause dur="0.4"/> but the treatment is not to give them more fluid because they they've got an excess of fluid anyway <pause dur="0.8"/> so you have this rather odd situation where you can be <pause dur="0.4"/> if you like generally overloaded with extra <pause dur="0.2"/> water in the body but it's

in the wrong place <pause dur="0.5"/> so it's not in the <pause dur="0.2"/> intravascular compartment where it should be <pause dur="0.9"/> so this <pause dur="0.4"/> it's quite difficult to get your head around an idea where you can be both wet and dry at the same time and you say well <pause dur="0.2"/> you can't you know you can't be black and white at the same time <pause dur="0.4"/> you can't be fast and slow at the same time and <pause dur="0.8"/> but in terms of fluid shifts <pause dur="0.3"/> you can be both actually <pause dur="0.2"/> it's taken me a long time to realize this i used to think you <trunc>ha</trunc> you you've got to be <pause dur="0.2"/> wet or dry but you can be both <pause dur="0.8"/> it depends how you get your head around it <pause dur="0.4"/> # you could say the purist would say <pause dur="0.4"/> of course that somebody who is fluid overloaded due to heart failure or liver failure or any other failures <pause dur="1.1"/> is not dry <pause dur="0.3"/> they can't be dry because they've got ankle swelling and they've got fluid in the lungs but the you can be intravascularly dry <pause dur="0.5"/> and peripherally wet <pause dur="0.9"/> and the body's reaction is the same which is often acute renal failure <pause dur="1.6"/> why is this why am i rabbiting on about this so much

<trunc>wh</trunc> <trunc>wh</trunc> why is it such an important distinction in terms of of of of treatment <pause dur="0.8"/> that <kinesic desc="indicates member of audience" iterated="n"/> lady in the blue there </u><pause dur="1.2"/> <u who="sf0533" trans="pause"> # <pause dur="0.9"/> is it if it's true <pause dur="0.4"/> # <pause dur="0.3"/> volume depletion then you can replace it </u><u who="nm0504" trans="latching"> very good and </u><u who="sf0533" trans="overlap"> but if it's # relative <pause dur="1.5"/> you can't </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> you can't <pause dur="0.2"/> and </u><u who="sf0533" trans="overlap"> just get volume overload if you <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0504" trans="overlap"> correct <pause dur="0.4"/> absolutely <pause dur="0.6"/> and <pause dur="0.3"/> # <pause dur="0.2"/> you've got to correct the underlying problem so as in heart failure they give you a heart or # boost the heart or liver failure you need a liver <pause dur="0.3"/> or whatever <pause dur="0.4"/> or you need to tide them over while the heart recovers or the liver recovers <pause dur="0.6"/> but # the treatment is quite different <trunc>a</trunc> and the principles <pause dur="0.4"/> i mean sometimes we cover our bases when we're not sure we do what i call a push me pull you which we give them fluids and frusemide which is completely

illogical and <pause dur="0.3"/> defies all <pause dur="0.6"/> physiology and pathophysiological textbooks but you know we know it works <pause dur="0.4"/> we i call it a push me pull you <pause dur="0.7"/> # <pause dur="0.8"/> okay <pause dur="0.7"/> there is a concept that the Americans have come up with which is called third spacing <pause dur="0.6"/> # <pause dur="0.7"/> i mention it partly because you may hear of it but i'd <pause dur="0.4"/> i'd <pause dur="0.4"/> rather like you to <shift feature="voice" new="laugh"/>forget about it <shift feature="voice" new="normal"/>and and try to think of it <trunc>i</trunc> in <kinesic desc="indicates board" iterated="n"/> this more simple way <pause dur="1.0"/> i don't know what the third space is <pause dur="0.8"/> i think what the Americans mean by third spacing <pause dur="0.4"/> is <pause dur="1.2"/> either true or relative volume depletion <pause dur="0.6"/> causes of of volume depletion <pause dur="0.3"/> in an area of the body you can't see <pause dur="1.4"/> # so what's an example <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="1"/> of a true <pause dur="1.3"/> volume depletion <pause dur="0.4"/> leading to <pause dur="0.4"/> so-called third spacing <pause dur="3.7"/><kinesic desc="writes on board" iterated="y" dur="2"/> what <trunc>w</trunc> what do you think the first and second spaces are <pause dur="1.8"/> we talk about the third word come on who did what's the first word </u><pause dur="0.3"/> <u who="sm0534" trans="pause"> is it <unclear>going to be</unclear> something like inside the blood vessels and the in the extracellular fluids </u><pause dur="0.5"/> <u who="nm0504" trans="pause">

yeah i mean basically yes i mean you have things in the cells and outside the cells <pause dur="0.4"/> # i think <pause dur="0.4"/> <shift feature="voice" new="laugh"/>i think <shift feature="voice" new="normal"/>that's what the first and second space is i'm not absolutely sure i've never seen it defined <pause dur="0.6"/> <shift feature="voice" new="laugh"/> but if <pause dur="0.6"/> # <shift feature="voice" new="normal"/> <pause dur="0.2"/> but the you know the Americans have come up with this idea of a third space i think it's a bit like the Third World it's a pile of bollocks you know and <vocal desc="laughter" iterated="y" n="ss" dur="1"/><pause dur="0.7"/> i'm not meant to <shift feature="voice" new="laugh"/>swear on video <shift feature="voice" new="normal"/>but <vocal desc="laughter" iterated="y" n="ss" dur="2"/><pause dur="0.3"/> the the # <pause dur="0.5"/> it it's # <pause dur="1.5"/> okay so <pause dur="0.3"/> just <pause dur="0.9"/> take it as read that this concept exists <pause dur="0.4"/> # <trunc>w</trunc> # what what would be an example of it <pause dur="1.5"/> true volume depletion <pause dur="0.5"/> in an area of the body you can't see feel touch perceive <pause dur="5.9"/> think of hidden <pause dur="0.7"/> bits of the body </u><u who="sf0535" trans="latching"> G-I bleed </u><pause dur="0.9"/> <u who="nm0504" trans="pause"> yeah yeah yeah very good G-I bleed <pause dur="0.2"/> i'm glad you said that because people don't think about <pause dur="0.3"/> the early stages of a G-I bleed <pause dur="0.4"/> when the blood has gone out of the body <pause dur="0.2"/> or gone out of the

wrong bit <pause dur="0.2"/> the right bit of the body and it's just sitting around in the bowel waiting to come out <pause dur="0.2"/> if you're bleeding slowly it may take a long time to come out <pause dur="0.4"/> and there's often a twenty-four <pause dur="0.2"/> forty-eight hour delay before you start seeing melena <pause dur="0.6"/> for example <pause dur="0.7"/> there are other spaces aren't there <pause dur="0.2"/> the abdomen there's a big hole in the abdomen <pause dur="0.3"/> pancreatitis classic example of a third space <pause dur="0.3"/> cause of <pause dur="0.6"/> true volume depletion <pause dur="0.8"/> burns <pause dur="0.4"/> well you can see burns maybe that's not a third spacing <pause dur="0.9"/> can you think of another <pause dur="0.6"/> space </u><pause dur="1.2"/> <u who="sm0536" trans="pause"> lungs </u><pause dur="0.6"/> <u who="nm0504" trans="pause"> lungs yes very good you can bleed in the lungs and not know it <pause dur="1.3"/> fractures <pause dur="0.4"/> fractures are probably the the classic example of third spacing particularly <pause dur="0.3"/> beware the fractured femur in an apparently fit young man after a game of rugby or football <pause dur="0.4"/> they may be bleeding pints <pause dur="0.3"/> into their <pause dur="0.3"/> thigh and you'll not see it they've got big thighs and they don't notice it <pause dur="0.2"/> they're bleeding into

their bones remember the bone is not <pause dur="0.6"/> a bunch of calcium it's a it's a vascular organ <pause dur="0.5"/> so there are areas of the body where you can easily hide blood so maybe this does exist <pause dur="0.4"/> # <pause dur="0.3"/> and # which is part of the reason i'm i'm talking about it today <pause dur="1.1"/><kinesic desc="writes on board" iterated="y" dur="1"/> of course third spacing could be relative volume depletion <pause dur="0.5"/> you know <pause dur="0.3"/> it is possible <pause dur="0.6"/> that i've said you can have fluid in the wrong space the wrong space can be invisible <pause dur="1.2"/> # i just can't think of an example of the one at the moment but usually third spacing <pause dur="0.3"/> is i think a variant of true volume depletion <pause dur="1.7"/> okay <pause dur="0.8"/> so <pause dur="1.0"/> generalized ischaemia this is a bit simpler to understand <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="3"/> and is really the causes of low blood pressure <pause dur="1.2"/> there are only <pause dur="0.2"/> seven major causes or groups of causes of low blood pressure of shock or hypertension and i and i've listed them there <pause dur="0.4"/> # but anything that causes <pause dur="0.2"/> low blood pressure around the body is also going to cause <pause dur="0.2"/> low blood pressure in the kidney so any

cause of low blood pressure can cause kidney failure <pause dur="1.9"/> this <pause dur="0.3"/><kinesic desc="writes on board" iterated="y" dur="1"/> # concept of renal ischaemia is is <pause dur="0.3"/> a bit harder to to understand <pause dur="1.0"/> and <pause dur="0.4"/> you can understand it in a <pause dur="0.2"/> simple way just thinking <kinesic desc="writes on board" iterated="y" dur="6"/> well if you've got something <pause dur="0.2"/> blocking say even a partial <pause dur="0.9"/> renal arteriosclerosis then you get a thrombosis or you you've got <pause dur="0.3"/> a <pause dur="0.3"/> renal vein thrombosis <pause dur="0.8"/> # <pause dur="0.7"/> that's easy to understand <pause dur="0.5"/> # but that structure <pause dur="0.7"/> function can go wrong <kinesic desc="writes on board" iterated="y" dur="3"/> here too <pause dur="1.5"/> and i'm not going to go into it today but there are a whole range of drugs <pause dur="0.2"/> that can affect the renal artery <pause dur="0.4"/> or <pause dur="0.2"/> more particularly the afferent and efferent <pause dur="0.5"/> # capillary <pause dur="0.3"/> to the glomerulus <pause dur="0.4"/> # such as non-steroidal such as ACE inhibitors <pause dur="0.4"/> such as <pause dur="2.2"/> they're all i can think of at the moment <pause dur="0.6"/> # <pause dur="0.2"/> so <pause dur="0.4"/> both the structure of the renal artery vein and the function of the renal artery of the vein can be affected <pause dur="0.6"/> and if you think about it <pause dur="0.5"/> there must be a disease you know generally speaking if the if you can conceive a disease in the

body <pause dur="0.3"/> it's almost certainly possible and it has happened at some point or it will happen at some point in the future <pause dur="0.7"/> # <pause dur="3.0"/> renal <pause dur="0.2"/> renal causes of <pause dur="0.3"/> acute renal failure are rare <pause dur="0.4"/> these ones are the common ones <kinesic desc="writes on board" iterated="y" dur="2"/> and the they make up ninety per cent of what we see in the hospitals <pause dur="1.0"/> the renal causes which is <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="3"/> # <pause dur="0.6"/> part of the reason or <pause dur="0.2"/> the main reason why <pause dur="0.2"/> most kidney doctors go into kidney medicine <pause dur="0.4"/> # are extremely rare <pause dur="0.5"/> and if you're a G-P you might see one in your whole lifetime <pause dur="0.7"/> and <pause dur="0.5"/> having said that <pause dur="0.2"/> # when you get one it's very exciting <pause dur="0.6"/> and remember what i said <kinesic desc="writes on board" iterated="y" dur="3"/> that the kidney's a tube <pause dur="1.1"/> # <pause dur="0.2"/> with a with a sieve in the middle <pause dur="2.1"/> when we talk about the renal causes of acute renal failure we're largely <kinesic desc="writes on board" iterated="y" dur="2"/> talking about the sieve or problems on the other side of the sieve in other words the glomerulus <pause dur="0.4"/> or <pause dur="0.2"/> the <pause dur="0.6"/> tubules of the kidney the proximal the distal convoluted tubule the collecting tubule et

cetera et cetera <pause dur="0.5"/> # and so you therefore have diseases such as <pause dur="0.2"/> acute glomerulonephritis <pause dur="0.2"/> acute vasculitis <pause dur="0.4"/> acute interstitial <pause dur="0.5"/> # nephritis <pause dur="0.6"/> and <pause dur="0.3"/> these are all autoimmune inflammations <pause dur="0.2"/> of either the glomerulus or the drainage system of the kidney <pause dur="0.6"/> and again today i'm not going to go into them in any <trunc>gree</trunc> great detail <pause dur="0.2"/> they are the thing we get excited about they are the thing we jump up and down about <pause dur="0.5"/> they are the thing that gets a <pause dur="0.4"/> kidney <pause dur="0.2"/> doctor most excited as i said last time <pause dur="0.8"/> but they're not that important in the real world <pause dur="0.4"/> Wegener's granulomatosis is a nice phrase <pause dur="0.4"/> # it's complicated <pause dur="0.3"/> # we talk about <pause dur="0.3"/> this endlessly on on <pause dur="0.6"/> # kidney ward rounds is this a case of <shift feature="voice" new="mimicking an other's voice"/>Wegener's granulomatosis or a case of polyarthritis nodosa and what would Dr Wegener <shift feature="voice" new="normal"/> the number of <pause dur="0.4"/> old git nephrologists who've actually said to me <shift feature="voice" new="mimicking an other's voice"/>what would Dr Wegener say <shift feature="voice" new="normal"/>you know <pause dur="0.4"/> i don't know what he would have said it doesn't matter <pause dur="0.2"/> it's not a common

cause <pause dur="0.3"/> of acute renal failure <pause dur="1.0"/> # <pause dur="1.1"/> what is a more important cause <pause dur="0.2"/> is what i call established renal failure <pause dur="0.7"/> <kinesic desc="writes on board" iterated="y" dur="7"/> now you'd have to forgive me <pause dur="0.3"/> # <pause dur="1.3"/> <trunc>in</trunc> inventing a few words <pause dur="0.3"/> or inventing a few phrases <pause dur="0.3"/> and this is a Dr <gap reason="name" extent="1 word"/> invention the concept of established renal failure <pause dur="0.2"/> it's not in your books <pause dur="0.3"/> it doesn't exist <pause dur="1.1"/> i'm telling you it probably exists why 'cause i've got the microphone <pause dur="0.6"/> # <pause dur="1.4"/> i don't like <pause dur="0.2"/> the phrase <pause dur="0.2"/> acute tubular necrosis and in some ways this is <pause dur="0.2"/> analogous or <pause dur="0.2"/> perhaps it is acute tubular necrosis <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> gentleman at the back on the left there <pause dur="0.5"/> what's wrong with the phrase acute tubular necrosis <pause dur="0.7"/> have you heard of the phrase </u><u who="sm0537" trans="latching"> no i've not </u><u who="nm0504" trans="latching"> okay <pause dur="0.9"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> we'll we'll # let's have a <trunc>l</trunc> lady with the with the light blue T-shirt on there <pause dur="0.6"/> have you heard of the phrase of A-T-N </u><u who="sf0538" trans="overlap"> # <pause dur="0.7"/> no </u><pause dur="0.4"/> <u who="nm0504" trans="pause">

oh <pause dur="0.2"/> you must have heard of it <pause dur="0.5"/> <kinesic desc="indicates member of audience" iterated="n"/> lady in the red there <pause dur="0.4"/> no <pause dur="0.5"/> nobody's heard of that phrase seriously <pause dur="0.9"/> come on </u><pause dur="0.8"/> <u who="sm0539" trans="pause"> it suggests that the tubule is completely dark </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> yeah that's the problem <pause dur="0.3"/> i mean you <trunc>ha</trunc> if you look in your renal book you'll be on chapters on acute tubular necrosis <pause dur="0.3"/> it it it suggests <pause dur="0.4"/> that <pause dur="0.7"/> necrosis happened <pause dur="0.2"/> that acute it's acute <pause dur="0.2"/> tubules there's a problem with the tubules they're all dead <pause dur="0.8"/> and and <pause dur="0.2"/> lady in the red there <kinesic desc="indicates member of audience" iterated="n"/> red top with # long hair what # </u><u who="sf0540" trans="latching"> <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0504" trans="overlap"> why # <pause dur="0.4"/> i always stop people talking don't worry <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="1.7"/> what's what's wrong with using a pathological phrase <pause dur="0.7"/> it's a pathological phrase acute <unclear>infarctal</unclear> cirrhosis <pause dur="3.0"/> we use them all the time don't we myocardial infarction <pause dur="1.6"/> we don't do heart biopsies we don't know if they're infarcted or not </u><pause dur="1.3"/> <u who="sf0540" trans="pause">

it's not suggestive of what's actually happened </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> yeah it doesn't really tell you about absolutely about the pathophysiology which is much more important than the nephrology <pause dur="0.3"/> <gap reason="inaudible" extent="1 sec"/> <pause dur="0.8"/> # <pause dur="0.2"/> the the the it's the pathophysiology that'll help you understand <pause dur="0.4"/> # <pause dur="0.2"/> how diseases happen and also how it's taught to patients you don't tell them <pause dur="0.3"/> you know you could be the world authority on the Kimmelstiel-Wilson disease <pause dur="0.3"/> try explaining that <pause dur="0.5"/> you know <pause dur="0.3"/> to <pause dur="0.4"/> Joe Public it's impossible <pause dur="0.4"/> but you might be able to explain diabetic nephropathy if you talk about <pause dur="0.2"/> the kidneys and blood sugar and damaging the kidney et cetera et cetera <pause dur="0.4"/> # <pause dur="0.4"/> and the same is true of <trunc>a</trunc> acute tubular necrosis that's why i don't like it <pause dur="0.4"/> there is another phrase which is acute tubular damage you may hear that phrase and that's a slight <pause dur="0.2"/> you know if you want <pause dur="0.4"/> a pathological phrase <pause dur="0.7"/> but these patients don't get renal biopsies and we don't know they've got acute tubular

necrosis we don't know they've got acute tubular damage it's just a presumption <pause dur="1.7"/> # i'm going to come back later on and talk to to this differentiation between <pause dur="0.3"/> prerenal failure <pause dur="0.2"/> and Dr <gap reason="name" extent="1 word"/>'s established renal failure in a bit more detail <pause dur="1.6"/> okay <pause dur="0.2"/> post-renal i'm not going to talk about in any great detail i think it's covered later on today <pause dur="0.4"/> # <pause dur="0.2"/> and is in some ways <pause dur="0.4"/> the simplest to understand <pause dur="0.6"/><kinesic desc="writes on board" iterated="y" dur="1"/> if <pause dur="0.2"/> # <pause dur="0.4"/> when one of you is very naughty later <trunc>y</trunc> later on and we take you down the front and operate on you in front of <pause dur="0.2"/> everybody else <pause dur="0.3"/> and tie off <pause dur="0.3"/> your ureters <pause dur="0.3"/> and # absolutely or cut the ureters there are absolutely <pause dur="0.2"/> zero <pause dur="0.3"/> i mean no possibility of any urine going from the kidney to the bladder <pause dur="1.5"/> that's obstructive nephropathy <pause dur="0.8"/> that i understand <pause dur="0.7"/> that's simple <pause dur="0.3"/> actually it's like <pause dur="0.2"/> minijoke what are what are the # <pause dur="1.1"/> three operations that a a gynaecologist is competent at <pause dur="0.5"/> have you heard this one <pause dur="2.6"/> <gap reason="inaudible" extent="1 sec"/> <pause dur="2.6"/> oh come on <pause dur="2.7"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> well they can either tie off one ureter <pause dur="0.3"/> the other ureter or both

they're the three operations that a <vocal desc="laughter" iterated="y" n="ss" dur="1"/><pause dur="0.4"/> that a a gynaecologist is competent at <pause dur="0.4"/> and # <pause dur="0.2"/> if if you # # <pause dur="0.4"/> give me a few drinks i'll tell you about some things they are less competent at <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> the # <pause dur="1.3"/> so # and this does happen actually they do <shift feature="voice" new="laugh"/>tie off ureters <shift feature="voice" new="normal"/><pause dur="0.3"/> i mean i i i i don't know how i mean i thought you know God if you believe in God made <pause dur="0.4"/> kidneys be yellow and <pause dur="0.7"/> arteries red veins blue and you know this is easy you go in there you know <pause dur="0.3"/> tie off the red ones <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> blue ones you know but you don't you don't sort of put a stitch round the yellow one <pause dur="0.4"/> but if only it was so easy <pause dur="0.5"/> and it is <shift feature="voice" new="laugh"/> apparently very easy <shift feature="voice" new="normal"/><pause dur="0.4"/> to tie off a ureter <pause dur="0.3"/> and i certainly have seen patients <pause dur="0.3"/> and one poor woman who was unlucky enough to have one kidney and the <pause dur="0.3"/> went on some vaguely <pause dur="0.5"/> minor or from a man's perception minor hysterectomy and <vocal desc="exploding noise" iterated="n"/><pause dur="1.1"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="0.7"/> <unclear>in the end they # so they actually</unclear> she she went in for something i can't remember and <pause dur="0.2"/> she was

unfortunate enough to have one kidney and he tied off the ureter <pause dur="1.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> that patient was in true proper obstructive <pause dur="0.2"/> nephropathy zero renal output <unclear>we like that</unclear> <pause dur="0.3"/> i've never seen that before <pause dur="0.7"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # and that was one of the reasons that made us think that the surgeon had had committed an error <pause dur="1.3"/> okay slight aside <pause dur="0.3"/> # <pause dur="0.9"/> if only it was so easy <pause dur="0.4"/> # <pause dur="0.3"/><kinesic desc="writes on board" iterated="y" dur="1"/> actually obstructive nephropathy i don't know if if the following lecture's going to go into this in great detail it's very difficult to understand <pause dur="0.4"/> because if you think about it <pause dur="0.7"/> it usually isn't complete obstruction <pause dur="1.5"/> # <pause dur="1.3"/> we know that because we see it all the time it's it's one of the commonest causes of both acute and chronic renal failure <pause dur="0.4"/> and they don't have <shift feature="voice" new="laugh"/> zero renal output <shift feature="voice" new="normal"/><pause dur="0.3"/> in fact if anything they're usually polyuric <pause dur="0.9"/> and for reasons we don't understand <pause dur="0.4"/> partial obstruction <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="1"/> to the ureter or the

drainage system to the kidney at some level <pause dur="0.3"/> doesn't normally cause <pause dur="0.7"/> # <pause dur="0.5"/> oliguria <pause dur="0.3"/> it's for some reason again this is nobody's ever worked this out <pause dur="0.2"/> do a PhD work out <pause dur="0.3"/> the pathophysiology of obstructive nephropathy <pause dur="0.5"/> save the world <pause dur="0.9"/> # <pause dur="0.9"/> it's very very interesting <pause dur="2.5"/> having said all of that what do i actually see in my normal life do i see people with Wegener's granulomatosis do i see people with their kidneys tied off by a gynaecologist no i don't <pause dur="0.2"/> what i actually see is what i call <pause dur="0.3"/> the surgical cocktail <pause dur="0.2"/> don't tell that to the surgeons <pause dur="0.6"/> the surgical cocktail <pause dur="0.3"/> is three things and this is the mantra <pause dur="0.3"/> i want you to recite in your head every night <pause dur="0.4"/> dry <pause dur="0.2"/> sepsis drugs <shift feature="tempo" new="acc"/> dry sepsis drugs dry sepsis drugs <shift feature="tempo" new="normal"/> <pause dur="0.2"/> that is the mantra <pause dur="0.2"/> that is what surgeons do <pause dur="0.6"/> after the operation <pause dur="0.4"/> dry sepsis <pause dur="0.2"/> drugs <pause dur="0.2"/> why <pause dur="0.3"/> how does that happen gentleman <pause dur="1.0"/> <kinesic desc="indicates member of audience" iterated="n"/> perceptive gentleman at the back on the right <pause dur="0.8"/> why how do surgeons cause a

patient to be <pause dur="0.3"/> dry septic <pause dur="0.3"/> and have drugs </u><pause dur="1.2"/> <u who="sm0541" trans="pause"> 'cause <pause dur="0.5"/> they bleed <pause dur="0.4"/> <gap reason="inaudible due to overlap" extent="1 sec"/></u><u who="nm0504" trans="overlap"> they bleed so they become dry yeah </u><u who="sm0541" trans="latching"> # they're open <pause dur="0.3"/> so they get septic </u><u who="nm0504" trans="overlap"> speak up </u><u who="sm0541" trans="latching"> they're open so they get septic </u><u who="nm0504" trans="overlap"> yeah so they open them up so they get septic spit in the wound </u><u who="sm0541" trans="latching"> and they pump them full of drugs during the operation <pause dur="0.3"/> and then afterwards </u><u who="nm0504" trans="overlap"> absolutely simple as that anaesthetic agents <pause dur="0.3"/> post-op what do they give them </u><pause dur="0.4"/> <u who="ss" trans="pause"> painkillers </u><u who="nm0504" trans="overlap"> pain relief non-steroidals <pause dur="0.4"/> okay prerenal failure local ischaemia what else do they give them post-operatively <pause dur="0.8"/> <gap reason="inaudible" extent="1 sec"/> <pause dur="3.3"/> for the fever </u><pause dur="0.8"/> <u who="sm0542" trans="pause"> antibiotics </u><pause dur="1.8"/> <u who="nm0504" trans="pause"> speak up </u><pause dur="0.2"/> <u who="sm0542" trans="pause"> antibiotics </u><u who="nm0504" trans="latching"> antibiotics which one <pause dur="1.5"/> which group </u><pause dur="0.7"/> <u who="sm0542" trans="pause"> <gap reason="inaudible" extent="3 secs"/> </u><u who="nm0504" trans="overlap"> gentamicin aminoglycosides <pause dur="0.3"/> notorious nephrotoxins <pause dur="0.4"/> so this is a lethal combination <pause dur="0.3"/> being dry being septic and having drugs now of course <pause dur="0.2"/> these are connected <pause dur="0.2"/> you know you may become septic post-operatively

which makes you dry <pause dur="0.4"/> via <pause dur="0.6"/> a volume depletion cause in other words septic shock <pause dur="1.0"/> and sepsis leads to drugs <pause dur="0.8"/> so <pause dur="2.0"/> you're septic you become dry and you get drugs for the whole thing so these <trunc>thi</trunc> three things are connected so <pause dur="0.3"/> whenever i go to the surgical wards and see somebody with # <pause dur="0.3"/> acute renal failure <pause dur="0.2"/> that is always my presumption that the patient <pause dur="0.2"/> has been given what i call the surgical cocktail <pause dur="0.6"/> so the treatment is actually quite simple <pause dur="1.2"/> you give them fluids you take away the drugs <pause dur="1.1"/> and <pause dur="0.6"/> you make them <trunc>bi</trunc> bit less septic <pause dur="0.6"/> # and it may involve writing up more drugs but at least you're going to cross off the drugs they were on and put them on <pause dur="0.3"/> on less nephrotoxic drugs <pause dur="0.9"/> and they almost always get better <pause dur="1.1"/> okay <pause dur="0.7"/> so <pause dur="0.4"/> the clinical features <pause dur="0.4"/> of acute renal failure are largely predictable <pause dur="0.6"/> # i don't particularly want to go <pause dur="0.3"/> through them in <trunc>a</trunc> in any great detail because <pause dur="0.4"/> it's all too easy <pause dur="1.0"/> # <pause dur="0.2"/> but basically <pause dur="0.7"/> the clinical features are those of the <pause dur="0.5"/> fluids and solutes that you can't get rid of <pause dur="1.4"/> and <pause dur="0.5"/>

the only two important clinical features i've listed there in bold <pause dur="0.3"/> which are <pause dur="1.3"/> fluid overload <pause dur="1.1"/> and hyperkalaemia <pause dur="0.5"/> and in fact <pause dur="0.5"/> these are the two <pause dur="0.6"/> important clinical features of acute renal failure <pause dur="0.2"/> and they're also the two reasons we normally do dialysis so <pause dur="0.2"/> you need to know those two <pause dur="0.4"/> for for those two reasons so if you forget everything else i say this morning <pause dur="0.3"/> just remember <pause dur="0.2"/> the two important and life-threatening complications of acute renal failure <pause dur="0.2"/> are fluid overload and hyperkalaemia and they are also the two <pause dur="0.2"/> absolute reasons <pause dur="0.2"/> or indications for dialysis all others are relative <pause dur="1.3"/> the other clinical features again <gap reason="inaudible" extent="1 sec"/> you don't get rid of hydrogen ions <pause dur="0.2"/> metabolic acidosis Kussmaul's breathing <pause dur="0.2"/> # any anybody seen anybody with Kussmaul's breathing <pause dur="1.8"/> nope <pause dur="0.6"/> okay <pause dur="0.3"/> # <pause dur="0.3"/> in the books it's described as air hunger absolute rubbish <pause dur="0.3"/> but you know <pause dur="0.4"/> people say they then go <vocal desc="gasp" iterated="n"/><pause dur="0.3"/> <vocal desc="sigh" iterated="n"/> they sort of sigh a bit they don't <trunc>c</trunc> <unclear>it's severe</unclear> short of breath <pause dur="0.4"/> and it's the differential diagnosis for somebody who's short of

breath <pause dur="0.8"/> they're not hungry at all <pause dur="0.5"/> they're just <pause dur="0.6"/> dying <pause dur="0.5"/> hungry <pause dur="0.5"/> # <pause dur="0.6"/> Kussmaul's breathing <pause dur="0.7"/> yes the phosphate goes up the calcium goes down the haemoglobin goes down these are more features of chronic renal failure <pause dur="0.4"/> they do happen to an extent in acute renal failure <pause dur="1.5"/> # <pause dur="0.3"/> there are other causes of anaemia in acute renal failure if the haemoglobin is inappropriately low or going down quickly <pause dur="0.9"/> what might be lady <kinesic desc="indicates member of audience" iterated="n"/> there <pause dur="0.7"/> what might be the <pause dur="0.2"/> cause of acute renal failure if the haemoglobin is inappropriately low six <pause dur="0.7"/> six and falling rapidly with a creatinine of four-hundred <pause dur="1.5"/> it's inappropriately low and falling rapidly <pause dur="0.5"/> so it's </u><pause dur="0.4"/> <u who="sf0543" trans="pause"> <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="nm0504" trans="overlap"> six today four tomorrow </u><pause dur="0.8"/> <u who="sf0543" trans="pause"> decreased oxygen </u><u who="nm0504" trans="latching"> mm <pause dur="1.4"/> yeah due to </u><pause dur="2.8"/> <u who="sf0543" trans="pause"> less oxygen bound to the haemoglobin </u><pause dur="0.6"/> <u who="nm0504" trans="pause">

possibly <pause dur="0.4"/> anybody else </u><u who="sm0544" trans="latching"> E-P-O </u><pause dur="0.6"/> <u who="nm0504" trans="pause"> sorry </u><u who="sm0544" trans="latching"> E-P-O lack of E-P-O </u><u who="nm0504" trans="overlap"> no no that's what i want you <pause dur="0.3"/> wanted you not to say 'cause that's the cause of <pause dur="0.4"/> anaemia in chronic renal failure <pause dur="2.9"/> it's only part of the cause of anaemia in acute renal <pause dur="0.5"/> bleeding <pause dur="0.5"/> so <pause dur="0.3"/> there are only two ways of having a rapidly falling haemoglobin bleeding and <pause dur="1.8"/> how can you get rid of blood cells from your body quickly if you don't bleed </u><pause dur="1.9"/> <u who="sm0545" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><u who="nm0504" trans="overlap"> speak up </u><u who="sm0545" trans="latching"> <gap reason="inaudible" extent="1 sec"/> <pause dur="1.8"/> through the urine </u><pause dur="0.5"/> <u who="nm0504" trans="pause"> # <pause dur="0.6"/> yes eventually yeah but <pause dur="0.3"/> before that </u><pause dur="0.3"/> <u who="ss" trans="pause"> <gap reason="inaudible, multiple speakers" extent="2 secs"/></u><u who="nm0504" trans="overlap"> speak up </u><pause dur="0.7"/> <u who="sm0546" trans="pause"> <unclear>haemoglobin</unclear> <pause dur="1.1"/> <unclear>haemoglobin</unclear> </u><pause dur="0.2"/> <u who="nm0504" trans="pause"> mm yeah <pause dur="0.8"/> haemolysis is the answer <unclear>there are only</unclear> two common causes of <pause dur="0.5"/> rapid <gap reason="inaudible" extent="1 sec"/> you know haemoglobin's ten six two <pause dur="1.0"/> not <pause dur="0.2"/> nine eight-point-eight <pause dur="0.6"/> seven-point-nine <pause dur="0.3"/> rapidly falling haemoglobin there must be some way <pause dur="0.3"/> of getting blood out of the body quickly and they're the only two ways <pause dur="0.5"/> and

so if somebody's haemoglobin is inappropriately low in acute renal failure <pause dur="0.4"/> just <trunc>a</trunc> as if they're inappropriately low and falling <unclear>in</unclear> the disease they're <pause dur="0.2"/> the two diagnoses we we think of <pause dur="1.4"/> okay uraemia <pause dur="0.2"/> uraemia <pause dur="0.6"/> now there's a word <pause dur="0.4"/> # <pause dur="1.3"/> Greek derivation <pause dur="0.2"/> probably means urine in the blood # have we got much further than the Greeks <pause dur="0.4"/> probably not actually <pause dur="0.3"/> i i don't think they <pause dur="0.3"/> understood uraemia i'm not sure all that we understand it <pause dur="0.8"/> all i can say is there was an ill defined syndrome in which you don't feel very well doctor <pause dur="0.6"/> # <pause dur="1.4"/> in which toxins build up in the blood there are tens of thousands perhaps hundreds of thousands <pause dur="0.3"/> there is a modern concept of middle molecules <pause dur="0.3"/> big toxic things <pause dur="0.5"/> of middle size that are <pause dur="0.2"/> # damaging or make you unwell nobody actually knows <pause dur="0.6"/> find out do a PhD probably already done one <pause dur="0.2"/> find out what the middle middle molecules are find out why people are unwell <pause dur="0.4"/> in both acute and chronic <trunc>f</trunc> you know we still don't know <pause dur="1.1"/> # <pause dur="1.3"/> medicine is not all over i'm sure i'm not

the only lecturer who's stood in the front <pause dur="0.3"/> and said it's all sorted out i mean <pause dur="0.2"/> i think if <pause dur="0.3"/> if # <pause dur="0.3"/> if we if medicine was a clock <pause dur="0.5"/> and we were <pause dur="0.3"/> attempting to sort it out we're probably about five past the hour at the moment <pause dur="0.6"/> # we're nowhere near having sorted it out we're <trunc>no</trunc> 'cause we're nowhere near understanding <pause dur="0.5"/> the pathophysiology of most disease processes and acute renal failure's just an example cancer <pause dur="0.3"/> <unclear>atheroma</unclear> whatever you like <pause dur="1.1"/> # <pause dur="1.5"/> okay <pause dur="0.6"/> there is an ill defined syndrome which i've <pause dur="0.5"/> listed the effects of there <pause dur="0.3"/> # <pause dur="0.3"/> it's ill defined therefore i'm not going to try to define it <pause dur="0.8"/> the history well of course the history is important history is always important <pause dur="0.5"/> # <pause dur="0.4"/> kidney doctors are famous for not taking histories <pause dur="0.2"/> we're numbers doctors we like numbers we <pause dur="0.2"/> say hello to the patient look at the numbers decide whether he dies and go home go to the pub <pause dur="0.4"/> whatever <pause dur="0.5"/> we we <pause dur="0.2"/> we # registrar hangs around puts a line in the patient gets better or dies we get biscuits <pause dur="0.7"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/>

but we we # <pause dur="0.5"/> the history is <shift feature="voice" new="laugh"/> important <shift feature="voice" new="normal"/><pause dur="0.3"/> and i shouldn't knock the history <pause dur="0.2"/> probably the most important thing that you can do in the history is find out what drugs they're on drugs drugs drugs <pause dur="0.4"/> okay <pause dur="0.2"/> because <pause dur="0.3"/> it's both the cause <pause dur="0.4"/> of acute renal failure in up to thirty per cent of patients <pause dur="0.4"/> # and it may also <pause dur="0.2"/> # <pause dur="0.3"/> give you clues about the underlying aetiology so if they're on a drug <pause dur="0.3"/> for hypertension <pause dur="0.3"/> perhaps an ACE inhibitor it may be they've got renovascular disease and they should have had the ACE inhibitor <pause dur="0.6"/> so the drugs are important in a variety of for a variety of reasons <pause dur="0.4"/> how do you how do you take lady at the <kinesic desc="indicates member of audience" iterated="n"/> black there with your thermos <pause dur="0.4"/> # <pause dur="0.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> you you # <pause dur="1.1"/> is that coffee in there or </u><u who="sf0547" trans="latching"> no it's water </u><u who="nm0504" trans="latching"> water </u><u who="sf0547" trans="overlap"> it's not a thermos </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> # <pause dur="0.5"/> it <shift feature="voice" new="laugh"/># <shift feature="voice" new="normal"/><pause dur="0.6"/> how do you <pause dur="0.2"/> how do you take a drug history then <pause dur="0.2"/> from the patient <pause dur="1.5"/> just a bit of role play </u><u who="sf0547" trans="overlap">

you ask to see their chart </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> bit of role play </u><pause dur="0.6"/> <u who="sf0547" trans="pause"> <vocal desc="sigh" iterated="n"/> <pause dur="2.0"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> if they're in hospital you can ask to see their chart rather than ask them </u><u who="nm0504" trans="overlap"> yeah i know but they're not they haven't got they're in the medical admissions <pause dur="0.2"/> ask me some questions </u><pause dur="0.2"/> <u who="sf0547" trans="pause"> <gap reason="inaudible" extent="1 sec"/> what drugs you're on </u><u who="nm0504" trans="overlap"> about what what drugs i'm on </u><pause dur="0.3"/> <u who="sf0547" trans="pause"> what tablets do you take every day </u><pause dur="0.7"/> <u who="nm0504" trans="pause"> i'm not telling you <pause dur="1.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> come on </u><pause dur="2.2"/> <u who="sm0548" trans="pause"> what are you taking </u><u who="nm0504" trans="overlap"> oh you better go than that <pause dur="0.8"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> that's just one you've got to ask the question again </u><u who="sf0547" trans="latching"> # can you <trunc>as</trunc> <pause dur="0.2"/> could you tell me what drugs you're taking </u><pause dur="1.1"/> <u who="nm0504" trans="pause"> <vocal desc="sigh" iterated="n"/> <unclear><trunc>g</trunc></unclear> i gave them to the other doctor earlier <pause dur="1.0"/> didn't you write them down </u><pause dur="0.3"/> <u who="sf0547" trans="pause"> <gap reason="inaudible" extent="1 sec"/> do you have them <pause dur="0.2"/> them with you any of them </u><u who="nm0504" trans="overlap"> well they're in my bag they're <pause dur="0.9"/> do you want me to get it </u><u who="sf0547" trans="latching"> yeah </u><u who="nm0504" trans="overlap"> all right </u><u who="sf0547" trans="overlap">

could i have a look at them </u><u who="nm0504" trans="latching"> okay <pause dur="0.6"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/> so # <pause dur="1.7"/> i don't know i don't know which one i'm i i don't know which one i'm i'm taking but you know and i've got a big i've got a list here from my G-P <pause dur="0.5"/> and and i've got a load here <pause dur="1.0"/> and i i i don't know you know i <trunc>j</trunc> i i don't know i mean every doctor i see puts me on a different tablet </u><pause dur="2.5"/> <u who="sf0547" trans="pause"> # </u><pause dur="1.3"/> <u who="nm0504" trans="pause"> come on Gestapo <vocal desc="laughter" iterated="y" n="ss" dur="3"/> </u><pause dur="3.1"/> <u who="sf0547" trans="pause"> which of those did you take this morning </u><u who="nm0504" trans="latching"> very good all right we're getting there very good <pause dur="0.7"/> <trunc>d</trunc> do you really want to know all right okay i took this <pause dur="0.3"/> # well i don't know what it's called it's blue <pause dur="1.0"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> do you know the do you know the blue one doctor <vocal desc="laughter" iterated="y" n="ss" dur="3"/></u><pause dur="2.0"/> <u who="sf0547" trans="pause"> <vocal desc="laughter" iterated="y" dur="1"/> do you have the bottle so i can

see the label </u><u who="nm0504" trans="latching"> all right here is here it is here it is okay so you're writing it down okay <pause dur="0.6"/> so <pause dur="0.3"/> very good okay i'll we'll stop there but <pause dur="0.2"/> but it's very hard to take a drug history <pause dur="0.3"/> # <pause dur="0.2"/> often the patient's got no idea <pause dur="0.4"/> the drug list is wrong <pause dur="0.3"/> and you actually have to get the actual tablets actually in front of you <pause dur="0.3"/> compare it to the drug list unless you've got a particularly articulate patient and you trust the drug list <pause dur="0.5"/> you know and find out what they're actually taking <pause dur="0.6"/> by taking a precise and careful drug history <pause dur="0.3"/> you may save the patient's life by being a bit of a pain in the arse <pause dur="0.4"/> # and it may involve sending the wife home to get the tablets from the bathroom by # you know ringing the G-P in the morning <pause dur="0.4"/> you've got to be a detective in terms of drug history and it's very very important not just in in in renal disease <pause dur="1.2"/> people <pause dur="0.3"/> # in my opinion <pause dur="0.3"/> very <pause dur="0.2"/> # too readily give up on a drug history of the patient and oh well i

don't know you know or <gap reason="inaudible" extent="1 sec"/> <pause dur="0.4"/> and they don't pay <gap reason="inaudible" extent="1 sec"/> <pause dur="0.2"/> you find there aren't any pink tablets you know <pause dur="0.4"/> # they you know they <pause dur="0.6"/> the <pause dur="0.2"/> don't give up take the history put the screws on <pause dur="0.6"/> get the light out Gestapo treatment is what's needed for <pause dur="0.3"/> # a drug history <pause dur="1.4"/> i missed some other <pause dur="0.2"/> # important features of the history there there is one <pause dur="0.3"/> modern myth <pause dur="0.4"/> # about # kidney failure <pause dur="0.3"/> which i've listed for you there which is <pause dur="0.2"/> high blood pressure causes kidney failure kidney failure causes high blood pressure it's a nice little mantra and if you'll repeat that you've read it in your book <pause dur="0.8"/> absolute rubbish <pause dur="0.3"/> absolute lie <pause dur="0.2"/> it's like most <pause dur="0.4"/> verbal <pause dur="0.2"/> oral myths <pause dur="0.4"/> it's it's a <trunc>m</trunc> oral myth because somebody told somebody who told somebody who told <pause dur="0.2"/> <gap reason="name" extent="2 words"/> who told me to tell you <pause dur="0.8"/> and that's how it's come <pause dur="0.3"/> into being <pause dur="0.6"/> there is no evidence <pause dur="0.7"/> that <pause dur="0.3"/> high blood pressure <pause dur="0.5"/> causes kidney failure <pause dur="1.2"/> so if you forget everything else i say just remember that <pause dur="1.2"/> kidney failure causes high blood pressure both in

acute and chronic kidney failure <pause dur="0.3"/> but bog standard mild to moderate essential hypertension no other risk factors does not cause kidney failure <pause dur="0.4"/> and never accept it as a diagnosis <pause dur="1.0"/> # <pause dur="0.3"/> accelerated hypertension can cause acute renal failure <pause dur="0.6"/> but accelerated hypertension is quite rare <pause dur="0.3"/> and it's <pause dur="0.3"/> only a major problem in blacks and Asians whites can get it but blacks and Asians in particular <pause dur="0.3"/> <trunc>d</trunc> do you all know what i mean by accelerated hypertension <pause dur="1.4"/> anybody not know some shakes in the back <pause dur="0.2"/> accelerated hypertension i'm not going to talk about it in detail today a well defined syndrome it's been written about for a couple of hundred years <pause dur="0.3"/> combination of extremely high blood pressure systolic over two-hundred <pause dur="0.2"/> for example <pause dur="0.3"/> being unwell <pause dur="0.2"/> hepatic encephalopathy <pause dur="0.2"/> hepatic retinopathy <pause dur="0.5"/> acute renal failure <pause dur="0.5"/> dissecting <pause dur="0.2"/> aneurysms a constellation of all the problems <pause dur="0.5"/> # <pause dur="0.3"/> which fits into the <unclear>dimensions</unclear> of accelerated or sometimes <pause dur="0.4"/> use of the malignant hypertension

that does cause acute renal failure <pause dur="0.5"/> but never take hypertension as a cause of acute renal failure otherwise <pause dur="1.5"/> okay <pause dur="0.4"/> # <pause dur="0.6"/> i've put a little phrase there funny diseases in the family <pause dur="0.4"/> # when you take a family history it's not enough to say <pause dur="0.5"/> what did your mum die of what did your dad die of oh sorry not <pause dur="0.4"/> sorry about that <pause dur="0.4"/> # what did your mum die of yeah oh your dad's still alive yeah sorry about that <pause dur="0.5"/> assuming your both your parents were dead <pause dur="0.3"/> # <pause dur="0.7"/> # be careful when you know you have a patient who's about <pause dur="0.2"/> fifty their parents might be alive or even sixty they might be alive so don't or go straight into what's what did your mother die of <pause dur="0.5"/> just be careful <pause dur="0.2"/> to say <pause dur="0.2"/> # <pause dur="0.3"/> is your <pause dur="0.2"/> mother well or you can start off with you know <pause dur="0.5"/> # do you still have your parents something a bit softer <pause dur="0.4"/> than what did they die of <trunc>d</trunc> don't assume everybody's dead <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="2.8"/> # funny diseases in the family # important in

kidney disease # <pause dur="0.2"/> there may be a family history of organ-specific autoimmune disease their <pause dur="0.3"/> auntie's got diabetes their cousin's got thyroid disease <pause dur="0.3"/> and these all <pause dur="0.2"/> # increase the possibility of of autoimmune disease so we're talking about <pause dur="0.2"/> glomerulonephritis vasculitis <pause dur="0.3"/> extremely rare <pause dur="1.3"/> examination <pause dur="0.4"/> what is a <trunc>rena</trunc> a student asked me couple of days ago that's why i put this section in <pause dur="0.4"/> when i was preparing this at two o'clock last night don't think look <pause dur="0.4"/> when we become consultant lecturers we don't do things at <pause dur="0.2"/> last-minute-dot-com we do <pause dur="0.5"/> # <pause dur="0.2"/> we're no more organized than you are we're just a bit older have a bit less hair <pause dur="0.4"/> # <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> when i was doing this <shift feature="voice" new="laugh"/>at two o'clock last night <shift feature="voice" new="normal"/><pause dur="0.7"/> # <pause dur="0.4"/> # i remembered a medical student asked me a couple of days what is a renal examination <pause dur="0.3"/> i thought that's a good question now i don't know what a renal <trunc>e</trunc> i mean there's never a a renal chapter in a book is there <pause dur="0.8"/> there's

cardiovascular respiratory G-I there's no renal examination <pause dur="0.3"/> i think what a renal examination is <pause dur="0.3"/> is a good cardiovascular <pause dur="0.5"/> because that tells you about fluid state <pause dur="0.3"/> a good G-I 'cause that tells you about the kidneys the liver <pause dur="0.3"/> plus the bladder which you always forget to feel <pause dur="0.6"/> plus listening for bruits particularly femoral particularly epigastric <pause dur="0.3"/> that's where you hear renal bruits in the epigastrium <pause dur="0.8"/> other things cause epigastric bruits aneurysms a load of other things but renal bruits <pause dur="0.2"/> also <pause dur="0.3"/> occur there <pause dur="0.3"/> and the very important thing the finger up the bottom <pause dur="0.6"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> the finger must go up the bottom every time you see a patient <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> with acute renal failure <pause dur="0.6"/> # <pause dur="0.3"/> and in a woman <pause dur="0.2"/> should go <pause dur="0.2"/> # into the vagina as well <pause dur="0.2"/> # unless there is a good reason not to <pause dur="0.9"/> okay that's a gross generalization there's never really <unclear>too many</unclear> in a hospital only a hundred-and-thirty a bit dry going to have a finger up the bottom no <pause dur="0.9"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> but <pause dur="0.6"/> if the renal

failure is unexplained <pause dur="0.2"/> and you have reason to think they may have obstructive nephropathy <pause dur="0.2"/> remember the common cause of obstructive nephropathy <pause dur="0.2"/> in men is prostate in women is pelvic cancer <pause dur="0.3"/> pelvic cancer till otherwise proven <pause dur="0.8"/> and <pause dur="0.5"/> if you don't want to do those things fine but <trunc>the</trunc> then the onus <trunc>i</trunc> on you is to get somebody else to do it so <pause dur="0.2"/> my advice to you is as soon as you get on the surgical ward <pause dur="0.2"/> start putting your fingers up people's bottoms just get used to it <pause dur="0.3"/> you know <vocal desc="laughter" iterated="y" n="ss" dur="1"/> <pause dur="0.4"/> all doctors have to be able to do it <pause dur="0.3"/> and # and you're no different and just get over that mental barrier <pause dur="1.5"/> # <pause dur="1.1"/> and maybe the only clinical signs if you don't do it you're doing a patient it's like <vocal desc="cough" iterated="n" n="sm0549"/> not examining <gap reason="inaudible due to noise from audience" extent="1 sec"/> you know you're actually not helping them very much <pause dur="0.2"/> because you don't want to do it <pause dur="0.5"/> 'cause you don't like <vocal desc="cough" iterated="n" n="sm0549"/><gap reason="inaudible due to noise from audience" extent="1 sec"/><pause dur="0.9"/> # <pause dur="2.9"/> in terms of anything else to examine not really <pause dur="1.0"/> it's a complete examination a renal <trunc>examina</trunc> but <trunc>s</trunc> <pause dur="0.2"/> but # <trunc>s</trunc>

specifying those particular areas <pause dur="1.6"/> right <pause dur="0.5"/> # <pause dur="2.0"/> investigations i'm not going to go into in any great detail i've listed a few questions for you there <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="3"/> just remember the big three <pause dur="0.4"/> the creatinine <pause dur="0.7"/> what do you think the other <pause dur="0.3"/> two big ones are <pause dur="0.6"/> the big three there's always a big three <pause dur="1.6"/> key investigation of somebody with acute or chronic renal failure <pause dur="0.5"/> creatinine <kinesic desc="indicates member of audience" iterated="n"/> </u><pause dur="1.4"/> <u who="sm0550" trans="pause"> urea </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> no <pause dur="1.3"/> anybody else <pause dur="1.1"/> speak up <pause dur="0.7"/> have a guess </u><pause dur="1.3"/> <u who="sm0551" trans="pause"> calcium </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> no </u><u who="sm0552" trans="overlap"> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.3"/> <u who="sm0553" trans="pause"> G-F-R </u><pause dur="0.5"/> <u who="nm0504" trans="pause"> no </u><pause dur="0.6"/> <u who="sf0554" trans="pause"> calcium </u><u who="sm0555" trans="overlap"> calcium in urine </u><pause dur="0.9"/> <u who="nm0504" trans="pause"> sorry </u><pause dur="0.3"/> <u who="sm0555" trans="pause"> calcium in your urine </u><pause dur="0.7"/> <u who="nm0504" trans="pause"> dipstick </u><pause dur="0.8"/> <u who="sm0555" trans="pause"> okay </u><u who="nm0504" trans="overlap"> okay <pause dur="0.3"/> and <pause dur="0.4"/><kinesic desc="writes on board" iterated="y" dur="2"/> important radiological tests <pause dur="4.0"/> calculated guess </u><pause dur="0.7"/> <u who="sm0556" trans="pause"> X-ray </u><pause dur="0.7"/> <u who="nm0504" trans="pause"> no </u><pause dur="0.2"/> <u who="sf0557" trans="pause"> ultrasound </u><u who="sm0558" trans="overlap"> ultrasound </u><u who="nm0504" trans="overlap"> <kinesic desc="writes on board" iterated="y" dur="2"/>

ultrasound okay <pause dur="0.2"/> X-rays can kill you <vocal desc="sniff" iterated="n"/><pause dur="0.3"/> ultrasounds don't <pause dur="0.6"/> # <pause dur="1.0"/> so these are the big three tests <pause dur="0.3"/> and anybody with acute renal failure <pause dur="0.3"/> needs a complete history and examination <pause dur="0.6"/> and a knowledge of the result of these big three tests within twelve hours or you haven't done your job right <pause dur="1.1"/> if the renal failure is unexplained if it's explained <pause dur="0.3"/> on clinical grounds you don't have to do everything all the time <pause dur="0.2"/> you don't have to do <pause dur="0.3"/> an anchor <pause dur="0.5"/> # antineutrophil cytoplasmic antibody on everybody with a creatinine of hundred-and-thirty in medical admissions who's got appendicitis <pause dur="0.5"/> but if the renal failure's unexplained you have to do it <pause dur="1.3"/> # <pause dur="1.0"/> and they are the big three tests potassium yes is all right big four but <pause dur="0.5"/> potassium in my mind slips in with the creatinine you know if you're doing a creatinine you're checking the potassium <pause dur="0.4"/> # <pause dur="0.2"/> yes you want to know the potassium because that's what kills people and that's <pause dur="0.5"/> the important thing on which you decide whether to dialyse people or not <pause dur="0.4"/> # but it doesn't tell you about kidney function and that's what the creatinine does <pause dur="0.3"/> what's what's the creatinine for the liver <pause dur="2.0"/> gentleman <kinesic desc="indicates member of audience" iterated="n"/>

in in red there <pause dur="0.4"/> what's happening to the liver </u><pause dur="0.7"/> <u who="sm0559" trans="pause"> no idea </u><pause dur="1.6"/> <u who="nm0504" trans="pause"> anybody <pause dur="0.8"/> do you want to <pause dur="0.7"/> he's the liver man is he <pause dur="1.9"/> what's the creatinine for the liver <pause dur="0.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> he's <pause dur="0.3"/> pointing to you so </u><pause dur="0.9"/> <u who="sm0560" trans="pause"> cheers <pause dur="0.5"/> # i don't know </u><pause dur="1.6"/> <u who="nm0504" trans="pause"> how do you measure liver function </u><pause dur="1.9"/> <u who="sm0561" trans="pause"> L-F-T </u><pause dur="0.2"/> <u who="sm0562" trans="pause"> L-F-T </u><pause dur="0.4"/> <u who="sm0563" trans="pause"> L-F-T </u><u who="nm0504" trans="overlap"> i'm glad you said that no <pause dur="0.5"/> # <pause dur="0.2"/> I-N-R the I-N-R is the creatinine for the liver that's what they measure on liver transplants four times a day <pause dur="0.5"/> there is to be honest there isn't a creatinine for the liver there isn't as good a way of <pause dur="0.4"/> measuring liver function i mean <pause dur="0.2"/> okay they're bright yellow <unclear>liver in the</unclear> three-hundred <unclear>in</unclear> <pause dur="0.2"/> trouble with the liver but <pause dur="0.5"/> there <pause dur="0.4"/> there isn't really a good creatinine they need they need a creatinine <pause dur="0.6"/> to to <trunc>m</trunc> as a <trunc>m</trunc> good marker of liver function but <pause dur="0.2"/> when the liver actually fails the I-N-R goes up and it goes up rapidly it goes up exponentially so

as soon as your I-N-R starts going up <pause dur="0.2"/> you're in big trouble <pause dur="0.9"/> # <pause dur="1.3"/> okay <pause dur="0.3"/> so they're the big three tests <pause dur="0.3"/> # <pause dur="2.4"/> are they easy to get yes all very easy the dipstick you can do the creatinine you can do the ultrasound you can organize it's a Friday evening you want to go home the patient's unwell <pause dur="1.0"/> you don't know whether to ring a radiologist they might shout at you <pause dur="0.6"/> who cares if they shout at you they don't have to like you <pause dur="0.4"/> you're not in this game to be liked <pause dur="0.6"/> # get that ultrasound by hook or by crook <pause dur="0.5"/> # within twelve hours in somebody with unexplained renal failure <pause dur="0.3"/> lie <pause dur="0.2"/> give your right arm <pause dur="0.2"/> firstborn whatever you like <pause dur="0.2"/> just get it <pause dur="0.5"/> # <pause dur="0.2"/> why do people become radiologists why do people become radiologists <pause dur="2.7"/> technicians <pause dur="1.6"/> <kinesic desc="indicates member of audience" iterated="n"/> why <gap reason="inaudible" extent="1 sec"/> radiologists </u><pause dur="0.7"/> <u who="sf0564" trans="pause"> they can't be a doctor </u><pause dur="0.6"/> <u who="nm0504" trans="pause"> 'cause they can't be a doctor <pause dur="2.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="11"/> what

a dreadful thing to say you <pause dur="1.1"/> evil cynical woman <pause dur="0.7"/> yes <pause dur="0.8"/> # <pause dur="1.9"/><shift feature="voice" new="laugh"/> # <pause dur="1.8"/> <gap reason="inaudible" extent="1 sec"/> there then <pause dur="0.2"/> # <pause dur="0.2"/> yeah no they don't want to be doctors <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> they don't want to take complete responsibility they're <pause dur="0.2"/> they're <pause dur="0.2"/> # <pause dur="1.1"/> they're very important they're vital <pause dur="0.7"/> but they don't want to take complete twenty-four hour it's like G-Ps i mean i was appalled yesterday at the crap i heard on the radio <pause dur="0.3"/> about <pause dur="0.2"/> G-Ps not wanting to take responsibility <pause dur="0.4"/> why do they become doctors that's what <pause dur="0.2"/> medicine's about taking <trunc>re</trunc> biscuits <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> taking responsibility <pause dur="0.4"/> and # <pause dur="0.2"/> i almost rang up a few of my mates who are G-Ps and gave them some of my mind <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> but # i knew that would have no effect 'cause they they hate doing on call <pause dur="0.5"/> # <pause dur="0.3"/> if you don't like doing on call then don't be a doctor you know get out of the kitchen <pause dur="0.5"/> and # <pause dur="0.4"/> you know go and do something else go back and do microbiology at Liverpool or you know just don't be a doctor

<vocal desc="laughter" iterated="y" n="ss" dur="2"/> if you don't like doing on call or or you're not willing to do on call <pause dur="0.7"/> that's my opinion <pause dur="0.7"/> harsh i know <pause dur="0.5"/> # <pause dur="1.0"/> okay so radiologists yeah they they <pause dur="0.2"/> they're nine to five people they're not you know they're nine to five Monday to Friday people <pause dur="0.4"/> actually i i'm maligning the <gap reason="name" extent="1 word"/> radiologists ours ours are quite good they're actually quite easy to get scans but they'll always say <shift feature="voice" new="whisp"/>oh can't i do it <unclear>in the morning</unclear><shift feature="voice" new="normal"/> <pause dur="0.6"/> no <pause dur="0.2"/> you can't do it in the morning <pause dur="1.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> one night i think i got four consultants in the hospital after midnight <pause dur="0.7"/> absolutely hated me in the morning <pause dur="0.5"/> i was completely wrong as well on on my diagnosis <pause dur="1.1"/> <vocal desc="laughter" iterated="y" n="ss" dur="4"/> # <pause dur="2.1"/> and there was a lot of lot of mumbling and swearing <trunc>un</trunc> under the breath going on about me that that night but # <pause dur="0.3"/> you know sometimes i get consultants in the hospital after midnight and i'm right

and and then <pause dur="0.3"/> that's that's okay <pause dur="0.6"/> so if you're on call you're paid to be on call <pause dur="0.4"/> and you come in if you're asked <pause dur="0.8"/> it doesn't stand up in court <pause dur="0.6"/> # <pause dur="0.3"/> not coming in <pause dur="0.3"/> you can come in and moan you can come in and swear you can come in and malign <pause dur="0.5"/> # my parentage <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> you can say what you like <pause dur="0.3"/> but you have to come in <pause dur="0.2"/> it does not stand up in court saying <pause dur="0.2"/> oh well i gave some advice on the phone and yes Dr <gap reason="name" extent="1 word"/> asked me to come in but i didn't think it was important and anyway i was watching # <trunc>y</trunc> you know <unclear>and oh</unclear> <pause dur="0.4"/> oh it's one minute past midnight <pause dur="0.2"/> doesn't stand up in court <pause dur="0.2"/> if you're on call <pause dur="0.3"/> you're asked to come in you come in there is no <pause dur="0.3"/> there's no middle there's no grey area you come in <pause dur="0.6"/> # <pause dur="0.3"/> it's completely indefensible <vocal desc="clears throat" iterated="n"/><pause dur="1.5"/> one night actually a slight aside # <pause dur="0.3"/> i <pause dur="0.3"/> i was a locum <pause dur="0.9"/> locum renal S-H-O in Portsmouth and i was on without a registrar it was a it was a D-G-H type <pause dur="0.2"/> renal unit <pause dur="0.5"/> do you know what i

mean by a D-G-H district general hospital </u><u who="sm0565" trans="overlap"> district general hospital </u><u who="nm0504" trans="overlap"> it's a non-teaching hospital <pause dur="0.5"/> and i was on with the professor <pause dur="0.2"/> who was # a well known # <pause dur="0.5"/> # extrovert <pause dur="0.5"/> a bit cravat-positive and <vocal desc="laughter" iterated="y" n="sl" dur="1"/><vocal desc="laughter" iterated="y" n="ss" dur="4"/><pause dur="0.5"/> # <pause dur="0.9"/> he <pause dur="0.3"/> i i'd never ever put a # # a peritoneal dialysis catheter into anybody <pause dur="0.3"/> and a patient came in <pause dur="0.2"/> very sick with acute renal failure over <gap reason="inaudible" extent="1 sec"/> the full monty <pause dur="0.6"/> and i rang him and he said <shift feature="voice" new="mimicking an other's voice"/> oh <gap reason="name" extent="1 word"/> # just pop a catheter in <shift feature="voice" new="normal"/><pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and i said but i've never done one sir <pause dur="0.3"/> actually we did use to call the bosses sir in the bad old days <pause dur="0.5"/> and # <pause dur="0.8"/> he said <shift feature="voice" new="mimicking an other's voice"/> oh get the nurses to talk talk you through it <shift feature="voice" new="normal"/> <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and i say <pause dur="0.4"/> well i i really don't think that's a good idea sir you know i think i think you'd better come in and supervise he said

<shift feature="voice" new="mimicking an other's voice"/> oh all right all right then<shift feature="voice" new="normal"/> <pause dur="0.6"/> and he just sort of had another port and came in <vocal desc="laughter" iterated="y" n="ss" dur="3"/> pissed out of his head <pause dur="0.8"/> # and i remember # to this day it was way past midnight <pause dur="0.2"/> and # i remember pushing him out of the way 'cause you could smell the port <vocal desc="laughter" iterated="y" n="ss" dur="1"/> <pause dur="0.3"/> you didn't have to see it <pause dur="0.6"/> and he talked me through it <pause dur="0.6"/> and <pause dur="0.6"/> the patient survived <pause dur="1.5"/> # he's <vocal desc="laugh" iterated="n"/> <shift feature="voice" new="laugh"/>now <shift feature="voice" new="normal"/>retired the great Professor <gap reason="name" extent="1 word"/> <pause dur="0.3"/> # in Portsmouth <pause dur="0.5"/> # <pause dur="2.0"/><vocal desc="laugh" iterated="n"/> <pause dur="0.7"/> forgot what i'm talking about now anyway # <vocal desc="laughter" iterated="y" n="ss" dur="1"/> distinguishing <pause dur="0.2"/> # <pause dur="0.8"/> prerenal <pause dur="0.4"/> and established <kinesic desc="writes on board" iterated="y" dur="9"/> renal failure <pause dur="0.6"/> # <pause dur="3.2"/> or distinguishing <pause dur="1.0"/> # what some people call a <trunc>tu</trunc> <pause dur="0.3"/> tubular <trunc>nec</trunc> necrosis <pause dur="0.3"/> why <pause dur="1.3"/> what is this <pause dur="0.3"/> syndrome of established renal failure stroke A-T-N stroke <unclear>A-T-D</unclear> <pause dur="0.6"/> what is it <pause dur="0.5"/> let's <pause dur="0.5"/> anyone like to have a stab at it <pause dur="1.4"/> and i want <pause dur="0.2"/> a full-blown

teleological evolutionary argument involving life the universe and <trunc>ev</trunc> <pause dur="0.2"/> and everything in the last ten minutes of this talk <pause dur="3.1"/> who's going to have a go <pause dur="2.4"/> come on <pause dur="0.3"/> doesn't matter if you get it wrong <pause dur="2.1"/><kinesic desc="indicates member of audience" iterated="n"/> lady in red there <pause dur="0.5"/> no <pause dur="0.3"/> not brave enough <pause dur="0.2"/> no i wouldn't be either <pause dur="0.9"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="0.2"/> there is a phenomenon <pause dur="0.4"/> there is a syndrome of established renal failure stroke A-T-D stroke A-T-N <pause dur="0.6"/> which does exist <pause dur="1.0"/> and <pause dur="0.4"/> there may be an evolutionary basis to it <pause dur="0.5"/> # <pause dur="0.4"/> what happens if you go into kidney failure whatever cause <pause dur="0.2"/> usually prerenal failure <pause dur="0.2"/> for a while you don't reverse the prerenal failure <pause dur="0.3"/> and the kidneys shut up shop <pause dur="1.2"/> so why might there be an evolutionary advantage to the kidney shutting up shop <pause dur="1.9"/> lady in red you can answer that <pause dur="1.6"/> why might it be a good idea <pause dur="0.8"/> for you to be able to <pause dur="0.3"/> stop your <pause dur="0.3"/> nodes working your kidneys working <pause dur="0.6"/> your heart working obviously it's not a good idea to stop your heart working <vocal desc="laughter" iterated="y" n="ss" dur="1"/> but why might it be a good idea to stop your

kidneys from working </u><pause dur="0.2"/> <u who="sf0566" trans="pause"> it might be # taking away from <pause dur="0.3"/> <unclear>else</unclear> <pause dur="1.5"/> kind of </u><pause dur="1.6"/> <u who="nm0504" trans="pause"> # lady on your on your right in the <pause dur="0.6"/> cream </u><u who="sf0567" trans="overlap"> to give your kidneys a bit of a rest </u><pause dur="0.5"/> <u who="nm0504" trans="pause"> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> yeah give them a rest very good give the kidneys a rest okay <pause dur="0.3"/> and and when <pause dur="0.2"/> # you're cornered <pause dur="0.4"/> you're in the cave you've been gored by a sabre-toothed tiger you're bleeding to death <pause dur="0.7"/> it's about to move in for the kill you're hiding behind that rock <pause dur="0.6"/> you're entering prerenal failure it may be a good idea to hang low for a while <pause dur="0.6"/> and <pause dur="0.3"/> for your kidneys to turn themselves off and that's exactly what established renal failure is <pause dur="0.3"/> an A-T-N A-T-D <pause dur="0.4"/> the kidneys have an ability to turn themselves off <pause dur="0.4"/> ten to fourteen days on average twelve-point-seven <pause dur="0.6"/> completely meaningless number <trunc>y</trunc> <pause dur="0.5"/> patient has asked you how long am i going be in kidney failure for i say twelve-point-seven days sir <pause dur="0.4"/> and <pause dur="0.2"/> i don't really <pause dur="0.3"/> no i usually say a week or two <pause dur="0.3"/> # <pause dur="0.7"/> the kidneys have an ability to

turn themselves off <pause dur="0.6"/> we don't understand it <pause dur="0.2"/> there may be an advantage to it or there may be a <pause dur="0.2"/> an advantage to it once in other words it's now maladaptation <pause dur="0.2"/> to the modern environment and therefore evolution eventually in a couple of hundred years' time or <pause dur="0.3"/> a thousand years' time will take it out of the out of <pause dur="0.5"/> out of the human being and perhaps all mammals <pause dur="0.6"/> # there are some clear advantages in being able to turn your kidneys off <pause dur="0.2"/> when i say turn them off <pause dur="0.3"/> they really go into a sort of <kinesic desc="writes on board" iterated="y" dur="6"/> recycled phase <pause dur="0.3"/> so <pause dur="0.2"/> the blood goes down the tube <pause dur="0.2"/> it meets the sieve and says no way Jose and comes back again so you don't <pause dur="0.3"/> you may make some urine you don't make much urine and and usually oliguria is a feature of established renal failure but not always <pause dur="0.4"/> well it's it's a feature initially <pause dur="1.6"/> # <pause dur="0.6"/> but <pause dur="1.0"/> the kidneys <pause dur="0.2"/> send the blood back if you like <pause dur="0.8"/> and you become oliguric <pause dur="0.8"/> if you stay <pause dur="0.3"/> in oliguric acute renal failure and you keep drinking what's going to

happen <pause dur="0.5"/> lady in the grey <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> there </u><pause dur="1.2"/> <u who="sf0568" trans="pause"> you're taking in the volume you're not getting rid of it so </u><u who="nm0504" trans="overlap"> yeah so what's going to happen to you clinically </u><u who="sf0568" trans="overlap"> you go into volume <pause dur="0.3"/> overload </u><u who="nm0504" trans="latching"> yeah you can volume overload exactly <pause dur="0.7"/> # so <pause dur="0.2"/> there is a phase in this cycle where you go from <kinesic desc="writes on board" iterated="y" dur="4"/> dry <pause dur="0.3"/> to in the middle <pause dur="0.3"/> to wet <pause dur="1.3"/> and what we try to do <pause dur="0.2"/> in nephrology <pause dur="0.5"/> is to spot this <kinesic desc="indicates point on board" iterated="n"/> transition point <pause dur="0.7"/> and hopefully stop them becoming wet but if they do become wet <pause dur="0.4"/><kinesic desc="writes on board" iterated="y" dur="2"/> we get rid of it with dialysis or diuretics or whatever <pause dur="1.5"/> and that <pause dur="0.5"/> is simply what established renal failure A-T-N A-T-D is and <pause dur="0.5"/> why the kidneys turn off and why they start up <trunc>u</trunc> up again we don't know what are what are the stimuli <pause dur="0.3"/> find it out <pause dur="0.5"/> become famous <pause dur="0.9"/> # <pause dur="0.2"/> it's a very very interesting phenomenon the the the

concept of established renal failure <pause dur="1.1"/> distinguishing it from prerenal is extremely difficult <pause dur="0.2"/> and i've listed there or a table i just took it out of a book <pause dur="0.2"/> it's in all your books <pause dur="0.5"/> you can measure the urinary osmolarity and the blood osmolarity and all it's all rubbish we don't do that <pause dur="0.5"/> # <pause dur="1.2"/> urinary sodium if you're going to <pause dur="0.2"/> pick a urinary test and there may be a question about this in one of your exams so <pause dur="0.3"/> it's the type of table you do need to to know <pause dur="0.4"/> # <pause dur="0.2"/> the urinary sodium is relatively useful i cannot think the last time i measured the urinary sodium <pause dur="1.1"/> why does a urinary sodium # go up in established renal failure well in prerenal failure <pause dur="0.3"/> the kidney's still trying to work and if you're still trying to reabsorb sodium <pause dur="0.5"/> and so the sodium levels <pause dur="0.2"/> in the urine stay down as soon as they start going up it means you have established renal failure it's all rubbish <pause dur="1.0"/> you know it's <pause dur="0.2"/> # <pause dur="0.3"/> and it's all messed up by a patient always on diuretics which increase <pause dur="0.3"/> # sodium losses anyway # it's almost

impossible to interpret a urinary sodium <pause dur="1.5"/> # i visited # a unit in in New York once drop that in the conversation <pause dur="0.4"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> and # <pause dur="0.4"/> and they start at <pause dur="0.7"/> six-thirty <pause dur="0.2"/> i mean <pause dur="0.4"/> their lectures start at seven <pause dur="0.2"/> <unclear>i mean</unclear> <pause dur="0.4"/> my God if you ask a British medical student to appear at seven <pause dur="0.4"/> why i sincerely hope you wouldn't turn up <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and i remember sitting through this like terrible lecture on urinary osmolarity and sodium at seven o'clock in the morning i <pause dur="0.3"/> i thought this this is this is just hell <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and the only thing that kept me going was that knowledge you had pizza at eight <pause dur="0.7"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> doughnuts at nine <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> eat all day long <pause dur="1.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> with <pause dur="0.4"/> and also on on on the I-T-U trolley <pause dur="0.6"/> i'll never forget this they had cans for your Coke <pause dur="1.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> <shift feature="voice" new="laugh"/>and everybody arrived with <shift feature="voice" new="normal"/><pause dur="0.5"/> your Coke and your Diet Coke Sprite Diet Sprite

and put them in the trolley <pause dur="0.5"/> that was the only bit i liked about it <pause dur="0.4"/> # <pause dur="1.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay <pause dur="0.4"/> treatment # <pause dur="0.6"/> i <pause dur="1.8"/> i know the <shift feature="voice" new="laugh"/>second half <shift feature="voice" new="normal"/>of this talk is meant to be about treatment and # <pause dur="0.5"/> partly because we've only got five minutes to go <pause dur="0.3"/> and and partly <pause dur="0.3"/> # <pause dur="0.3"/> i don't think it's nearly as important <pause dur="0.5"/> as what i've talked about so far <pause dur="0.4"/> i'm not going to go into it in any massive detail <pause dur="0.4"/> other than to say <pause dur="0.2"/> the key decision <pause dur="0.3"/> is the <kinesic desc="writes on board" iterated="y" dur="3"/> D decision <pause dur="0.7"/> in other words <pause dur="0.5"/> do they need dialysis or don't they <pause dur="0.7"/> and that's a decision that i make on a daily basis <pause dur="0.6"/> and it's not that complicated <pause dur="0.5"/> # <pause dur="0.4"/> the books will list hundreds of indications for dialysis there are only two remember i said <trunc>ear</trunc> earlier on in the lecture <pause dur="0.4"/> there are only two important clinical features <pause dur="0.2"/> hyperkalaemia <pause dur="0.2"/> and <unclear>fluid</unclear> overload <unclear><trunc>i</trunc></unclear> <pause dur="0.7"/> and the <pause dur="0.2"/> only indications or absolute indications for dialysis are hyperkalaemia unresponsive to medical management <pause dur="0.5"/> and <pause dur="0.4"/> fluid

overload unresponsive to medical management yeah i've listed a few others there <pause dur="0.3"/> two-A i've written down as acidosis <pause dur="1.3"/> so having said that sometimes we do dialyse people for rather obscure reasons particularly on an I-T-U <pause dur="0.3"/> if on an I-T-U <pause dur="0.2"/> situation somebody's got a creatinine of two-hundred <pause dur="0.2"/> a urine output of <pause dur="0.2"/> forty mls a minute <pause dur="0.9"/> they're going into renal failure <pause dur="0.2"/> but they don't really need dialysis but we know tomorrow we may want to give them a lot of fluid for some reason <pause dur="0.3"/> or we may want to give them an angiogram <pause dur="0.3"/> which is nephrotoxic <pause dur="0.3"/> or tomorrow we may want to give them T-P-N or N-G-P <pause dur="0.3"/> we may dialyse people for rather odd reasons but but <pause dur="0.4"/> most of the time they are the only two absolute reasons for dialysis <pause dur="0.8"/> i don't think it's necessary that <pause dur="0.2"/> you <pause dur="0.3"/> # <pause dur="0.6"/> go into how we dialyse in any great detail <pause dur="0.3"/> # <pause dur="0.2"/> just <pause dur="0.4"/> it's much more important you understand the physiology and the pathophysiology <pause dur="0.3"/> and the indications for dialysis <pause dur="0.5"/> the technicalities you'll learn later you put a

tube in the neck you attach them to a whirly <pause dur="0.2"/> it isn't much more complicated than that <pause dur="1.3"/> # <pause dur="1.6"/> finally finally <pause dur="0.2"/> # <pause dur="0.3"/> who should be managing people with renal failure i've said that <pause dur="0.6"/> twenty thirty per cent of people coming into hospital have a raised creatinine <pause dur="0.7"/> and there must be <pause dur="0.8"/> between fifty and a hundred people coming to the <gap reason="name" extent="1 word"/> every day <pause dur="0.3"/> so a lot of them will have a raised creatinine can they all be referred to the renal team <pause dur="0.6"/> please no <pause dur="0.5"/> i hope not <pause dur="0.5"/> that's one of the points of this lecture that you're going to be managing people <pause dur="0.2"/> where when the cause of renal failure is obvious and when you can reverse it <pause dur="0.5"/> easily <pause dur="0.9"/> it's when it starts to get tricky you need to call the cavalry <pause dur="1.5"/> and <pause dur="0.3"/> fortunately # in <pause dur="0.4"/> <gap reason="name" extent="1 word"/> and <gap reason="name" extent="1 word"/> we have a reasonable cavalry i'm one of six nephrologists and there's one that's on every day of the year including Christmas Day including New Year's Day <pause dur="0.7"/> and <pause dur="0.4"/> # <pause dur="0.8"/> if you're having problems call there's no point in <trunc>tr</trunc> being a hero you get

no medals for being a hero in medicine <pause dur="0.4"/> just because you can manage <pause dur="0.2"/> a case of Wegener's granulomatosis on your own as a house officer <pause dur="0.2"/> out in <gap reason="name" extent="1 word"/> <pause dur="0.8"/> it doesn't mean you should <pause dur="0.5"/> and i think if you have anybody with any major body system failure and you can't reverse it quickly <pause dur="0.2"/> you can't identify the cause quickly you should be seeking help <pause dur="0.2"/> and if you're in a hospital without a renal unit such as <gap reason="name" extent="1 word"/> <pause dur="0.3"/> Nuneaton et cetera <pause dur="0.2"/> you need to be <pause dur="0.2"/> ringing the <gap reason="name" extent="1 word"/> <pause dur="0.2"/> and asking for advice from a renal registrar or renal consultant <pause dur="0.6"/> and that's true of of <trunc>a</trunc> any <pause dur="0.3"/> major body system failure <pause dur="1.4"/> okay <pause dur="0.7"/> that's it <pause dur="0.5"/> questions <pause dur="1.8"/> <gap reason="inaudible" extent="1 sec"/> <pause dur="3.5"/> not too many <trunc>anec</trunc> anecdotes <pause dur="0.4"/> and only one bollocks <pause dur="0.2"/> sorry </u><pause dur="1.8"/> <u who="nf0569" trans="pause"> can i just say anybody here who hasn't signed the register can you do so <pause dur="2.9"/> i don't know whether they are either they must be somewhere </u><pause dur="2.3"/> <u who="nm0504" trans="pause">

what happens # <pause dur="0.4"/> <unclear>by the way</unclear> what happens if you if you <pause dur="1.0"/> don't <pause dur="0.6"/> appear if you don't sign the register </u><pause dur="0.3"/> <u who="nf0569" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><pause dur="0.4"/> <u who="sf0570" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><pause dur="1.2"/> <u who="nm0504" trans="pause"> <gap reason="name" extent="1 word"/> can fail you <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.9"/> <u who="nf0569" trans="pause"> <gap reason="inaudible" extent="1 sec"/> last year </u><pause dur="1.7"/> <u who="nm0504" trans="pause"> did you fail any last year </u><u who="nf0569" trans="overlap"> just to let you know it was very close last year there were about <pause dur="0.4"/> four people who nearly failed the urinary </u><pause dur="0.4"/> <u who="nm0504" trans="pause"> on attendance </u><pause dur="0.4"/> <u who="nf0569" trans="pause"> on attendance yeah </u><pause dur="0.3"/> <u who="nm0504" trans="pause"> excellent <pause dur="1.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay any any questions on on acute renal failure </u><u who="nf0569" trans="overlap"> whether you agree with it or not is irrelevant it's