Q&A on Gout, CKD & Malnutrition

Summary

In this informative lecture, doctors discuss the interconnection of gout, chronic kidney disease, and malnutrition, emphasizing the importance of diet and lifestyle modifications in managing these conditions. They provide specific dietary recommendations for Filipino patients, including avoiding organ meats and high-fructose drinks, and highlight personalized approaches to gout triggers. The role of biomarkers in screening high-risk patients for CKD is explored, along with strategies to prevent its progression. The conversation also touches on the challenges of malnutrition in the elderly and the use of anti-inflammatory ingredients in cancer treatment.

Takeaways

• 👨‍⚕️ The discussion emphasizes the interconnectedness of gout, chronic kidney disease (CKD), and malnutrition, highlighting the importance of a holistic approach to treatment.
• 🍽️ Dietary recommendations for Filipino patients with gout should include avoiding organ meats and high-fructose corn syrup drinks, as well as reducing salt intake from preserved and canned foods.
• 🌱 The challenge of finding organic foods in the Filipino context is acknowledged, and the importance of patient education on diet is stressed to prevent malnutrition.
• 🧬 Personalized dietary approaches are crucial for managing gout triggers, as individual patients may have specific food sensitivities that can exacerbate their condition.
• 💊 The role of medication in managing uric acid levels is discussed, with an emphasis on the need for careful monitoring and adjustment of dosages to prevent complications like Stevens-Johnson Syndrome (SJS).
• 🧬 Biomarkers for CKD screening are identified as potentially useful for high-risk populations, such as the elderly and those with hypertension or diabetes, but their widespread use and availability are still developing.
• 📝 The Malnutrition Screening Tool (MST) is recommended for outpatient and community settings, with an emphasis on BMI, weight loss, and changes in food intake as key indicators.
• 💊 The necessity of addressing micronutrient deficiencies in the elderly through tailored supplementation, rather than a one-size-fits-all approach, is highlighted.
• 🏥 The role of critical care physicians in managing ICU patients' nutrition is recognized, with referrals to nutrition management services reserved for more complex cases.
• 🛑 The management of asymptomatic hyperuricemia involves close monitoring and patient education to prevent progression to more severe conditions like CKD.
• 🧘‍♂️ Lifestyle modifications, including stress reduction and dietary changes, are as important as medication management in controlling conditions like gout and CKD.

Q & A

What are the intertwined health issues discussed in the lecture?

The lecture discusses gout, chronic kidney disease (CKD), and malnutrition, highlighting how these conditions are interconnected.

What dietary recommendations are suggested for Filipino patients with gout?

Filipino patients with gout should avoid organ meats, high fructose corn syrup drinks, and preserved foods high in salt. A personalized approach to dietary triggers is also recommended.

Why is it difficult to find organic foods in the Philippines as mentioned in the lecture?

The lecture suggests that due to economic and availability reasons, it is often hard for Filipinos to access organic foods, especially for those on a strict diet.

How does the speaker address the risk of malnutrition among patients, especially in the context of strict diets?

The speaker acknowledges the risk of malnutrition due to strict diets and emphasizes the importance of providing adequate nutrition and managing comorbidities like diabetes and hypertension.

What is the impact of stress on the body's metabolism according to the lecture?

The lecture suggests that stress can induce hyperuricemia because the body needs to metabolize stress hormones, and if it cannot do so effectively, it can lead to problems.

What is the role of biomarkers in screening for CKD among high-risk patients?

Biomarkers can play a role in identifying patients at high risk for CKD, such as those with hypertension or diabetes, and may be used for screening in the future.

How soon might the discussed biomarkers become commercially available for clinical use?

While some biomarkers like urinary NGAL are already in use, others like beta trace protein and beta-2 microglobulin may become available in a few months to a year.

What is the recommended method to assess malnutrition in outpatients according to the lecture?

The lecture recommends using the Malnutrition Screening Tool (MST) which involves asking three questions and checking BMI, with a target BMI of 22 for elderly patients.

Why might elderly patients be advised against taking vitamin B complex without proper guidance?

Elderly patients may not consume a balanced diet, increasing the risk of micronutrient deficiencies. However, it's suggested to check vitamin levels first and provide therapeutic doses if a deficiency is suspected.

How should doctors approach the management of asymptomatic hyperuricemia to prevent adverse effects?

Doctors should focus on close monitoring and follow-up, establishing a good relationship with patients to ensure the message about the importance of managing hyperuricemia is effectively communicated.

What is the significance of the four pillars approach in managing gout according to the lecture?

The four pillars approach includes considering medication, lifestyle modifications, identifying personalized triggers, and ensuring adequate nutrition, all of which are essential in managing gout effectively.

Outlines

00:00

🍽️ Dietary Management for Chronic Conditions

The first paragraph discusses the interconnection between gout, chronic kidney disease, and malnutrition, emphasizing the importance of dietary recommendations for managing these conditions effectively. It highlights the need to avoid organ meats and high-fructose corn syrup drinks, especially in the Filipino population. The speaker also touches on the challenges of finding organic foods and the risk of iatrogenic malnutrition in geriatric patients. Personalized dietary approaches are suggested due to individual triggers for gout, and the role of lifestyle modifications in managing these conditions is acknowledged.

05:01

🧪 Biomarker Availability and Nutritional Screening

The second paragraph delves into the topic of biomarkers for screening patients at high risk for chronic kidney disease (CKD), such as hypertensive and diabetic patients, as well as the elderly. It discusses the current unavailability of certain biomarkers for commercial use and speculates on when they might become available. The conversation also shifts to the use of the Malnutrition Screening Tool (MST) for outpatients, emphasizing the importance of BMI checks, weight loss monitoring, and changes in food intake as indicators of malnutrition.

10:02

💊 Vitamin Supplementation and Gout Treatment

The third paragraph addresses the use of vitamin B complex supplementation in the elderly, noting that while a balanced diet may negate the need for multivitamins in adults, the elderly may benefit due to potential micronutrient deficiencies. It also discusses the management of gout in elderly patients, including the cautious initiation of allopurinol to prevent severe cutaneous adverse reactions (SCARs) and the personalized approach to treatment, including the adjustment of medication dosages based on uric acid levels.

15:04

🛑 Strategies to Prevent CKD Progression

In the fourth paragraph, the focus is on strategies to slow or prevent the progression of chronic kidney disease. The role of diet, particularly low-protein diets, is underscored, along with the importance of managing comorbidities like hypertension and diabetes. The paragraph also highlights the significance of identifying and addressing underlying causes of CKD, such as stress, inflammation, and environmental toxins, and the necessity of a holistic approach to patient care, including lifestyle modifications.

20:07

🏥 ICU Nutrition Management and Anti-Inflammatory Therapies

The fifth paragraph discusses the selective referral of ICU patients to nutrition management services, noting that not all ICU patients require such referrals due to the expertise of critical care medicine physicians in managing nutrition. It also touches on anti-inflammatory ingredients for cancer patients, with a focus on the role of Omega-3 fatty acids and the shift in understanding from an anti-inflammatory to a pro-resolving inflammation perspective. The paragraph concludes with a brief mention of the management of asymptomatic hyperuricemia in OBD patients, emphasizing the importance of close monitoring and patient education.

Keywords

💡Gout

Gout is a form of inflammatory arthritis characterized by sudden, severe attacks of joint pain, swelling, redness, and tenderness, caused by the accumulation of uric acid crystals in the joints. In the video, gout is discussed as a common condition in geriatric patients, with a focus on dietary recommendations and personalized triggers for flare-ups.

💡Chronic Kidney Disease (CKD)

Chronic Kidney Disease is a progressive condition that damages the kidneys' ability to filter waste and excess fluids from the bloodstream. The script discusses the interconnectedness of CKD with gout and malnutrition, highlighting the importance of managing comorbidities and the potential use of biomarkers for screening high-risk patients.

💡Malnutrition

Malnutrition refers to an imbalance in the body's intake of nutrients, which can lead to health problems. The video emphasizes the risk of malnutrition in geriatric patients, especially in relation to restrictive diets and the importance of personalized dietary recommendations to prevent it.

💡Dietary Recommendations

The video script provides specific dietary recommendations for managing conditions like gout and CKD, such as avoiding organ meats and high-fructose corn syrup drinks, and the importance of a balanced diet tailored to individual needs.

💡Filipino Population

The term 'Filipino population' is used in the context of cultural dietary habits and the challenges of providing specific dietary advice within this demographic. The script notes the particular preferences of Filipinos for certain foods and the need for careful guidance on dietary changes.

💡Organic Foods

Organic foods are those produced without the use of synthetic chemicals, genetically modified organisms, or ionizing radiation. The script mentions the difficulty of finding organic foods in the Filipino context and the potential implications for patients' diets.

💡Biomarkers

Biomarkers are measurable substances in the body that can indicate normal or disease processes. The video discusses the potential future use of biomarkers for screening and diagnosis in high-risk populations, such as those with hypertension or diabetes.

💡Malnutrition Screening Tools (MST)

MST refers to tools or methods used to identify individuals at risk of malnutrition. The script mentions the use of a simple MST involving BMI checks and questions about weight loss and food intake to assess outpatients for malnutrition risks.

💡Vitamin B Complex

Vitamin B complex includes a group of eight vitamins that play crucial roles in energy production and cellular metabolism. The video discusses the consideration of vitamin B complex supplementation for elderly patients who may not be consuming a balanced diet and the importance of addressing specific micronutrient deficiencies.

💡Febuxostat

Febuxostat is a medication used to treat gout by lowering uric acid levels in the blood. The script discusses the use of febuxostat as a first-line treatment and the considerations for starting this medication in patients with gout, including the risk of severe skin reactions.

💡Keto Analogues

Keto analogues are compounds that resemble ketones in structure but are not derived from ketosis. The video mentions keto analogues in the context of CKD treatment, emphasizing their role in conjunction with a low-protein diet to manage the disease's progression.

Highlights

The interconnection between gout, chronic kidney disease, and malnutrition and their common occurrence in geriatric patients.

The importance of dietary management in Filipino patients with gout, emphasizing the need to avoid organ meats and high-fructose corn syrup drinks.

Challenges in providing organic food options and the risk of malnutrition in the elderly due to strict diets.

Personalized dietary approaches for gout patients, acknowledging individual triggers and tolerances.

The role of lifestyle modifications, including exercise and stress reduction, in managing chronic conditions.

The impact of only 20% of uric acid being absorbed from diet, highlighting the significance of other factors.

The potential of biomarkers in screening for chronic kidney disease, especially in high-risk populations.

The current and future availability of biomarkers like urinary NGAL for clinical use.

The use of the Malnutrition Screening Tool (MST) for assessing malnutrition in outpatient and community settings.

The significance of BMI thresholds in elderly patients and the risk of sarcopenia.

The debate over the necessity of vitamin B complex supplementation for the elderly and the importance of micronutrient balance.

The cautious approach to medication dosages in elderly patients, especially with allopurinol and the risk of Stevens-Johnson Syndrome (SJS).

Strategies for managing gout flares and the importance of addressing the underlying cause of the flare.

The role of diet in slowing the progression of chronic kidney disease and the management of comorbidities.

The potential of keto analogues and low-protein diets in managing chronic kidney disease.

The importance of a holistic approach to patient care, including diet, lifestyle, and environmental factors.

The considerations for blanket referral of ICU patients to nutrition management services and the role of critical care physicians in nutrition.

The use of Omega-3 fatty acids as anti-inflammatory agents and their role in resolving inflammation in certain conditions.

The management of asymptomatic hyperuricemia to prevent adverse effects and the importance of patient education and follow-up.

The adjustment of medication dosages based on uric acid levels and the use of allopurinol as a tool for managing uric acid load.

Transcripts

thank you doctors

for your very informative lecture about gaute

chronic kidney disease and malnutation

which are all intertwined

and being a geriatic specialist myself

I see all these problems with my patients

so for the first question

um Doctor Aldo what specific dietary recommendation

should be provided to patients with doubt

to help manage their condition effectively

especially among the Filipino population

yes now you have to remember when it comes to diet

well Filipinos are very particular with that

so you have to be careful when you tell them okay

but definitely

there are certain things that you need to be avoiding

you need to avoid the organ meats

you need to avoid high fructose corn syrup drinks

so don't pull up a socky my soft drinks

don't pull up a socky and don't pull up a socky

and iced tea

you my sweet and drinks you want to stay away from

you want to stay away from preserved foods

such as those that are canned

because those are high in salt

and when it comes to the Filipino

you have to remember that a lot of times

it's very hard to find all of these organic foods

because a lot of people a lot of time people say

you have to be loose also with them deeper care

patient has a patient has got when they're admitted

you will see right away loop you're in diet

but admit you should also give

you should also give them nutrition and and you you uh

we are actually under uh

risk of of of giving them malnutration

yes and

and when it comes to

when it comes to gout triggers for me uh

the more patience I see

the more I tend to believe that

when it comes to triggers

it's really more of a personalized approach to it

everybody has personalized triggers

meaning although there is a list of meat

food that you have to avoid

food that you can eat such as when it comes to girl

you can eat vegetables you can eat beans

some people will swear

it

so therefore

even if it's part of the guidelines to play there

because they got a trigger from that

then that's what they will be avoiding

so in the end it's really about

making sure they get enough nutrition

you make sure that you manage their comorbidities

high blood so that's the dash diet diabetes

so that's taking a look at their sugar intake

and then

you make sure that they do not get malnourished

may I okay okay

so um you know

we have to recognize that 20% of the uric acid is

is all absorbing the diet only

so it is really it has an impact

especially for taking a lot

but you're talking about

you did mention how inflammation

so it's not just the hyperin diet

but the inflammation that you had mentioned also

and so other forms uh

you know stress stress can

probably also induce hyper acemia

because your body needs to metabolize at the bar

so it's your body needs to

if you're not able to metabolize that

then you have a problem so I think beyond nutrition

and we have to also go lifestyle modifications

which was in his first um pillar

I listened okay

and so the first pillar is lifestyle

and it's not just diet we talk about exercise

we talk about decreasing stress game

and so I return the mic to you

thank you thank you for those answers doctor

but I agree sometimes malnutrition is ietrogenic

especially in the geriatic population

so we better be careful

while we advocate for the specific dietary requirements

for specific diseases

just be more lenient with the geriatic population

because they tend to No. 1

trust us with all their guts

and really no salt diet

alleged on that was hyponed by the things CEO

or very strict with foods

especially if they have CTD

diabetes um hypertension

and then they don't have options for food anymore

and then we ask ourself bucket malnourish

hit that I bucket show my bed

so I guess I linen by Lynette and okay

for Doctor Emil

will these biomic biomarkers be used for screening

example for patients with hypertension

with normal kidney function

or to support clinical clues on diagnosis

um how can you predict the use of these biomarkers

in the future I think um

the use uh the role of

of these biomarkers will really be in

patients were at high risk for CKD

so that includes hypertensive patients

diabetes patients elderly

yeah so uh

I think yes it uh

it will have a role in screening for CKD

maybe in the future for the high risk population

not for everyone like young patients wanting to know

do I have a rest for CKD in the future

yeah I think it will be you know too costly especially

especially

so that they are not yet commercially available

unfollow up DOC when do you think this

biomarkers be commercially available

to us clinicians

for example when

at what year do you imagine Medical City offering this

um biomarkers for clinical use

but urinary ngal has been in use for some time before

no better not not it has not become popular already

no but I think maybe you during your time as a resident

we we used to use um

urinary N Gal for patients exposed to contrast

in anticipation of contrast induced nephropathy

for Aki

so urinary NGAL

I think is is already available in in the country

but as to the others

I heard among the different biomarkers

beta trace protein and beta to microglobuline um

is already will soon be available well abroad no

but me pretty soon you know

once they have it America in a few months

we'll probably have it too

thank you so much doctor for the 13 Reus

what would be the best scoring

system to assess malnutration in an outpatient basis

to use for our own clinics um

in the community as well

um for me actually I would probably use the MST okay

it actually ask three questions only

it's your BMI and it's classified BMI based to age okay

you know with cyclopedia happening in elderly

we cannot be satisfied with a BMI of uh 18.5 and above

you think oh 18.9 okay

PA pero if elderly we consider cyclopedia

you would think that the muscle is really small

so you know

muscle content wise in terms of body composition

that must be really low

so the BMI we target for elderly would actually be 22

and 22 less than 22 was elderly

17 above in the patio elderly okay

so so 17 above would be 22 uh

we would want to target 22 if less than 22

you can see you should be um

that's already a red flag okay

so the question was what's the best MST

the simplest or the for me the first half of the NR

s just three questions you have to ask yourself

for outside patient or community or outpatient

is there a BMI check out the BMI

I give you the cut off for elderly which is not uh 18.5

so check out the BMI

less than 20 is already a little bit of a red flag

also for other adult um

weight loss

weight loss is there weight loss in the past um

few months significant weight loss is definitely uh

2% in one week and 5% in uh

3% in one month and 5% in three months

so and then if there is actually uh

weight loss changes in food intake for the past week

okay so three questions if you have yes

in any of that you start one checking already

what are the underlying costs to this

different changes in terms of BMI

weight loss and poor oral intake

yes sir Doctor Devara

yes Doctor Else

I wanted to ask Pusana because when you go on TV

you will see a lot of ads telling people hey

go ahead

take vitamin B complex when it comes to the elderly

given that we want to treat specific new

microdeficiencies

would you say to these patients who are elderly no

you don't need to take vitamin B complex

well

normally we would always say for our adults we would

you know if you're eating a eating a balanced diet

you don't really need to eat to take multivitamins

but our elderly

may actually not be eating a balanced diet

which is a challenge and we

we showed you a direction of aging

that's definitely less variety

because there's less variety

high risk for micronutrient deficiencies

you would just recommend RDA

which is recommended daily allowance

you know which is fine

but note that if you are suspecting deficiency

you need to give therapeutic

values or therapeutic dosages

so that's why for for some of our patients

we actually will check the vitamin levels

vitamin B is quite expensive

you know so since there is really

you look for me a good marker to use

if you're suspecting B12 and folic acid

commonly seen in our elderly patient is homosexistine

which is cheaper

okay so home assistine is something cheaper

if it's high then you

you know that your patient is uh may have

may have it's not confirmatory

but it's uh may have folic acid in B12 deficiency

vitamin d is really not so expensive

so it's something that we can probably do

because supplementing with vitamin d has toxicity

unlike water soluble vitamins

so I would do a test so if you're giving RDA no issue

but if you wanna be able to really manage deficiency

you need to take the blood and give therapeutic doses

thank you doctor and lots of learning for me as well

for my own practice I'm Doctor Aldo

I'm connected young question goi um

I am so scared guess of SGS from all your perinol

especially for the elderly patients

is it okay if I prefer giving books

a stat as first line treatment for uric acid

and as an added added question

how do you proceed with gall treatment

after your patient experience

and adverse drug action at worse as 3

as to allupurinol

when do you start with the new medication

okay so that's a very good question

so just a reminder for all of the residents here

when you have gout

you think of the four pillars all the time okay

so when it come well

well with the first question

can you go straight to febuxa stat

yes that's something that rheumatologists do

and the reason for choosing the febuxa stat is

there are some patients who come in that

you know for a fact that this is

somebody's not gonna be coming back

so if they're not going to be coming back

you know they're gonna be taking the medication

it's gonna be dangerous to give them a medication

and then they will not come back

and then they get all of these problems

and that's the reason why that

that's the

that's one of the reasons why you have to start slow

and you go slow

because when you start the medication slow

then then you will not expect to see this uh you the

the risk for SGS intense will not be so high

and that's the reason why

when you have patients with CKD

you don't want to give high doses of alourinol

because the higher the allopurinol

in the patients with CKD

the higher the risk for the SGS

so yes so definitely when it comes to that

usually when you start when you have a patient with

who starts developing these symptoms

more often than not

these are patients who will also develop gout flares

because stress is one of the triggers of gout

that's why that's why you get referrals for patients

not kata puslang surgery

kakata Islamic heart attack

the gaut flair cellar so when you have SGS

only have tense more often than not

because somebody in the gaut Flair

and you want to be able to

you want to remove the offending agent

which is the aloepuranol treat the gaud flare

and then when the gaud flare is over

you can start

you can start giving the medication after 2 weeks

or after 4 weeks but first of all

you want to make sure that

that if the patient gets a reaction you

you want to make sure that it's

you want to make sure that

because with any medication

you can get the reaction a month

so you have to be careful

thank you for that though

um DOC Camille

what are the primary strategies

and interventions that can potentially slow

or prevent the progression of CKD

and how effective are they in your practice

but of course uh

we cannot over emphasize the the role of diet here

um there are there are many

um well

you've heard of keto analogues

and not all nephologists are

believers of the use of keto analogues

but if you if you um

listen closely to how keto analogues is being promoted

or being taught on its use

a big part of it is diet uh

it is a um very

a very low protein diet so overall

I think everything boils down to uh

referral to somebody like uh

doctorate in here on the strict uh

seek uh CKD diet management everyone and of course

um treatment and manage

advocate management of the control of comorbidities

hypertension diabetes or the underlying cost

but then it's management of the underlying cost of CKD

that will best slow down its progression

I I I think that was what I was gonna add

it's really identifying what's pushing your patient

there so if it's the high the comabaities

of course you can't do anything about aging right

but the comabaities

we would also consider against stress inflammation

external inflammation toxin

environmental toxin

that can actually be pushing your patients

you know

in a total inflammation that affects your kidney

so aside you know a lot of our patients are so yeah

focus on the diet it is a factor but you know what

even if you put down your diet

but you do all this other thing

you're still smoking you're still drinking

you're still you know not able to live a good life

a healthy life

that's really not going to slow it down enough

duct in sugar feral to the tree

be a blanket referral for all ICU patients

in your opinion

no because not all ICU

patients really need to be in the icy haha

because we do have patients that are just monitoring

right so you know so um um so they are at risk

we identify actually

I would say 90% of the patients in the ICU are um

blanket referral do you know what

are critical care medicine physicians know

how to manage nutrition

they are actually part of the nutrition team

so you ask why

when do they refer to nutrition management service

they refer patients who are more complicated

okay

well you know

when they can handle it themselves

they're equipped anyway

their critical care doctors are so good

bless the fellows they're

they've they've done their training

nutrition is included in their training

so they know how to manage it

but we do have those that need a little bit more focus

that we need a little bit more attention

and with that you may want to call nutrition um

management service

because you know that when they're there

there are different aspects of nutrition

will be managed or will be considered

also DOC

what are anti inflammatory ingredients

okay anti inflammatory ingredients for cancer patients

that's where you were talking about

that's actually they have approved Omega 3 fatty acids

so fish oil fish oil uh

it's uh anti inflammatory

you know what

the concept of anti inflammatory actually has changed

regarding fish oil

it's not anymore an anti inflammatory

it just helps resolve inflammation faster

the pro resolving

which is the active form of the fish oil

is what's going to really activate

so that's actually one thing to consider for flares

okay because it helps put down inflammation

resolve inflammation faster

and that's what that's one of the sample of anti

inflammatory ingredients that are considered

of course we have a concept of turmeric

and all these things that you may want to consider

but that's not someone with uh

that's admitted in the hospital

that someone who's outside maybe

thank you doctor and Doctor Aldo

for OBD patients with asymptomatic hyper eurosemia

how would you go about management

to prevent the adverse effects of hyper eurosemia

you have mentioned earlier um

like progression to CKD oral fibrillation

diabetes uncontrolled etcetera

how do we advise these people

close monitoring and follow up

essentially every time you see a patient

the first time you see them

you will establish a relationship

and if you have a good relationship with them

then you would be able to drive your message in

because whatever you do whatever you write

whatever you request

if the message doesn't get through to the patient

then it's all for nothing

another question

do I have patients who started the book to start

and their targets were achieved and then ask me

what about DOC if they are able to

for example I have patients who stopped taking them

for three months for a book to start

and then they were able to maintain

yeah now it's

it's a no it's that's that's a very good question

now you have to remember just like diabetes

just like blood pressure

doubt is no cure and the uric acid load is controlled

because you're taking medication

so the moment you stop the medication

little by little that load will go up

so you can talk to your patient

you can tell your patient okay

because of course you want to work with them the amount

whether you tell them no take it

you have to work with them so you tell them okay

you come back then we will resume it

but you have to make it clear that if you stop

the medicines will go back regarding

regarding the different dosages of the medication

we are so fortunate that there is alloperinole 100

alloperinole 300

you can go all the way to 800 by the way

and when it's we boost that we have 40

80 and you can actually bring the medication down

so from 80 you can go to 40

from 40 go to 20 so it's a minimal dosage

but at least you're controlling it

because when it starts

aside from the increase uric acid load

you will also have that Nidos

which is a source of inflammation

which can make all of the other comorbilities active

too

low uric acid levels but wait

let's stop because it's getting too low like 2 yes

less than three so so if it's less than 3 you

you you can you can back off your dosage

one of the things that is nice about alupuranol

for example

is that depending on the patient's uric acid load

a good way of

eyeballing how much dosage they would need is

for every 100 milligrams of alupuranol

it will bring down your uric acid by 1 milligram

per deciliator

so it gives you an idea oh okay

so the uric acid is 9 then you might

then you know that okay

eventually he will be on Aluperino 300

and then if you bring it down low

then you're already hitting metromobaba

then you can say okay

let's make it 100 mg instead

Salamat mga doktor

para sa iyong napaka-kaalaman na panayam tungkol sa gaute

talamak na sakit sa bato at malnutasyon

na lahat ay magkakaugnay

at pagiging isang geriatic specialist sa aking sarili

Nakikita ko ang lahat ng mga problemang ito sa aking mga pasyente

kaya para sa unang tanong

Um Doctor Aldo anong partikular na rekomendasyon sa pagkain

Dapat ibigay sa mga pasyente na may pagdududa

upang makatulong na pamahalaan ang kanilang kalagayan nang epektibo

lalo na sa populasyong Pilipino

oo ngayon kailangan mong tandaan pagdating sa diyeta

Well, ang mga Pilipino ay napaka-partikular diyan

Kaya kailangan mong mag-ingat kapag sinabi mo sa kanila na okay

ngunit tiyak

may mga bagay na kailangan mong iwasan

kailangan mong iwasan ang mga karne ng organ

kailangan mong iwasan ang mataas na fructose corn syrup na inumin

Kaya 't huwag mong hilahin ang aking mga soft drink

Huwag hilahin ang isang medyas at huwag hilahin ang isang medyas

at iced tea

You my sweet and drinks na gusto mong layuan

gusto mong lumayo sa mga preserved na pagkain

tulad ng mga de-latang

mataas kasi sa asin ang mga yan

at pagdating sa Filipino

kailangan mong tandaan iyon ng maraming beses

napakahirap hanapin ang lahat ng mga organikong pagkain na ito

dahil maraming tao ang maraming beses na sinasabi ng mga tao

kailangan mong maging maluwag din sa kanila ng mas malalim na pangangalaga

Ang pasyente ay may nakuhang pasyente kapag sila ay na-admit

makikita mo kaagad ang loop na nasa diet ka

pero aminin mo dapat magbigay ka rin

dapat bigyan mo rin sila ng nutrisyon at ikaw uh

nasa ilalim talaga kami uh

panganib na bigyan sila ng malnutration

oo at

at pagdating sa

pagdating sa gout triggers para sa akin uh

mas maraming pasensya ang nakikita ko

The more na naniniwala ako dun

pagdating sa triggers

ito ay talagang higit pa sa isang personalized na diskarte dito

lahat ay may mga personalized na trigger

ibig sabihin kahit may listahan ng karne

pagkain na dapat mong iwasan

pagkain na maaari mong kainin tulad ng pagdating sa babae

maaari kang kumain ng mga gulay maaari kang kumain ng beans

magmumura ang ilang tao

ito

kaya samakatuwid

kahit na ito ay bahagi ng mga alituntunin upang maglaro doon

dahil nakakuha sila ng trigger mula doon

saka yun ang iiwasan nila

So in the end tungkol talaga

Siguraduhing nakakakuha sila ng sapat na nutrisyon

tinitiyak mo na pinamamahalaan mo ang kanilang mga komorbididad

High blood kaya yan ang dash diet diabetes

So that 's taking a look sa kanilang sugar intake

at pagkatapos

Siguraduhin mong hindi sila malnourished

okay lang ba ako

So um alam mo

kailangan nating kilalanin na 20% ng uric acid ay

Ang lahat ay sumisipsip ng diyeta lamang

So may impact talaga

lalo na sa pagkuha ng marami

pero pinag-uusapan mo

nabanggit mo kung paano pamamaga

So hindi lang yung hyperin diet

ngunit ang pamamaga na iyong nabanggit din

at iba pang anyo uh

Alam mo namang pwede ang stress stress

Marahil ay nagdudulot din ng hyper acemia

dahil ang iyong katawan ay kailangang mag-metabolize sa bar

So kailangan ng katawan mo

kung hindi mo ma-metabolize iyon

Tapos may problema ka kaya sa tingin ko beyond nutrition

at kailangan din nating pumunta sa mga pagbabago sa pamumuhay

na nasa kanyang unang um haligi

Nakinig ako okay

at kaya ang unang haligi ay pamumuhay

at hindi lang diet ang pinag-uusapan natin tungkol sa ehersisyo

pinag-uusapan natin ang pagpapababa ng stress game

at kaya ibinalik ko sa iyo ang mikropono

salamat salamat sa mga sagot na yan doktor

ngunit sumasang-ayon ako kung minsan ang malnutrisyon ay ietrogenic

lalo na sa populasyon ng geriatic

Kaya mas mabuting mag-ingat tayo

habang itinataguyod namin ang mga partikular na pangangailangan sa pandiyeta

para sa mga partikular na sakit

maging mas maluwag sa populasyon ng geriatic

dahil sila ay madalas na No

magtiwala sa amin sa lahat ng kanilang lakas ng loob

at talagang walang salt diet

diumano sa na ay hyponed sa pamamagitan ng mga bagay CEO

o napakahigpit sa mga pagkain

lalo na kung may CTD sila

hypertension ng diabetes um

at pagkatapos ay wala na silang mga pagpipilian para sa pagkain

at pagkatapos ay hinihiling namin sa aming sarili bucket malnourish

hit na balde ko ipakita ang aking kama

So I guess linen ako ni Lynette at okay

para kay Doctor Emil

Gagamitin ba ang mga biomic biomarker na ito para sa screening

halimbawa para sa mga pasyente na may hypertension

na may normal na paggana ng bato

o upang suportahan ang mga klinikal na pahiwatig sa diagnosis

um paano mo mahuhulaan ang paggamit ng mga biomarker na ito

sa hinaharap sa tingin ko um

ang gamit uh ang papel ng

sa mga biomarker na ito ay talagang papasok

Ang mga pasyente ay nasa mataas na panganib para sa CKD

So kasama diyan ang mga hypertensive na pasyente

Mga pasyente ng diabetes matatanda

oo kaya uh

Sa tingin ko oo uh

magkakaroon ito ng papel sa screening para sa CKD

marahil sa hinaharap para sa mataas na panganib na populasyon

hindi para sa lahat tulad ng mga batang pasyente na gustong malaman

may pahinga ba ako para sa CKD sa hinaharap

yeah I think it will be you know masyadong magastos lalo na

lalo na

para hindi pa sila commercially available

Unfollow up DOC kailan mo ito iniisip

Ang mga biomarker ay magagamit sa komersyo

sa amin na mga clinician

halimbawa kapag

At anong taon mo naiisip na inaalok ito ng Medical City

Um biomarker para sa klinikal na paggamit

Buti na lang matagal nang ginagamit ang urinary

No better not hindi pa ito naging sikat

hindi pero sa tingin ko baka ikaw sa panahon mo bilang residente

ginagamit namin dati um

urinary N Gal para sa mga pasyenteng nalantad sa contrast

sa pag-asa ng contrast sapilitan nephropathy

para kay Aki

Sobrang ihi NGAL

Sa tingin ko ay magagamit na sa bansa

ngunit tungkol sa iba

Narinig ko sa iba 't ibang biomarker

beta trace protein at beta sa microglobuline um

ay malapit nang maging available sa ibang bansa no

But me pretty soon alam mo na

sa sandaling mayroon sila nito America sa loob ng ilang buwan

Malamang magkakaroon din tayo nito

Maraming salamat doktor para sa 13 Reus

ano ang magiging pinakamahusay na pagmamarka

System para masuri ang malnutration sa isang outpatient na batayan

para gamitin sa sarili nating mga klinika um

sa komunidad din

Um for me actually gagamitin ko yung MST okay

Tatlong tanong lang talaga ang itatanong nito

BMI mo ito at classified BMI ito batay sa edad okay

alam mo na may cyclopedia na nangyayari sa mga matatanda

hindi tayo makuntento sa BMI na uh 18.5 pataas

sa tingin mo oh 18.9 okay

PA pero kung matatanda ay cyclopedia ang tingin natin

You would think na maliit talaga ang muscle

So alam mo

Ang nilalaman ng kalamnan ay matalino sa mga tuntunin ng komposisyon ng katawan

dapat mababa talaga yan

So ang BMI na tinatarget natin para sa mga matatanda ay talagang 22

at 22 mas mababa sa 22 ay matatanda

17 sa itaas sa patio matatanda okay

Kaya ang 17 sa itaas ay magiging 22 uh

Gusto naming i-target ang 22 kung mas mababa sa 22

makikita mo dapat ikaw ay um

Red flag na yan okay

kaya ang tanong ay kung ano ang pinakamahusay na MST

ang pinakasimple o para sa akin ang unang kalahati ng NR

Tatlong tanong lang ang dapat mong itanong sa iyong sarili

para sa labas ng pasyente o komunidad o outpatient

may BMI bang tingnan ang BMI

Ibinibigay ko sa iyo ang cut off para sa mga matatanda na hindi uh 18.5

kaya tingnan ang BMI

less than 20 ay medyo red flag na

para din sa ibang matanda um

pagbaba ng timbang

Ang pagbaba ng timbang ay mayroong pagbaba ng timbang sa nakaraan um

ilang buwan makabuluhang pagbaba ng timbang ay tiyak uh

2% sa isang linggo at 5% sa uh

3% sa isang buwan at 5% sa tatlong buwan

So and then kung meron talaga uh

Mga pagbabago sa pagbaba ng timbang sa paggamit ng pagkain sa nakaraang linggo

okay kaya tatlong tanong kung mayroon kang oo

Sa alinman sa mga iyon ay sinimulan mo na ang isang pagsusuri

ano ang mga pinagbabatayan na gastos dito

iba 't ibang pagbabago sa mga tuntunin ng BMI

pagbaba ng timbang at mahinang paggamit ng bibig

oo sir Doctor Devara

oo Doctor Iba

Gusto kong tanungin si Pusana dahil kapag pumunta ka sa TV

makakakita ka ng maraming ad na nagsasabi sa mga tao hey

sige lang

Uminom ng bitamina B complex pagdating sa mga matatanda

Given na gusto naming tratuhin ang mga partikular na bago

mga microdeficiencies

sasabihin mo ba sa mga pasyenteng ito na matatanda na hindi

hindi mo kailangang uminom ng bitamina B complex

mabuti

karaniwang sinasabi namin para sa aming mga matatanda na gagawin namin

alam mo kung kumakain ka ng balanseng diyeta

hindi mo na kailangan kumain para uminom ng multivitamins

ngunit ang aming mga matatanda

Maaaring hindi talaga kumakain ng balanseng diyeta

Which is a challenge at tayo

Ipinakita namin sa iyo ang direksyon ng pagtanda

Tiyak na mas kaunting pagkakaiba-iba iyon

dahil mas kaunti ang pagkakaiba-iba

mataas na panganib para sa mga kakulangan sa micronutrient

irerekomenda mo lang ang RDA

na inirerekomenda araw-araw na allowance

alam mo kung alin ang mabuti

ngunit tandaan na kung pinaghihinalaan mo ang kakulangan

kailangan mong magbigay ng therapeutic

mga halaga o therapeutic dosage

kaya iyon ang dahilan kung bakit para sa ilan sa aming mga pasyente

Susuriin talaga namin ang mga antas ng bitamina

Medyo mahal ang bitamina B

You know so since meron talaga

hanapin mo ako ng magandang marker na gagamitin

kung pinaghihinalaan mo ang B12 at folic acid

Karaniwang nakikita sa aming matatandang pasyente ay homosexistine

alin ang mas mura

okay kaya mas mura ang home assistine

kung mataas, ikaw

alam mo na ang iyong pasyente ay maaaring mayroon

May hindi ito confirmatory

ngunit ito ay uh maaaring may folic acid sa kakulangan ng B12

Hindi naman talaga mahal ang bitamina d

So ito ay isang bagay na maaari nating gawin

dahil ang pagdaragdag ng bitamina d ay may toxicity

Hindi tulad ng mga bitamina na natutunaw sa tubig

kaya gagawa ako ng pagsubok kaya kung binibigyan mo ng RDA walang isyu

ngunit kung gusto mong talagang pamahalaan ang kakulangan

kailangan mong kunin ang dugo at magbigay ng mga therapeutic doses

Salamat doktor at maraming pag-aaral para sa akin din

For my own practice ako si Doctor Aldo

Konektado ako batang tanong goi um

Takot na takot akong hulaan ang SGS mula sa lahat ng iyong perinol

lalo na sa mga matatandang pasyente

Okay lang ba kung mas gusto kong magbigay ng mga libro

isang stat bilang unang linya ng paggamot para sa uric acid

at bilang karagdagang tanong

paano ka magpapatuloy sa paggamot sa apdo

pagkatapos ng iyong karanasan sa pasyente

at masamang pagkilos ng gamot na mas malala pa sa 3

tungkol sa allupurinol

kailan ka magsisimula sa bagong gamot

okay kaya napakagandang tanong iyan

So reminder lang sa lahat ng residente dito

kapag may gout ka

You think of the four pillars all the time okay

kaya kapag ito ay dumating na rin

Well sa unang tanong

pwede ka bang dumiretso sa febuxa stat

oo iyan ay isang bagay na ginagawa ng mga rheumatologist

at ang dahilan ng pagpili ng febuxa stat ay

may ilang pasyente na pumapasok niyan

alam mo para sa isang katotohanan na ito ay

may hindi na babalik

So kung hindi na sila babalik

Alam mong iinom sila ng gamot

Mapanganib na bigyan sila ng gamot

at pagkatapos ay hindi na sila babalik

at pagkatapos ay nakukuha nila ang lahat ng mga problemang ito

at iyon ang dahilan kung bakit iyon

yan ang

Iyon ang isa sa mga dahilan kung bakit kailangan mong magsimula nang mabagal

at dahan-dahan ka

dahil kapag sinimulan mo ang gamot ay mabagal

tapos hindi mo aasahan na makikita mo ito uh you the

ang panganib para sa matinding SGS ay hindi magiging napakataas

at iyon ang dahilan kung bakit

kapag mayroon kang mga pasyente na may CKD

hindi mo nais na magbigay ng mataas na dosis ng alourinol

dahil mas mataas ang allopurinol

sa mga pasyenteng may CKD

mas mataas ang panganib para sa SGS

So yes so sure pagdating sa ganyan

kadalasan kapag nagsimula ka kapag may kasama kang pasyente

na nagsisimulang magkaroon ng mga sintomas na ito

mas madalas kaysa sa hindi

ito ay mga pasyente na magkakaroon din ng gout flare

dahil ang stress ay isa sa mga trigger ng gout

kaya naman nakakakuha ka ng mga referral para sa mga pasyente

hindi katas na operasyon ng puslang

Kakataong Islamic heart attack

The gaut flair cellar kaya kapag may SGS ka

Mas madalas lang magkaroon ng tense kaysa hindi

dahil may tao sa gaut Flair

at gusto mong magawa

gusto mong tanggalin ang nakakasakit na ahente

which is ang aloepuranol treat ang gaud flare

And then kapag tapos na ang gaud flare

pwede ka nang magsimula

maaari mong simulan ang pagbibigay ng gamot pagkatapos ng 2 linggo

o pagkatapos ng 4 na linggo ngunit una sa lahat

gusto mong makasigurado na

na kung ang pasyente ay makakakuha ng isang reaksyon sa iyo

gusto mong tiyakin na ito ay

gusto mong makasigurado na

dahil sa anumang gamot

maaari mong makuha ang reaksyon sa isang buwan

Kaya kailangan mong mag-ingat

Salamat sa iyo para dito bagaman

isang DOC Camille

ano ang mga pangunahing estratehiya

at mga interbensyon na posibleng makapagpabagal

o pigilan ang pag-unlad ng CKD

at gaano kabisa ang mga ito sa iyong pagsasanay

pero syempre uh

hindi natin mabibigyang-diin ang papel ng diyeta dito

Um marami

Umayos ka

narinig mo na ang mga analogue ng keto

at hindi lahat ng nephologist ay

mga naniniwala sa paggamit ng keto analogues

pero kung ikaw um

makinig nang mabuti sa kung paano isinusulong ang mga analogue ng keto

o tinuturuan sa paggamit nito

isang malaking bahagi nito ay diyeta uh

ito ay isang um napaka

isang napakababang protina na diyeta kaya sa pangkalahatan

Sa tingin ko lahat ay bumagsak sa uh

referral sa isang tao tulad ng uh

Doctorate dito sa mahigpit uh

seek uh CKD diet management sa lahat at siyempre

Umgamot at pamahalaan

tagapagtaguyod ng pamamahala ng kontrol ng mga komorbididad

hypertension diabetes o ang pinagbabatayan na gastos

ngunit pagkatapos ito ay pamamahala ng pinagbabatayan na halaga ng CKD

na pinakamahusay na magpapabagal sa pag-unlad nito

Sa tingin ko iyon ang idadagdag ko

Talagang tinutukoy nito kung ano ang nagtutulak sa iyong pasyente

doon kaya kung ito ay ang mataas na comabaities

syempre wala kang magagawa sa pagtanda ng tama

ngunit ang mga komaba

isasaalang-alang din namin laban sa pamamaga ng stress

panlabas na pamamaga lason

lason sa kapaligiran

na maaaring aktwal na itulak ang iyong mga pasyente

alam mo

sa kabuuang pamamaga na nakakaapekto sa iyong bato

So aside you know marami sa mga pasyente natin ang ganyan yeah

Focus on the diet it is a factor pero alam mo kung ano

Kahit na ibababa mo ang iyong diyeta

ngunit ginagawa mo ang lahat ng iba pang bagay na ito

naninigarilyo ka pa umiinom ka pa

alam mo pa rin na hindi mo kayang mamuhay ng maayos

isang malusog na buhay

na talagang hindi pagpunta sa pabagalin ito sapat

maliit na tubo sa asukal feral sa puno

maging blanket referral para sa lahat ng pasyente ng ICU

sa iyong palagay

No because hindi lahat ng ICU

Kailangan talagang nasa yelo ang mga pasyente haha

kasi meron tayong mga pasyente na nagmomonitor lang

Right so you know so um um kaya nasa panganib sila

kinikilala namin talaga

Masasabi kong 90% ng mga pasyente sa ICU ay um

blanket referral alam mo ba kung ano

Alam ng mga doktor ng gamot sa kritikal na pangangalaga

kung paano pamahalaan ang nutrisyon

Parte talaga sila ng nutrition team

So itatanong mo kung bakit

kailan sila tumutukoy sa serbisyo sa pamamahala ng nutrisyon

tinutukoy nila ang mga pasyente na mas kumplikado

Sige

Well alam mo

kapag kaya na nila ang sarili nila

may gamit pa rin sila

Napakahusay ng kanilang mga doktor sa kritikal na pangangalaga

pagpalain ang mga kasama nila

nagawa na nila ang kanilang pagsasanay

Kasama ang nutrisyon sa kanilang pagsasanay

So alam nila kung paano i-manage

ngunit mayroon kaming mga nangangailangan ng kaunting pagtuon

na kailangan natin ng kaunting atensyon

And with that baka gusto mong tawagan ang nutrisyon um

serbisyo sa pamamahala

kasi alam mo yun kapag nandiyan sila

may iba 't ibang aspeto ng nutrisyon

ay pamamahalaan o isasaalang-alang

DOC din

ano ang mga sangkap na anti-namumula

okay anti inflammatory ingredients para sa mga pasyente ng cancer

doon mo pinag-uusapan

That 's actually inaprubahan na nila ang Omega 3 fatty acids

So fish oil langis ng isda uh

ito ay uh anti nagpapasiklab

alam mo ba

ang konsepto ng anti inflammatory ay talagang nagbago

tungkol sa langis ng isda

hindi na ito anti inflammatory

Nakakatulong lamang ito sa paglutas ng pamamaga nang mas mabilis

ang pro paglutas

na siyang aktibong anyo ng langis ng isda

ay kung ano ang pagpunta sa talagang buhayin

Kaya iyon ay talagang isang bagay na dapat isaalang-alang para sa mga flare

okay dahil nakakatulong ito na mabawasan ang pamamaga

mas mabilis na malutas ang pamamaga

at iyon ang isa sa sample ng anti

Mga nagpapaalab na sangkap na isinasaalang-alang

siyempre mayroon tayong konsepto ng turmerik

at lahat ng mga bagay na ito na maaaring gusto mong isaalang-alang

pero hindi yun kasama uh

na-admit yan sa ospital

na baka may tao sa labas

Salamat doktor at Doktor Aldo

para sa mga pasyente ng OBD na may asymptomatic hyper eurosemia

paano mo gagawin ang pamamahala

upang maiwasan ang masamang epekto ng hyper eurosemia

nabanggit mo kanina um

tulad ng pag-unlad sa CKD oral fibrillation

diabetes na walang kontrol atbp

paano natin pinapayuhan ang mga taong ito

malapit na pagsubaybay at pagsubaybay

esensyal sa tuwing makakakita ka ng pasyente

sa unang pagkakataon na makita mo sila

magtatatag ka ng isang relasyon

at kung maganda ang relasyon mo sa kanila

pagkatapos ay magagawa mong ipasok ang iyong mensahe

dahil kahit anong gawin mo kahit anong isulat mo

kahit anong hiling mo

kung ang mensahe ay hindi nakarating sa pasyente

pagkatapos ang lahat ng ito ay para sa wala

isa pang tanong

Mayroon ba akong mga pasyente na nagsimula ng libro upang magsimula

At ang kanilang mga target ay nakamit at pagkatapos ay tanungin ako

Paano naman ang DOC kung kaya nila

Halimbawa, mayroon akong mga pasyente na huminto sa pag-inom sa kanila

sa loob ng tatlong buwan para magsimula ang isang libro

at pagkatapos ay nakapag-maintain sila

oo ngayon na

ito ay isang hindi ito ay iyon ay isang napakagandang tanong

ngayon kailangan mong tandaan tulad ng diabetes

parang blood pressure lang

Ang pagdududa ay walang lunas at ang uric acid load ay kontrolado

dahil umiinom ka ng gamot

Kaya sa sandaling ihinto mo ang gamot

Unti-unting tataas ang kargada na iyon

para makausap mo ang pasyente mo

masasabi mo sa pasyente mo okay

dahil siyempre gusto mong magtrabaho sa kanila ang halaga

kung sasabihin mo sa kanila na huwag tanggapin ito

You have to work with them para sabihin mo sa kanila na okay

bumalik ka tapos ipagpatuloy natin

ngunit kailangan mong linawin na kung titigil ka

babalik ang mga gamot patungkol

tungkol sa iba 't ibang dosis ng gamot

Napakapalad namin na mayroong alloperinole 100

Alloperinole 300

maaari kang pumunta hanggang sa 800 nga pala

And when it 's we boost na meron tayong 40

80 at maaari mo talagang ibaba ang gamot

Kaya mula 80 maaari kang pumunta sa 40

Mula 40 pumunta sa 20 kaya ito ay isang minimal na dosis

Pero at least kinokontrol mo

kasi kapag nagsimula na

Bukod sa pagtaas ng uric acid load

magkakaroon ka rin ng Nidos na yan

na pinagmumulan ng pamamaga

na maaaring gawing aktibo ang lahat ng iba pang comorbilities

masyadong

mababang antas ng uric acid ngunit maghintay

let 's stop kasi sobrang baba na parang 2 yes

wala pang tatlo kaya kung wala pang 3 ikaw

maaari mong i-back off ang iyong dosis

isa sa mga bagay na maganda sa alupuranol

halimbawa

depende ba yan sa uric acid load ng pasyente

isang magandang paraan ng

Pinagmamasdan kung gaano karaming dosis ang kakailanganin nila

para sa bawat 100 milligrams ng alupuranol

ibababa nito ang iyong uric acid ng 1 milligram

Deciliator

So nagbibigay ito ng ideya oh okay

So 9 ang uric acid then you might

saka alam mo na okay

Sa kalaunan ay nasa Aluperino 300 siya

at pagkatapos ay kung ibababa mo ito

Tapos tinatamaan mo na ang metromobaba

tapos masasabi mong okay

gawin natin itong 100 mg sa halip