Discussions


Hi Everyone,

In Ontario, there is growing interest in the changes to the NP role that will be impacted by Bill 179 - legislation that once passed will take away the "lists" that NPs working in acute care...


Hi Everyone,

In Ontario, there is growing interest in the changes to the NP role that will be impacted by Bill 179 - legislation that once passed will take away the "lists" that NPs working in acute care organizations (ie not Primary Care NPs) are bound by in practice. Currently, NPs working in outpatient settings can prescribe independently but only from set lists for drugs, diagnostics and labs. The problem is that these lists are not broad enough to cover our practice in nephrology - many drugs are "reorder only" and many are not represented at all. Therefore, we work under Medical Directives - that allow us to write orders that RNs and other health disciplines can carry out.  With Bill 179, there will be no more lists. NPs will be able to prescribe all investigations and treatments excepting narcotics. This will eliminate in many cases the need for medical directives. However, our organization needs to be ok with this, and approve our working to full scope once the legislation is passed.


Out of curiosity - how many of you across the country who work in outpatient areas (dialysis, clinics) are able to work to full scope of practice within your organization without medical directives?


 


 


  1.   Alison Thomas
  2.   500 Hits
  3.   7 Replies
  4. Last replied by Alison Thomas
Resolved Locked Unanswered

This question was forwarded by one of our nurse practitioner colleagues:


"I have a clinical question for you...I have a lady with severe hypertension that meds don't seem to work for (she's on just about everything!). Do you know if...

This question was forwarded by one of our nurse practitioner colleagues:


"I have a clinical question for you...I have a lady with severe hypertension that meds don't seem to work for (she's on just about everything!). Do you know if anyone is doing the renal sympathetic nerve ablation for hypertension in Toronto? Have you heard much about it?"


This is a very topical question actually. More and more data is being accumulated that this might actually be an option for patients with truly refractory hypertension. It is still early to draw conclusions but it looks promising. To my knowledge, no one in Toronto is performing this as of yet


Here is a commentary from Dr. Matthew Sparks from the Renal Fellow Network and a direct copy of his posting:


Hypertension continues to be major public health concern. Efforts to manage this sometimes difficult to treat condition have only started to positively impact patient health. In some instances hypertension can be refractory to intense medical therapy. It is difficult to ascribe exactly why medical therapy is ineffective. Some have postulated that this failure to achieve adequate BP control is due to ineffective physician prescribing patterns and/or patient non-adherence to lifelong meds for an asymptomatic illness. However, a certain subset of patients clearly have hypertension that is not amenable to pharmacological intervention (or termed resistant hypertension). A group in Australia published an interesting article in Lancet (April 2009) about a novel catheter-based technique for renal sympathetic denervation as a new therapeutic avenue for resistant hypertension.


Blood pressure homeostasis is achieved by the coordinated action of several bodily systems and the kidney plays a prominent role. The renal sympathetic efferent nerves contribute to volume and BP homeostasis as they innervate the renal tubules, vasculature, and juxtaglomerular apparatus, all of which can impact BP. Historically, surgical lumbar sympathectomy was used for reduction of “resistant hypertension” before effective antihypertensive medications were available. This approach was complicated by significant side effects, such as postural hypotension, syncope, and impotence. Selective renal denervation may offer help for patients with resistant hypertension. With the emergence of interventional techniques for selective ablation of efferent nerves, enter this intriguing study.


The study was performed in Australia and Europe as a proof-of-principle study. This was NOT a randomized clinical trial.


It showed that this novel catheter-based device produced renal denervation and had a substantial decrease in BP in a select group of 45 patients with resistant hypertension.



  1. Mean baseline office SBP and DBP were 177 ± 20 and 101 ± 15 mm Hg

  2. eGFR was 81 ± 23 mL/min/1.73 m2

  3. Patients were on an average of 4.7 BP meds.


The catheter-based radiofrequency sympathetic never ablation resulted in


  1. Renal denervation with a 47% reduction in renal noradrenaline spillover (a marker of sympathetic efferent activity)

  2. 43/45 had no adverse events. 1 patient had renal artery dissection treated with stent. 1 patient had pseudoaneurysm of the femoral artery.

  3. Office SBP and DBP after the procedure (while maintaining patients on their usual meds) were decreased by 27/17 mm Hg at 12 months

  4. eGFR was reported to be stable from baseline (79 ± 21 mL/min/1.73 m2) to 6 months' follow-up (83 ± 25 mL/min/1.73 m2), with 6 of 25 patients having an increase > 20% in eGFR and only 1 patient with a decrease in eGFR.

  5. Data related to the mechanism of the hypotensive response, such as natriuresis or suppression of renin, angiotensin II, and plasma catecholamines, were not reported.


Catheter based ablation of the renal artery sympathetic nerves offers a novel approach to resistant hypertension. Several limitations are immediately apparent. First, as a proof-of-principle study, a control group was lacking. Secondly, identifying which patients would benefit from such an intervention is not clear. This study was performed in centers with sustantial experience in this procedure. Adverse event rates would likely be much more significant if performed in centers with less experience. I can imagine that damage to renal parenchyma could occur from a variety of mechanisms using this techique (contrast, atheroemboli, bleeding, etc). Lastly, it is not known how long this BP lowering benefit of catheter based ablation would last. I will be curious to see the results of a randomized controlled trial (RCT) of catheter-induced renal sympathetic denervation.


http://renalfellow.blogspot.com/2010/10/renal-sympathetic-nerve-ablation-for.html;

  1.   Jordan Weinstein
  2.   462 Hits
  3.   1 Replies
  4. Last replied by Alison Thomas
Resolved Locked Unanswered
No discussions created yet
Unable to load tooltip content.
ukidneyisup