<s>[INST] Please read the below case history & awnser the questions at the end Mr. Gurcharan Singh / Male DOB: 24.12.1936 Initially Strong Athletic Built / Non Vegetarian / Tea totaller / Strong Willed 1980: His BP raised to 170/250 and effected all vital organs, resulting swelling in brain, heart enlargement & renal failure (RCF). One of his heart beat got missed in readings of ECGs. He was treated in PGI, Chandigarh (India) and was put on to medicines. 1993: He was taken to local cardiologist due to sudden excess nose bleeding & said cardio physician put him on to some medicines for keeping the BP low. 2001: He felt angina pain in the chest. Was again taken to PGI, Chandigarh (India) for angiography & then was shifted to Escorts Heart Hosp., Delhi (India) & Heart Bye Pass surgery was performed there (CABG done (LIMA to LAD)). 2002: Dr. K.S. Chug (Ex – HOD, Nephrology (PGI-Chandigarh) was consulted. He pointed out that though his BP is stable (80/140) but Urea, Cratenine was on higher side (Createnine – 4.5 & Urea – 132) and put him on additional medicines for the same. Below said is the complete medicine list that was recommended: 1.     Tab Dytor 20 mg, once daily 2.     Tab Amlopres 5 mg, once daily 3.     Shelcal 500 mg, twice a day 4.     Alfacip 0.25 mg, once daily 5.     Heamup (Iron), once daily 6.     Clavix 75 mg, once daily 7.     Simcard 10 mg, once daily 8.     Razo-D (SOS, if vomit sensation persists) 2005: He again had a severe nose bleeding & nose coterie procedure was done in Silver Oak Hosp., Mohali (India) by an ENT surgeon. 2007: Fistula was made on his left wrist due to Ctatenine – 7.5 & Urea - 220. Consulted dietician again and started recommended dietary precautions & strict medicine routine. Feb’ 2010: -     Started taking Homeopathy medicines along with allopathic medicines (primarily as: BERBERIS VULGARIS & ECHINACEA ANGUSTIFOLIA) from a qualified Homeo Physician -     Started checking parameters (Urea & Cratenine) on monthly basis & after 2 – 3 months of homeopathy medicines, slight reverse trend in the said parameters was observed for the first time in last 2 years. BP is observed stable on the whole. -     Fistula was never used for dialysis but it started budging out like a water filled balloon so we approached local surgeon for closing said fistula & he did the same for us. -     Swelling in the feet, itching on back side of neck, less appetite, laziness (feeling sleepy/drowsy in whole of the day time), red/blood coloured patches on his hands & arms, etc. were discussed with homoeopathic physician on weekly basis and with his medicines the same got partially managed. -     Body immunity level seems low as frequently catching cough, cold, etc. increased. -     Hernia problem also there from quite long but aggravates rarely and got subsided of its own after some time (5 – 6 hrs.) Oct’ 2010: -     Mucus (chocolate/brown coloured) vomiting -     Severe giddiness/dizziness Was immediately taken to Local Hosp. & was observed in ICU for 24 hrs., CT Scan/MRI done and everything was found normal. Then it was guessed that it may happen due to intake of vegetable with high urea/pesticide spray or aftereffects of Iron capsule (was regularly taking Iron capsule from last 5 -6 years) Jan’ 2011 – Jun’2011: -     Cratnine toggled between 6 to 7 -     Urea toggled between  180 to 195 Jul’ 2011: Cratnine reached 7.8 Oct’ 2011: -     Cratnine crossed 8 -     Continuous low appetite / itching on back of neck increased / vomit sensation quite frequently / drowsiness increased during day time / feeling chest pain once to twice a day -     Got him admitted in local hospital : •     Angiography done: CART done on 15.11.2011 s/o triple vessel disease, patent graft and cardiologist advised that his angina to be controlled with medicines itself as major blood vessels are in OK shape & only a small blood flow interruption in one of the minor veins so no need for putting stunt. •     Found that suffering from chronic kidney disease stage V , chronic AF/CVR, unstable angina, hypertension, BPH, coronary artery disease P/S CABG in 2001 (LIMA to LAD).  Having frail body & weighing 50.4 Kg. •     Started hemo-dialysis ( done on 15 oct, 17 oct & 25 oct) Now it is recommended by the nephrologist that Mr. Gurcharan Singh being a heart patient should opt for Peritoneal Dialysis & surgery to be performed to tackle his hernia, making fresh fistula again & putting catheter in his kidneys. Presently he is on below said medicines: 1.     Tab Pantocid-D, twice a day (empty stomach) 2.     Tab Urimax-D 0.4 mg, once a day 3.     Tab Clavix 75 mg, once a day 4.     Tab Flavedon MR, Twice a day 5.     Tab Monit GTN 6.4 mg, twice a day 6.     Tab Modlip-ASP (10+75 mg), once a day 7.     Tab Dytor 40 mg, once a day 8.     Tab Shelcal 500 mg, twice a day 9.     Tab Alpha-Cip 0.25 mg, once a day 10.     Tab Nikoran 5 mg, twice a day 11.     Tab Amtas  5 mg, twice a day Our Queries: 1.     What type of dialysis is best for him & why? 2.     Generally, till how long he can comfortably continue with present heart & kidneys situation. 3.     He has been given his first hepatitis shot on 15th Oct’11 & said injection course shall be continued till Apr’12. How to protect him from any type of infections till then? 4.     If peritoneal dialysis is recommended, then: -      it should be done manually (3 times a day) or with machine (Baxter brand is available here). -     What all precautions needed to be taken for making  the possibility of infection as ZERO. -     Dietary routine (extensive list of items: ‘To be taken with qty.’ & “Not to be taken”) 5.     Other precautions (living routine / medicine / diet / which path tests with what frequency) 6.     His HB is low as 8.0 so if we will go for HB increasing injections then how to control his BP? [/INST] Hello Gursharan and welcome to HCM.As an Urologist,i can understand your concern.Your question takes time.You've Prostate enlargement with CAD,H.T.,Anemia and renal failure.You'll need a hemodialysis,till your renal function,electrolytes and anemia are stable. You'll be advised to have maintainence dialysis, 2-3 per week.A low salt,low protein,restricted fluid intake is standard advise given.Regular check-up with tests of Hb,creatinine,electrolytes and B.P.is a must.If you want my expert opinion,send all reports,as a direct question to me.Dr.Matthew J. Mangat. </s>