<s>[INST] AOA, My father aged 63 weight 69 height 6feet now is suffering from hypertension since last 25+years and is also a heart patient since 1998. Since last one year he is suffering from renal problem. At this point in time his creatinen is 9.9 and urea 131. He tried many different medicines allopathic, homeopathic etc for a year but couldn’t find any improvement. He is on homo dialysis since the start of this month (June 2011) which happens twice a week and is now increased to thrice a week. He goes through the dialysis through the temporary Cathe while he went through a fistula surgery for the dialysis last Tuesday (21st June) which is now not working. I am worried about the infection in the temp cathe. . .Please Advise. These days the major issue he is facing is the shortness of breath I would like to mention here that his Hemoglobin is dangerously low. (5.9 According to the reports on 27th June, 2011), While it was 6.5 on the 1st of this month. The agony is that he had two RBC transfusions between the two tests still his hemoglobin is falling this way. Now after the last results i.e. 27th June he had another transfusion of whole blood on 28th and had an injection for Hemoglobin (Mircera 200mg) on the 29th now today on 30th he’ll have another RBC transfusion of RBC and then on the next dialysis which is scheduled on Saturday the third one. This way he’ll have 5 blood transfusions 4 RBC’s and 1 whole blood. Please guide regarding hemoglobin and the temp cathe, permanent cathe, fistula options. Currently he is under the temp cathe and had 1 failed fistula surgery too. Awaiting an earliest reply. Jazakallah khair. June 30, 2011 [/INST] walaikum wassalam. First of all it is important for you to know the condition of the patient and the diagnosis as patient has a complex of diseases. Patient has hypertension induced Renal failure and hypertension induced heart failure. The reports suggest that patient has advance renal failure and the residual function of kidney is less than 10 %. As you have mentioned that the main problem of the patient is shortness of breath. the causes of shortness of breath are as follow: A) As the patient has an HB of 5.5 which is of course dangerously low. This low haemoglobin is due to non functioning kidneys. Basically the chemical that causes blood formation in the bone marrown is derived from thekidneys. When kidneys lose its function the blood formation reduces significantly which cause Anemia(low Hb). This low HB results in shortness of breath because of the low oxygen carrying capacity of the blood to deliver oxygen to the body tissues. B) Heart failure is another cause of the shortness of breath. Heart functions as a pump that pushes the blood towards the tissue. Decline in heart function leads to Inadequate supply of blood to the tissue which cause shortness of breath and also the blood starts to pool in the peripheral tissues like lungs that also causes shortness of breath. C) Ureamia; patient has a significantly elevated urea and creatinine levels that shows that toxins have not properly eliminated from the body. These toxins in turn virtually disrupt function of every organ of the body. At this particular point of time the most suitable and life saving treatment is of course Haemodialysis. Three times a week is one of the best regimens along side the concomitant treatment for Hypertension and heart failure. Regarding low HB the most suitable treatment would be ESPOGEN( recombinant erythropoietin). This is the chemical that induces blood formation as mentioned earlier on. Patient is already taking it. If economically feasible it would be best if 2000 units be given twice a week subcutaneously. It will have significant impact on both low HB and Shortness of breath. Regarding the catheters it's necessary to know that long term dialysis needs fistula. The dual lumen catheters have a high chance of bacterial infection and are thus used as a temporary bridge to fistula. Formation of fistula to until it works takes up to 2 months. Central venous catheter( used as a bridge to fistula) have two varieties; 1) the first variety are temporary catheters that passed directly to central veins and are thus easy to use but have high rate of infection and less half life. 2) Permanent catheters that are passed into the central veins via a tunnel in the skin. The chances of infection are low and half life is more but these require high skill to pass and are costly. Thus if the patient has already one failed surgery procedure, it's better to use a permanent Catheter(the second variety) and then try for a second fistula surgery and if the surgery gets successful then remove catheter and proceed further with fistula. I hope you find this helpful. regards.Dr.Abdur Rehman Alozai. </s>