The state nephrologist, another nephrologist and the clinical site manager were the panel of examiners.

The other nephrologist who is also a HD center owner started off with:

1) Your patient goes on holidays and continues HD at another center, then comes back. What precautions should you take?

Answer: Status of HIV, Hep B and Hep C is now unknown. Take infectious control measures as such: send off blood for screening, use separate, dedicated HD machine, if not available, put patient on last shift and apply single use dialyzer.

This should continue for 3 months (window period in spite of early negative screening test results).

2) Tell us about the water treatment system.

Answer: Water source is only from Air Kelantan for Kelantan (treated water, well water not allowed).

Raw water enters tank then goes through three filters and the R.O. system, then goes to the HD machines. If there is a tank prior to HD machines, it is called an ‘indirect’ system (vs direct).

Monthly testing for electrolytes and three monthly for endotoxins.

For indirect systems, which are largely discouraged, mechanisms must be in place so that water is not stagnant and additional tests required to ensure there is no growth of microorganisms.

Indirect systems are sometimes preferred to overcome the ‘water pressure’ problem.

3) How often does the PIC need to review patients and what is to be reviewed?

Answer: Monthly.

While HD is ongoing, check BP, weight, IDWG…

Why BP? Why weight?
Reflection of body fluid status.

What’s the target BP pre-HD?
140/90 (for elderly 150/90 is acceptable)
After HD?

4) What are reasons for hypotension during HD and what can be done about it?

Answers: Take antihypertensives after HD

Explanation: Many ESRD patients have underlying hypertension plus excess fluid exacerbating the situation.

Some patients develop hypotension as a complication of HD (there are many reasons, many due to failure of autonomic nervous system) because fluid is removed. Thus in these patients we would ask them to take their anti hypertensive medication after HD instead of before.

UF (ultrafiltration) profiling

What is the cause of hypotension during the first hour of HD?
Answer: Cardiac cause

5) Care of catheter:

Maximum duration of temporary catheter: 6 weeks to 3 months, at least use a cuffed catheter if long duration.

Patient touch catheter only after using sterilizer, use a face mask when unwell and coughing, keep clean and dry, cover when having bath, do not use shower (use bucket only).