In this first episode of the ESRD series, Dr. Montano and Bernstein discuss how to diagnose kidney failure while Drs. Hart and Aklilu wrestle with the fraught history of using race in the measurement of kidney function.

=== Outline ===

Chapter 1: A gradual progression

Chapter 2: A history of EGFR through the lens of race

Chapter 3: Involving the nephrologist

Chapter 4: Medication adjustments and monitoring

=== Learning Points ===

1. The symptoms underlying a progression from CKD to ESRD are often vague. A definitive diagnosis requires measuring kidney function.
2. The history of measuring kidney function includes the use of creatinine as a biomarker and the development of equations to calculate EGFR. Many of these equations have historically explicitly involved race, which has come under scrutiny and controversy.
3. Once a patient’s creatinine is consistently higher than 1.6, consider referral to a nephrologist for assistance with ongoing monitoring and considerations for transplantation.
4. A diagnosis of ESRD may require medication adjustments and careful monitoring for complications such as anemia, electrolyte changes, bone mineral disease, and swings in blood pressure.

=== Our Expert(s) ===

Dr. Paul Bernstein graduated from Union College in 1982, where he earned a BA in Biology. He then attended the Albert Einstein College of Medicine, where he was elected to AOA. In 1988, he joined the Yale Traditional Internal Medicine Residency, serving as Chief Resident from 1991-1992. From 1992-1995, he was a Yale nephrology fellow, and after that, he joined the faculty at the University of Rochester. From 1997-2000, he was an APD for the University of Rochester Primary Care Residency, and from 2000-2012, he was Program Director for the Internal Medicine Residency at Rochester General Hospital.

=== Further Reading ===

1. NIH National Institutes of Diabetes and Digestive and Kidney Diseases: Fast Facts on Kidney Disease https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease
2. Diao JA et al. National Projections for Clinical Implications of Race-Free Creatinine-Based GFR Estimating Equations. J Am Soc Nephrol. 2023 Feb 1;34(2):309-321. doi: 10.1681/ASN.2022070818. Epub 2022 Nov 11. PMID: 36368777; PMCID: PMC10103103.
3. St Peter WL et al; Written on behalf of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Moving forward from Cockcroft-Gault creatinine clearance to race-free estimated glomerular filtration rate to improve medication-related decision-making in adults across healthcare settings: A consensus of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Am J Health Syst Pharm. 2024 Nov 18:zxae317. doi: 10.1093/ajhp/zxae317. Epub ahead of print. PMID: 39552516.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Host: Josh Onyango

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: I Think I Can Help You, John Patitucci, Chris Haugen, DivKid, Asher Fulero, Jesse Gallagher, Saidbysed

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In our final episode of the Geriatric series, Dr. Xu and Drs. Ouellets discuss how to manage neurocognitive disorders in elderly patients. Daniel facilitates the conversation with a sweet couple navigating these challenges.

=== Outline ===

Chapter 1: An Unexpected Diagnosis

Chapter 2: Diagnosing Dementia

Chapter 3: Dementia Treatment and Specialist Care

Chapter 4: Supporting Caregivers

=== Learning Points ===

1. Dementia is characterized by both functional and cognitive impairment. While it’s important to consider a broad differential, it’s not strictly necessary to rule out all causes of impairment before proceeding with assessment for dementia.
2. Once a diagnosis of dementia has been made, there are certain components of long-term care to be addressed. This is where referral to a geriatrician can be helpful, as they can help to connect patients with resources and help to provide long-term counseling.
3. As dementia progresses, behavioral issues in patients may emerge. It’s important to gather as much information about the context of these issues as possible, in order to think about non-pharmacologic solutions and interventions.
4. Maintain a high index of suspicion for caregiver burnout, and try to determine what resources a caregiver needs and/or if they are willing to accept help.

=== Our Expert(s) ===

Dr. Gregory Ouellet graduated from Brown University in Providence, RI with a Bachelor of Science in biology and then attended medical school at the University of Rochester. Dr. Jennifer Ouellet is a geriatrician who specializes in the care of older adults with multiple chronic illnesses. They completed their clinical training in Internal Medicine and Geriatrics at Yale and are currently full time faculty in the Section of Geriatrics.

=== References ===

1. Albrecht T, Schroeder M, LeCaire T, Endicott S, Marschall K, Felten K, Sayavedra N, Russmann S, Kern V, Blazek MC, Kales HC, Carlsson CM, Mahoney J, Walaszek A. Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study. Geriatr Nurs. 2022 Nov-Dec;48:74-79. doi: 10.1016/j.gerinurse.2022.08.016. Epub 2022 Sep 22. PMID: 36155312; PMCID: PMC11881159.
2. Mehrani I, Sachdev PS. The role of Memory Clinics in the assessment and management of dementia, now and into the future. Curr Opin Psychiatry. 2022 Mar 1;35(2):118-122. doi: 10.1097/YCO.0000000000000777. PMID: 35026801.
3. Reuben DB, Romero T, Evertson LC, Jennings LA. Overwhelmed: a Dementia Caregiver Vital Sign. J Gen Intern Med. 2022 Aug;37(10):2469-2474. doi: 10.1007/s11606-021-07054-3. Epub 2021 Aug 13. PMID: 34389938; PMCID: PMC9360256.
4. van Dyck CH, Swanson CJ, Aisen P, Bateman RJ, Chen C, Gee M, Kanekiyo M, Li D, Reyderman L, Cohen S, Froelich L, Katayama S, Sabbagh M, Vellas B, Watson D, Dhadda S, Irizarry M, Kramer LD, Iwatsubo T. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023 Jan 5;388(1):9-21. doi: 10.1056/NEJMoa2212948. Epub 2022 Nov 29. PMID: 36449413.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Helen Cai

Producers: Helen Cai, Josh Onyango, Daniel Wang

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: True Cuckoo, Asher Fulero, Dan Bodan, Ammil, Dan Bodan

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In our first episode of the Geriatric series, Dr. Xu and Drs. Ouellets discuss how to have difficult topics with patients involving death and loss of function. Darius facilitates the conversation with a beautiful couple facing these existential questions.

=== Outline ===

Chapter 1: Introduction to Advance Care Planning

Chapter 2: Discussing Difficult Topics

Chapter 3: Who’s in the room? Stakeholders

Chapter 4: Key Elemaents of an Advance Care Plan

=== Learning Points ===

1. We can define advance care planning in 1 of 2 ways: as a form of legal document or contract, or as an ongoing conversation about a patient’s values that will be revisited over the course of a patient’s lifetime.
2. Another way of approaching the topic of ACP is in framing it as building a team who will be able to best support the patient through a difficult time: this could include family members, home health aides, financial planners, and so on. The most important member of this team to identify is the healthcare proxy: this person is designated to assist in making decisions should the patient be unable to.
3. Discussing ACP is applicable in any care setting: on the floors, in the ICU, and in the clinic. In the clinic, we have the benefit of time and a longitudinal relationship to keep on revising this topic--since a patient’s goals and priorities may shift over time, and the interventions they may desire will also shift accordingly.

=== Our Expert(s) ===

Dr. Gregory Ouellet graduated from Brown University in Providence, RI with a Bachelor of Science in biology and then attended medical school at the University of Rochester. He completed his clinical training in Internal Medicine and Geriatrics at Yale. He concomitantly completed a postdoctoral fellowship in Geriatric Epidemiology and Aging-Related Research and a Master in Health Science degree in 2018. Dr. Ouellet subsequently joined the full time faculty in the Section of Geriatrics.

Dr. Jennifer Ouellet is a geriatrician who specializes in the care of older adults with multiple chronic illnesses.

=== References ===

1. Sudore RL, Fried TR. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010 Aug 17;153(4):256-61. doi: 10.7326/0003-4819-153-4-201008170-00008. PMID: 20713793; PMCID: PMC2935810.
2. Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017 May;53(5):821-832.e1. doi: 10.1016/j.jpainsymman.2016.12.331. Epub 2017 Jan 3. PMID: 28062339; PMCID: PMC5728651.
3. Fried TR, Bradley EH. What matters to seriously ill older persons making end-of-life treatment decisions?: A qualitative study. J Palliat Med. 2003 Apr;6(2):237-44. doi: 10.1089/109662103764978489. PMID: 12854940.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Helen Cai

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: Noir Et Blanc Vie, Asher Fulero, Astron, The Tides

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls