cd /home/daytona/workspace/attachments/404f423d-a0eb-4b09-8134-7f95cd843294 && p…

mkdir -p /home/daytona/workspace/renal-dialysis-pdf && ls /home/daytona/workspac…

~/renal-dialysis-pdf/build_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.platypus.flowables import Flowable
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import os

OUTPUT = "/home/daytona/workspace/renal-dialysis-pdf/Indications_Renal_Dialysis_Enhanced.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DEEP_BLUE   = colors.HexColor("#1A3A5C")
MED_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8FA")
ACCENT      = colors.HexColor("#E8550A")   # orange-red accent
TEAL        = colors.HexColor("#0E7C7B")
LIGHT_TEAL  = colors.HexColor("#D0EFEF")
YELLOW_BG   = colors.HexColor("#FFF9E6")
YELLOW_BORD = colors.HexColor("#F0C040")
RED_BG      = colors.HexColor("#FDE8E8")
RED_BORD    = colors.HexColor("#C0392B")
GREEN_BG    = colors.HexColor("#E8F5E9")
GREEN_BORD  = colors.HexColor("#27AE60")
LIGHT_GRAY  = colors.HexColor("#F4F6F9")
MID_GRAY    = colors.HexColor("#7F8C8D")
WHITE       = colors.white
BLACK       = colors.HexColor("#1C1C1C")

W, H = A4  # 595.27 x 841.89 pt

# ── Document ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.5*cm, bottomMargin=2.5*cm,
    title="Indications for Renal Dialysis",
    author="Orris Medical Reference"
)

styles = getSampleStyleSheet()

# ── Custom styles ─────────────────────────────────────────────────────────────
def S(name, **kw):
    return ParagraphStyle(name, **kw)

H1 = S("H1", fontSize=22, textColor=WHITE, fontName="Helvetica-Bold",
        spaceAfter=4, leading=28, alignment=TA_CENTER)
H2 = S("H2", fontSize=15, textColor=DEEP_BLUE, fontName="Helvetica-Bold",
        spaceAfter=4, spaceBefore=10, leading=20)
H3 = S("H3", fontSize=12, textColor=MED_BLUE, fontName="Helvetica-Bold",
        spaceAfter=3, spaceBefore=6, leading=16)
H4 = S("H4", fontSize=10, textColor=TEAL, fontName="Helvetica-Bold",
        spaceAfter=2, spaceBefore=4, leading=14)
BODY = S("BODY", fontSize=9.5, textColor=BLACK, fontName="Helvetica",
         spaceAfter=4, leading=14, alignment=TA_JUSTIFY)
BODY_SM = S("BODY_SM", fontSize=8.5, textColor=BLACK, fontName="Helvetica",
            spaceAfter=3, leading=12, alignment=TA_JUSTIFY)
BULLET = S("BULLET", fontSize=9.5, textColor=BLACK, fontName="Helvetica",
           spaceAfter=3, leading=13, leftIndent=14, bulletIndent=0)
CAPTION = S("CAPTION", fontSize=8, textColor=MID_GRAY, fontName="Helvetica-Oblique",
            spaceAfter=2, leading=10, alignment=TA_CENTER)
REF_STYLE = S("REF", fontSize=8, textColor=MID_GRAY, fontName="Helvetica-Oblique",
              leading=11, spaceAfter=2)
MNEMO = S("MNEMO", fontSize=28, textColor=DEEP_BLUE, fontName="Helvetica-Bold",
          leading=34, alignment=TA_CENTER)
MNEMO_LABEL = S("MNEMO_LABEL", fontSize=10, textColor=DEEP_BLUE, fontName="Helvetica",
                leading=13, alignment=TA_CENTER)
WHITE_BOLD = S("WHITE_BOLD", fontSize=10, textColor=WHITE, fontName="Helvetica-Bold",
               leading=14, alignment=TA_CENTER)
WHITE_BODY = S("WHITE_BODY", fontSize=8.5, textColor=WHITE, fontName="Helvetica",
               leading=12, alignment=TA_CENTER)
TH = S("TH", fontSize=9, textColor=WHITE, fontName="Helvetica-Bold",
       leading=13, alignment=TA_CENTER)
TD = S("TD", fontSize=8.5, textColor=BLACK, fontName="Helvetica",
       leading=12, alignment=TA_LEFT)
TD_C = S("TD_C", fontSize=8.5, textColor=BLACK, fontName="Helvetica",
         leading=12, alignment=TA_CENTER)
WARN = S("WARN", fontSize=9, textColor=RED_BORD, fontName="Helvetica-Bold",
         leading=13, alignment=TA_LEFT)

# ── Helper flowables ──────────────────────────────────────────────────────────

def rule(color=MED_BLUE, thickness=1.5):
    return HRFlowable(width="100%", thickness=thickness, color=color, spaceAfter=6, spaceBefore=2)

def vspace(h=0.3):
    return Spacer(1, h*cm)

def section_header(text, color=DEEP_BLUE):
    """Full-width coloured banner for section title."""
    data = [[Paragraph(text, H2)]]
    t = Table(data, colWidths=[W - 4*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), LIGHT_BLUE),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 7),
        ("BOTTOMPADDING",(0,0), (-1,-1), 7),
        ("ROUNDEDCORNERS", [4]),
        ("LINEBELOW", (0,0), (-1,-1), 2, MED_BLUE),
    ]))
    return t

def callout_box(title, body_paras, bg=LIGHT_TEAL, border=TEAL):
    """Coloured callout box with optional title."""
    inner = []
    if title:
        inner.append(Paragraph(f"<b>{title}</b>", H4))
    for p in body_paras:
        inner.append(p)
    data = [[inner]]
    t = Table(data, colWidths=[W - 4*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("BOX", (0,0), (-1,-1), 1.5, border),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 8),
        ("BOTTOMPADDING",(0,0), (-1,-1), 8),
        ("VALIGN", (0,0), (-1,-1), "TOP"),
    ]))
    return t

def bullet(text):
    return Paragraph(f"• {text}", BULLET)

def build_table(headers, rows, col_widths=None, header_color=DEEP_BLUE):
    if col_widths is None:
        n = len(headers)
        col_widths = [(W - 4*cm) / n] * n
    data = [[Paragraph(h, TH) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), TD) if i==0 else Paragraph(str(c), TD_C) for i, c in enumerate(row)])
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND", (0,0), (-1,0), header_color),
        ("TEXTCOLOR",  (0,0), (-1,0), WHITE),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, LIGHT_GRAY]),
        ("GRID", (0,0), (-1,-1), 0.5, colors.HexColor("#CCCCCC")),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("LINEBELOW", (0,0), (-1,0), 2, header_color),
    ]
    t.setStyle(TableStyle(style))
    return t

# ─────────────────────────────────────────────────────────────────────────────
# PAGE BACKGROUND
# ─────────────────────────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # Header bar
    canvas.setFillColor(DEEP_BLUE)
    canvas.rect(0, H - 1.8*cm, W, 1.8*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 9)
    canvas.drawString(2*cm, H - 1.2*cm, "Indications for Renal Dialysis  |  Davidson's & Archit Baloor")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(W - 2*cm, H - 1.2*cm, f"Page {doc.page}")
    # Footer bar
    canvas.setFillColor(LIGHT_BLUE)
    canvas.rect(0, 0, W, 1.5*cm, fill=1, stroke=0)
    canvas.setFillColor(MED_BLUE)
    canvas.setFont("Helvetica-Oblique", 7.5)
    canvas.drawCentredString(W/2, 0.55*cm,
        "For educational use only. Combine with local protocols and specialist consultation.")
    canvas.restoreState()

# ─────────────────────────────────────────────────────────────────────────────
# CONTENT
# ─────────────────────────────────────────────────────────────────────────────
story = []

# ══════════════════════════════════════════════════════════════════════════════
# COVER PAGE
# ══════════════════════════════════════════════════════════════════════════════
def cover_page():
    # Big blue banner
    cov_data = [[
        Paragraph("Indications for Renal Dialysis", H1),
        Paragraph("Insights from Archit Baloor &<br/>Davidson's Principles of Medicine", H1),
    ]]
    cov = Table(cov_data, colWidths=[W - 4*cm])
    cov.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DEEP_BLUE),
        ("LEFTPADDING",  (0,0), (-1,-1), 20),
        ("RIGHTPADDING", (0,0), (-1,-1), 20),
        ("TOPPADDING",   (0,0), (-1,-1), 30),
        ("BOTTOMPADDING",(0,0), (-1,-1), 30),
    ]))
    story.append(vspace(1.5))
    story.append(cov)
    story.append(vspace(0.5))

    # Sub-headline
    sub = Paragraph(
        "A comprehensive, evidence-oriented reference synthesising Davidson's Principles of Medicine, "
        "Archit Baloor's Medicine, and leading international textbooks (Harrison's 22e, "
        "Fischer's Mastery of Surgery 8e, Brenner &amp; Rector's The Kidney, Washington Manual). "
        "Covers all accepted clinical indications for initiating renal replacement therapy (RRT) "
        "across acute and chronic settings, with practical decision thresholds and the "
        "<b>A-E-I-O-U mnemonic.</b>",
        BODY
    )
    story.append(sub)
    story.append(vspace(0.4))

    # Quick-reference box
    qr_items = [
        ["Setting", "Primary Goal", "Key Tool"],
        ["Acute AKI", "Reverse life-threatening derangements", "A-E-I-O-U mnemonic"],
        ["CKD/ESRD", "Manage symptoms, maintain quality of life", "eGFR + symptom burden"],
        ["Toxin ingestion", "Remove dialysable poison", "Molecular properties + toxicology"],
        ["Special populations", "Individualised modality & timing", "Shared decision-making"],
    ]
    story.append(build_table(
        qr_items[0], qr_items[1:],
        col_widths=[5.5*cm, 7.5*cm, 5.5*cm]
    ))
    story.append(vspace(0.3))
    story.append(Paragraph(
        "<i>References: Harrison's 22e, Fischer's Mastery of Surgery 8e, "
        "Brenner &amp; Rector's The Kidney, Washington Manual, Sabiston, Rosen's EM, "
        "Comprehensive Clinical Nephrology 7e, Morgan &amp; Mikhail's Anesthesiology.</i>",
        REF_STYLE
    ))
    story.append(PageBreak())

cover_page()

# ══════════════════════════════════════════════════════════════════════════════
# 1. OVERVIEW — THE A-E-I-O-U MNEMONIC
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("1.  The A-E-I-O-U Mnemonic for Dialysis Indications"))
story.append(vspace(0.2))
story.append(Paragraph(
    "Both Davidson's and Archit Baloor organise dialysis indications using the "
    "<b>A-E-I-O-U</b> mnemonic. This is the cornerstone framework taught in undergraduate and "
    "postgraduate medicine examinations and mirrors international consensus from Harrison's, "
    "KDIGO, and leading nephrology textbooks.",
    BODY
))
story.append(vspace(0.3))

# Big mnemonic table
mnemo_rows = [
    ["A", "Acidosis", "Severe metabolic acidosis refractory to bicarbonate (pH < 7.1)"],
    ["E", "Electrolytes", "Refractory hyperkalemia (K⁺ > 6.5 mEq/L with ECG changes); also hyperphosphataemia, hyperuricaemia (TLS)"],
    ["I", "Intoxications", "Dialysable poisons: methanol, ethylene glycol, salicylates, lithium, severe metformin-associated lactic acidosis"],
    ["O", "Overload (Fluid)", "Pulmonary oedema / anasarca unresponsive to diuretics"],
    ["U", "Uraemia", "Uraemic encephalopathy, pericarditis, coagulopathy, intractable nausea/malnutrition, pruritus"],
]

# Build coloured mnemonic card
letter_style = ParagraphStyle("letter", fontSize=22, fontName="Helvetica-Bold",
                               textColor=WHITE, alignment=TA_CENTER, leading=28)
word_style   = ParagraphStyle("word",   fontSize=11, fontName="Helvetica-Bold",
                               textColor=DEEP_BLUE, leading=14)
desc_style   = ParagraphStyle("desc",   fontSize=9,  fontName="Helvetica",
                               textColor=BLACK, leading=13)

letter_colors = [MED_BLUE, TEAL, ACCENT, colors.HexColor("#7B2D8B"), colors.HexColor("#C0392B")]

mnemo_data = []
for (letter, word, desc), lc in zip(mnemo_rows, letter_colors):
    mnemo_data.append([
        Paragraph(letter, letter_style),
        Paragraph(word, word_style),
        Paragraph(desc, desc_style),
    ])

mt = Table(mnemo_data, colWidths=[1.2*cm, 4*cm, 13.3*cm])
mt_style = TableStyle([
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("RIGHTPADDING",  (0,0), (-1,-1), 8),
    ("LINEBELOW", (0,0), (-1,-2), 0.5, colors.HexColor("#CCCCCC")),
    ("ROWBACKGROUNDS", (0,0), (-1,-1), [LIGHT_BLUE, WHITE]),
])
# colour each letter cell
for i, (_, _, lc_) in enumerate(zip(mnemo_rows, mnemo_rows, letter_colors)):
    mt_style.add("BACKGROUND", (0,i), (0,i), letter_colors[i])

mt.setStyle(mt_style)
story.append(mt)
story.append(vspace(0.3))
story.append(Paragraph(
    "<i>Sources: Washington Manual; Fischer's Mastery of Surgery 8e; "
    "Harrison's 22e; Morgan &amp; Mikhail's Clinical Anesthesiology 7e.</i>",
    REF_STYLE
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 2. ACUTE KIDNEY INJURY — EMERGENCY INDICATIONS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("2.  Acute Kidney Injury (AKI) — Emergency Dialysis Indications"))
story.append(vspace(0.2))
story.append(Paragraph(
    "In AKI, RRT initiation is driven by <b>clinical instability and life-threatening complications</b> "
    "rather than a single creatinine or urea cut-off. The following are the accepted emergency indications "
    "(Brenner &amp; Rector; Harrison's 22e; Washington Manual; Campbell-Walsh Urology):",
    BODY
))
story.append(vspace(0.2))

aki_data = [
    ["Indication", "Clinical Features", "Threshold / Notes"],
    ["Refractory Hyperkalemia",
     "Persistent K⁺ elevation with peaked T waves, wide QRS, sine wave, or VF",
     "K⁺ > 6.5 mEq/L with ECG changes; unresponsive to insulin-glucose, calcium, β-agonists, bicarbonate"],
    ["Severe Metabolic Acidosis",
     "Haemodynamic instability, impaired vasopressor response, Kussmaul breathing",
     "pH < 7.1 (some use < 7.15–7.20) refractory to bicarbonate therapy"],
    ["Refractory Fluid Overload",
     "Pulmonary oedema with hypoxaemia, anasarca, JVD, worsening SOB",
     "Most common indication for RRT in AKI; unresponsive to high-dose loop diuretics"],
    ["Uraemic Complications",
     "Encephalopathy, pericarditis (friction rub ± tamponade risk), bleeding diathesis",
     "Urgent/emergency indication; do not wait for these — ideally dialyse before they develop"],
    ["Toxin / Poisoning Removal",
     "High-risk ingestions with rising toxin levels, deteriorating clinical status",
     "Methanol, ethylene glycol, salicylates, lithium — see Section 6"],
    ["Oliguria / Anuria",
     "Urine output < 0.5 mL/kg/hr for > 6–12 hrs despite adequate resuscitation",
     "KDIGO AKI Stage 3 criterion; consider RRT when other indications co-exist"],
    ["Severe Azotaemia",
     "Nausea, vomiting, anorexia, encephalopathy",
     "BUN > 100 mg/dL (some use > 60 mg/dL pre-emptively); creatinine > 10 mg/dL — use as guides, not absolutes"],
]
story.append(build_table(
    aki_data[0], aki_data[1:],
    col_widths=[3.8*cm, 5.5*cm, 9.2*cm],
    header_color=ACCENT
))
story.append(vspace(0.3))
story.append(callout_box(
    "⚠  Key Clinical Principle",
    [Paragraph(
        "RRT should not be triggered by a single lab value alone. Integrate: "
        "trend of kidney function, oliguria duration, cumulative fluid balance, "
        "severity scores (KDIGO staging), and clinical symptoms. "
        "Early vs. delayed RRT RCTs (ELAIN, AKIKI, STARRT-AKI) show <b>no consistent "
        "mortality benefit from early start</b> in the absence of emergent indications "
        "— individualised judgement is paramount. <i>(Brenner &amp; Rector; Harrison's 22e)</i>",
        BODY_SM
    )],
    bg=YELLOW_BG, border=YELLOW_BORD
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 3. CHRONIC KIDNEY DISEASE — MAINTENANCE DIALYSIS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("3.  Chronic Kidney Disease (CKD) / ESRD — Maintenance Dialysis"))
story.append(vspace(0.2))
story.append(Paragraph(
    "For CKD, Harrison's 22e states: <i>'Clear indications for initiation of renal replacement "
    "therapy for patients with CKD include anorexia and nausea not attributable to reversible causes, "
    "evidence of malnutrition, and fluid and electrolyte abnormalities refractory to other measures.'</i> "
    "Davidson's and Archit Baloor emphasise planning and shared decision-making over arbitrary biochemical thresholds.",
    BODY
))
story.append(vspace(0.2))

# Two-column layout: Indications | eGFR / Timing
ckd_ind = [
    Paragraph("<b>Indications for Maintenance Dialysis</b>", H3),
    bullet("Persistent uraemic symptoms: anorexia, nausea, vomiting"),
    bullet("Intractable pruritus not responding to other treatments"),
    bullet("Uraemic encephalopathy or neuropathy"),
    bullet("Uraemic pericarditis (friction rub — late sign)"),
    bullet("Refractory hypertension uncontrolled medically"),
    bullet("Volume overload / refractory oedema"),
    bullet("Refractory electrolyte disturbance (especially hyperkalemia)"),
    bullet("Progressive malnutrition / failure to thrive"),
    bullet("Declining functional status attributable to renal failure"),
    vspace(0.2),
    Paragraph("<i>Harrison's 22e, p.2440; Comprehensive Clinical Nephrology 7e</i>", REF_STYLE),
]
ckd_egfr = [
    Paragraph("<b>eGFR Thresholds &amp; Timing</b>", H3),
    Paragraph(
        "eGFR alone should <b>not</b> dictate dialysis start. However, practice guidelines suggest:",
        BODY_SM
    ),
    bullet("eGFR 5–10 mL/min/1.73m²: typical range for initiation in symptomatic patients"),
    bullet("eGFR < 6 mL/min/1.73m²: consider even if asymptomatic (high-risk of sudden deterioration)"),
    bullet("Early start (eGFR 10–14) vs. late start (eGFR 5–7) — IDEAL-HD trial showed no survival benefit with early start"),
    bullet("Rate of decline matters more than a single eGFR value"),
    vspace(0.2),
    Paragraph("<b>Preparation (start at CKD Stage 4):</b>", H4),
    bullet("AV fistula creation (6 months lead time recommended)"),
    bullet("Peritoneal dialysis catheter insertion"),
    bullet("Patient education: HD vs PD vs transplant"),
    bullet("Pre-emptive transplant listing if eligible"),
    Paragraph("<i>Harrison's 22e; Comprehensive Clinical Nephrology 7e</i>", REF_STYLE),
]

ckd_tbl = Table([[ckd_ind, ckd_egfr]], colWidths=[9*cm, 9.5*cm])
ckd_tbl.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0), (-1,-1), 6),
    ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("TOPPADDING",   (0,0), (-1,-1), 6),
    ("BOTTOMPADDING",(0,0), (-1,-1), 6),
    ("LINEAFTER", (0,0), (0,-1), 1, colors.HexColor("#CCCCCC")),
]))
story.append(ckd_tbl)
story.append(vspace(0.3))
story.append(callout_box(
    "Davidson's Key Principle",
    [Paragraph(
        "It is <b>ill-advised to assign an arbitrary urea nitrogen or creatinine level</b> to the need "
        "to start dialysis. Patients may become accustomed to chronic uraemia and deny symptoms, "
        "only to realise in retrospect how poorly they felt before dialysis. "
        "Encephalopathy and pericarditis are <b>very late</b> complications and should not be waited for. "
        "<i>(Harrison's 22e, p.2440)</i>",
        BODY_SM
    )],
    bg=GREEN_BG, border=GREEN_BORD
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 4. DETAILED INDICATION-BY-INDICATION BREAKDOWN
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("4.  Detailed Breakdown of Each Indication"))
story.append(vspace(0.1))

# 4A Acidosis
story.append(Paragraph("A — Acidosis (Metabolic)", H3))
story.append(rule(TEAL, 1))
story.append(Paragraph(
    "Severe metabolic acidosis can be fatal and impairs vasopressor action and myocardial contractility. "
    "Alkali (bicarbonate) replacement carries risks of volume overload and hypernatraemia, making "
    "RRT the preferred modality for refractory cases. There is <b>no universally agreed pH threshold</b>, "
    "but most centres initiate RRT when:",
    BODY
))
story.append(bullet("pH < 7.1 despite adequate bicarbonate therapy"))
story.append(bullet("Bicarbonate < 10 mEq/L with haemodynamic instability"))
story.append(bullet("Acidosis contributing to impaired cardiac contractility or respiratory failure"))
story.append(bullet("Lactic acidosis in critically ill patients with AKI (particularly metformin-associated)"))
story.append(Paragraph(
    "<b>Modality tip:</b> CRRT (continuous RRT) is preferred in haemodynamically unstable patients "
    "for slower, more controlled pH correction. Avoid overly rapid correction in patients with "
    "chronic compensated metabolic acidosis to protect respiratory drive.",
    BODY_SM
))
story.append(Paragraph("<i>Fischer's Mastery of Surgery 8e; Washington Manual; Brenner &amp; Rector</i>", REF_STYLE))
story.append(vspace(0.2))

# 4B Electrolytes
story.append(Paragraph("E — Electrolyte Abnormalities", H3))
story.append(rule(TEAL, 1))
elec_rows = [
    ["Electrolyte", "Threshold for Dialysis", "Notes"],
    ["Hyperkalemia (K⁺)", "K⁺ > 6.5 mEq/L with ECG changes; or rising K⁺ unresponsive to treatment",
     "Most dangerous; temporising measures (insulin-glucose, calcium, salbutamol) buy time only. Dialysis is definitive."],
    ["Hyperphosphatemia", "Refractory to phosphate binders; symptomatic hypocalcemia (tetany)",
     "Especially in tumour lysis syndrome (TLS) — dialysis prevents permanent renal injury"],
    ["Hyperuricaemia", "TLS: uric acid causing oliguria/AKI unresponsive to rasburicase",
     "Remove uric acid and phosphate simultaneously with RRT"],
    ["Hypermagnesemia", "Mg²⁺ causing respiratory depression or cardiac arrest",
     "In renal failure, Mg²⁺ cannot be cleared — dialysis required"],
    ["Hypo/Hypernatraemia", "Severe, with concurrent renal failure preventing safe correction",
     "Rate of correction must be controlled to avoid osmotic demyelination syndrome"],
]
story.append(build_table(elec_rows[0], elec_rows[1:],
    col_widths=[3.5*cm, 6*cm, 9*cm], header_color=TEAL))
story.append(Paragraph("<i>Fischer's Mastery of Surgery 8e; Washington Manual; Harriet Lane Handbook</i>", REF_STYLE))
story.append(vspace(0.25))

# 4C Intoxications
story.append(Paragraph("I — Intoxications / Poisonings", H3))
story.append(rule(ACCENT, 1))
story.append(Paragraph(
    "Haemodialysis is indicated for toxins that are <b>water-soluble, low molecular weight, "
    "low protein-bound, and have a small volume of distribution</b>. "
    "Early dialysis is associated with better outcomes in methanol/ethylene glycol poisoning. "
    "Coordinate with toxicology. Use adjunctive antidotes in parallel where available.",
    BODY
))
tox_rows = [
    ["Toxin", "Selection Criteria / Notes", "Antidote to Co-administer"],
    ["Methanol", "Causes blindness, anion-gap acidosis; HD rapidly removes methanol and formate",
     "Fomepizole (4-methylpyrazole)"],
    ["Ethylene Glycol", "Oxalate nephropathy; HD removes glycolate/oxalate",
     "Fomepizole"],
    ["Salicylates (Aspirin)", "Severe overdose (level > 100 mg/dL or CNS/renal involvement); HD enhances clearance 6-fold",
     "Urinary alkalinisation first; HD if severe"],
    ["Lithium", "Li⁺ > 4 mEq/L (chronic) or > 5 mEq/L (acute); neurological features; HD removes Li⁺",
     "Supportive; avoid activated charcoal (not adsorbed)"],
    ["Metformin", "Metformin-associated lactic acidosis with renal failure; pH < 7.1",
     "Supportive; discontinue metformin"],
    ["Theophylline", "Levels > 90 mg/L (acute) or > 40 mg/L with clinical deterioration",
     "Activated charcoal; haemoperfusion preferred if available"],
    ["Barbiturates (selected)", "Phenobarbitone: significant removal by HD; pentobarbital less so",
     "Supportive"],
]
story.append(build_table(tox_rows[0], tox_rows[1:],
    col_widths=[3.5*cm, 8.5*cm, 6.5*cm], header_color=ACCENT))
story.append(Paragraph("<i>Washington Manual; Rosen's Emergency Medicine; Brenner &amp; Rector</i>", REF_STYLE))
story.append(PageBreak())

# 4D Volume Overload
story.append(Paragraph("O — Volume/Fluid Overload", H3))
story.append(rule(MED_BLUE, 1))
story.append(Paragraph(
    "<b>Volume overload is the most common indication for RRT in AKI.</b> (Fischer's Mastery of Surgery 8e) "
    "Patients show evidence of impaired cardiac and respiratory function when diuretics fail:",
    BODY
))
vol_items = [
    "Acute pulmonary oedema with increasing oxygen requirements (SpO₂ < 90% on supplemental O₂)",
    "Radiographic pulmonary oedema or bilateral pleural effusions",
    "Basilar crackles on auscultation + jugular venous distension",
    "Worsening shortness of breath / respiratory failure requiring mechanical ventilation",
    "Anasarca (generalised oedema) impairing wound healing or organ function",
    "Positive fluid balance leading to abdominal compartment syndrome or third-spacing",
    "Peripheral oedema causing skin breakdown or impaired mobility",
]
for item in vol_items:
    story.append(bullet(item))
story.append(vspace(0.15))
story.append(callout_box(
    "Haemodynamic Instability — Modality Choice",
    [Paragraph(
        "In haemodynamically unstable patients, <b>CRRT or SLED (Sustained Low-Efficiency Dialysis)</b> "
        "allow slower ultrafiltration and are preferred over intermittent HD to avoid intradialytic "
        "hypotension. Careful assessment of dry weight and stepwise ultrafiltration goals reduce complications. "
        "<i>(Brenner &amp; Rector; Washington Manual)</i>",
        BODY_SM
    )],
    bg=LIGHT_BLUE, border=MED_BLUE
))
story.append(Paragraph("<i>Fischer's Mastery of Surgery 8e; Campbell-Walsh Urology; Rosen's EM</i>", REF_STYLE))
story.append(vspace(0.25))

# 4E Uraemia
story.append(Paragraph("U — Uraemia and Uraemic Complications", H3))
story.append(rule(colors.HexColor("#C0392B"), 1))
story.append(Paragraph(
    "Uraemic toxins cause systemic dysfunction across multiple organ systems. "
    "Modern practice aims to <b>initiate dialysis before late complications develop</b>:",
    BODY
))
ur_rows = [
    ["Feature", "Mechanism", "Urgency", "Notes"],
    ["Uraemic Encephalopathy", "Retained toxins cross BBB → asterixis, confusion, seizures, coma",
     "URGENT", "Reverses with dialysis; protect airway"],
    ["Uraemic Pericarditis", "Toxin-induced fibrinous pericarditis → friction rub → tamponade risk",
     "URGENT", "Anticoagulation contraindicated; use heparin-free HD or CRRT"],
    ["Uraemic Coagulopathy", "Platelet dysfunction (von Willebrand factor abnormality)",
     "Moderate", "Spontaneous bleeding, subdural haematoma risk"],
    ["Anorexia / Nausea / Vomiting", "Gastric uraemic toxin effect → weight loss, malnutrition",
     "Planned", "Often first symptom of ESRD requiring dialysis planning"],
    ["Uraemic Pruritus", "Retained toxins + secondary hyperparathyroidism",
     "Elective/Planned", "Intractable; dialysis provides relief"],
    ["Uraemic Frost", "Crystallisation of urea on skin (BUN very high, > 200–300 mg/dL)",
     "Very Late Sign", "Indicates severe, prolonged uraemia — requires emergency dialysis"],
    ["Uraemic Neuropathy", "Peripheral sensorimotor neuropathy from toxin accumulation",
     "Elective", "Symptoms improve slowly after dialysis initiation"],
    ["Restless Legs / Sleep", "Uraemic neurotoxin effect", "Elective", "Improves with dialysis"],
]
story.append(build_table(ur_rows[0], ur_rows[1:],
    col_widths=[3.5*cm, 6.5*cm, 2.5*cm, 6*cm],
    header_color=colors.HexColor("#C0392B")))
story.append(Paragraph("<i>Harrison's 22e; Washington Manual; Fischer's Mastery of Surgery 8e</i>", REF_STYLE))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 5. KEY BIOCHEMICAL THRESHOLDS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("5.  Key Biochemical Thresholds for Dialysis Initiation"))
story.append(vspace(0.2))
story.append(Paragraph(
    "These are <b>clinical guides</b>, not absolute cutoffs. Clinical context, trajectory, "
    "and symptom burden must always be integrated. <i>(Harrison's 22e)</i>",
    BODY
))
story.append(vspace(0.2))

thresh_rows = [
    ["Parameter", "Threshold Considered", "Interpretation / Caveat"],
    ["Serum Potassium (K⁺)", "> 6.5 mEq/L with ECG changes",
     "Emergency dialysis. Temporise first, but dialysis is definitive"],
    ["Blood pH", "< 7.1 refractory to bicarbonate",
     "Lactic acidosis, toxic ingestion, or severe AKI — urgent indication"],
    ["Serum Bicarbonate", "< 10 mEq/L with instability",
     "Used alongside pH; not used in isolation"],
    ["BUN (Blood Urea Nitrogen)", "> 100 mg/dL emergency; > 60 mg/dL pre-emptive",
     "Rosen's EM: initiate when BUN > 100 mg/dL; not a stand-alone indication"],
    ["Serum Creatinine", "> 10 mg/dL",
     "Used as contextual guide; trajectory matters more than a single value"],
    ["eGFR (CKD)", "5–10 mL/min/1.73m² in symptomatic patients",
     "Earlier (10–14) not shown to improve survival in IDEAL-HD trial"],
    ["Urine Output", "< 0.5 mL/kg/hr for > 6–12 hrs (KDIGO AKI Stage 3)",
     "Oliguria/anuria despite resuscitation — consider RRT if other indications co-exist"],
    ["Fluid Balance", "Cumulative positive balance > 10% body weight",
     "Associated with worse outcomes in ICU; may prompt earlier RRT"],
    ["Serum Uric Acid (TLS)", "> 10 mg/dL with AKI unresponsive to rasburicase",
     "Tumour lysis syndrome — RRT removes urate and phosphate together"],
]
story.append(build_table(thresh_rows[0], thresh_rows[1:],
    col_widths=[4.5*cm, 5.5*cm, 8.5*cm],
    header_color=DEEP_BLUE))
story.append(vspace(0.2))
story.append(callout_box(
    "KDIGO AKI Staging Relevant to RRT",
    [
        Paragraph("<b>Stage 1:</b> Cr ×1.5–1.9 baseline or rise ≥ 0.3 mg/dL; UO < 0.5 mL/kg/hr for 6–12 hrs", BODY_SM),
        Paragraph("<b>Stage 2:</b> Cr ×2.0–2.9 baseline; UO < 0.5 mL/kg/hr for ≥ 12 hrs", BODY_SM),
        Paragraph("<b>Stage 3:</b> Cr ×3.0 baseline or ≥ 4.0 mg/dL or RRT or GFR < 35 mL/min; UO < 0.3 mL/kg/hr for ≥ 24 hrs or anuria ≥ 12 hrs — <b>RRT typically indicated at this stage with clinical indications</b>", BODY_SM),
        Paragraph("<i>Sabiston Textbook of Surgery; Brenner &amp; Rector</i>", REF_STYLE),
    ],
    bg=LIGHT_BLUE, border=MED_BLUE
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 6. MODALITY SELECTION
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("6.  Modality Selection — Matching RRT to the Patient"))
story.append(vspace(0.2))
story.append(Paragraph(
    "The choice of RRT modality should be tailored to haemodynamic stability, clinical context, "
    "available resources, and patient goals. There is <b>no single modality proven superior in mortality</b> "
    "across all settings. <i>(Brenner &amp; Rector; Washington Manual)</i>",
    BODY
))
story.append(vspace(0.2))

mod_rows = [
    ["Modality", "Full Name", "Best For", "Advantages", "Limitations"],
    ["IHD", "Intermittent Haemodialysis",
     "Haemodynamically stable; toxin removal; hyperkalaemia",
     "Rapid solute clearance; widely available",
     "Hypotension risk; not ideal for unstable patients"],
    ["CRRT", "Continuous Renal Replacement Therapy",
     "ICU/haemodynamic instability; ARDS; acute liver failure",
     "Slow continuous correction; better haemodynamic tolerance",
     "Requires ICU, anticoagulation; filter clotting"],
    ["SLED", "Sustained Low-Efficiency Dialysis",
     "Bridge between IHD and CRRT; haemodynamic instability",
     "Extended sessions (6–12 hrs); good haemodynamic tolerance",
     "Less available; operator experience required"],
    ["PD", "Peritoneal Dialysis",
     "Chronic ESRD; home dialysis; paediatrics; resource-limited settings",
     "No vascular access; home-based; gentler",
     "Slow clearance; peritonitis risk; not for acute life-threatening indications"],
    ["Haemo-perfusion", "Haemoperfusion (activated charcoal/resin column)",
     "Selected drug overdoses (theophylline, paraquat)",
     "Excellent for large lipid-soluble molecules",
     "Limited availability; specific indications only"],
]
story.append(build_table(mod_rows[0], mod_rows[1:],
    col_widths=[1.8*cm, 3.5*cm, 4*cm, 4.5*cm, 4.7*cm],
    header_color=TEAL))
story.append(vspace(0.2))
story.append(Paragraph(
    "<b>Note:</b> CRRT effluent flow should be targeted to <b>25 mL/kg/hour</b> in critically ill patients "
    "with AKI. Higher doses (35–45 mL/kg/hr) have not shown improved outcomes (ATN trial, RENAL trial). "
    "<i>(Brenner &amp; Rector)</i>",
    BODY_SM
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 7. SPECIAL POPULATIONS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("7.  Special Populations"))
story.append(vspace(0.2))

pop_rows = [
    ["Population", "Special Considerations", "Modality Preference"],
    ["Elderly / Frail",
     "Assess frailty score and functional status. Dialysis may prolong life without improving quality. "
     "Conservative non-dialytic management is a valid alternative after shared decision-making.",
     "PD or home HD preferred for independence; IHD if access feasible"],
    ["Critically Ill / ICU",
     "Haemodynamic instability common. Permissive hypercapnia (ARDS) may require CRRT to correct mixed acidosis. "
     "Balance anticoagulation needs with bleeding risk. Catheter-related infection prevention critical.",
     "CRRT or SLED first-line"],
    ["Pregnancy",
     "Standard indications apply (hyperkalemia, refractory fluid overload, AKI). "
     "Potential fetotoxicity of urea prompts earlier initiation. "
     "Optimal serum urea target is lower than non-pregnant (< 17 mmol/L). "
     "Intensified dialysis schedules (≥ 20 hrs/week) in ESRD pregnancy improve fetal outcomes.",
     "CRRT preferred for AKI; IHD acceptable for ESRD maintenance"],
    ["Paediatric",
     "Indications same as adults: A-E-I-O-U framework applies. "
     "Weight-based dosing for CRRT. Vascular access size constraints. "
     "TLS is common indication in paediatric oncology.",
     "CRRT most common in critically ill children; PD in infants"],
    ["Liver Failure",
     "Hepatorenal syndrome and AKI common. CRRT preferred to minimise risk of cerebral oedema and herniation "
     "in acute liver failure (key point from Brenner &amp; Rector).",
     "CRRT preferred — protects against cerebral oedema"],
    ["Post-cardiac Surgery",
     "AKI after CPB common. Contrast nephropathy, haemodynamic instability, rhabdomyolysis. "
     "Early RRT if AKI Stage 3 with any AEIOU indication.",
     "CRRT or SLED in early post-op period"],
]
story.append(build_table(pop_rows[0], pop_rows[1:],
    col_widths=[3.5*cm, 10*cm, 5*cm],
    header_color=colors.HexColor("#7B2D8B")))
story.append(vspace(0.2))
story.append(Paragraph(
    "<b>Key unifying principle:</b> Individualise modality, timing, and goals; "
    "emphasise communication, advanced care planning, and integration with palliative care where appropriate. "
    "<i>(Davidson's; Archit Baloor; Harrison's 22e)</i>",
    BODY_SM
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 8. QUICK-REFERENCE SUMMARY TABLE
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("8.  Quick-Reference Summary — All Indications"))
story.append(vspace(0.2))

all_ind_rows = [
    ["Category", "Specific Indication", "Urgency", "Key Threshold"],
    ["A — Acidosis", "Severe metabolic acidosis refractory to bicarbonate",
     "Urgent", "pH < 7.1; bicarb < 10 mEq/L"],
    ["E — Electrolytes", "Refractory hyperkalemia with ECG changes",
     "Emergency", "K⁺ > 6.5 mEq/L + ECG changes"],
    ["E — Electrolytes", "Hyperphosphatemia / hyperuricemia in TLS",
     "Urgent", "Refractory to medical Rx"],
    ["I — Intoxications", "Methanol poisoning",
     "Emergency", "Clinical severity + toxin level"],
    ["I — Intoxications", "Ethylene glycol poisoning",
     "Emergency", "Clinical severity + oxalate crystals"],
    ["I — Intoxications", "Severe salicylate overdose",
     "Emergency", "Level > 100 mg/dL or CNS/renal involvement"],
    ["I — Intoxications", "Lithium toxicity",
     "Urgent", "Li⁺ > 4 mEq/L (chronic) or neurological features"],
    ["I — Intoxications", "Metformin-associated lactic acidosis",
     "Urgent", "pH < 7.1 with renal failure"],
    ["O — Overload", "Pulmonary oedema refractory to diuretics",
     "Emergency", "Hypoxaemia despite O₂ ± NIV"],
    ["O — Overload", "Refractory anasarca / generalised oedema",
     "Urgent", "Impaired organ function"],
    ["U — Uraemia", "Uraemic encephalopathy",
     "Emergency", "Confusion, asterixis, seizures"],
    ["U — Uraemia", "Uraemic pericarditis",
     "Emergency", "Friction rub; tamponade risk"],
    ["U — Uraemia", "Uraemic coagulopathy / bleeding",
     "Urgent", "Spontaneous bleeding"],
    ["U — Uraemia", "Uraemic anorexia / malnutrition (CKD)",
     "Planned (CKD)", "Progressive weight loss, protein-energy malnutrition"],
    ["U — Uraemia", "Intractable pruritus (CKD)",
     "Elective (CKD)", "Unresponsive to antihistamines, UV-B"],
    ["CKD — Maintenance", "eGFR 5–10 with symptoms",
     "Planned", "Symptoms + eGFR trajectory"],
    ["CKD — Maintenance", "Refractory HTN uncontrolled medically",
     "Planned", "BP despite ≥ 3 agents"],
]
story.append(build_table(all_ind_rows[0], all_ind_rows[1:],
    col_widths=[3.8*cm, 6*cm, 3*cm, 5.7*cm],
    header_color=DEEP_BLUE))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 9. CLINICAL DECISION FRAMEWORK
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("9.  Clinical Decision Framework"))
story.append(vspace(0.2))
story.append(Paragraph(
    "Davidson's and Archit Baloor both emphasise integrating <b>multiple clinical factors</b> rather "
    "than relying on any single threshold. The following framework guides RRT decision-making:",
    BODY
))
story.append(vspace(0.2))

framework_data = [
    [Paragraph("<b>Step 1</b>\nIs there an EMERGENCY indication?", WHITE_BOLD),
     Paragraph("<b>Step 2</b>\nAssess the full clinical picture", WHITE_BOLD),
     Paragraph("<b>Step 3</b>\nChoose modality", WHITE_BOLD),
     Paragraph("<b>Step 4</b>\nCommunicate &amp; monitor", WHITE_BOLD)],
    [Paragraph("Check A-E-I-O-U:\n• K⁺ > 6.5 + ECG changes\n• pH < 7.1 refractory\n• Pulmonary oedema\n• Uraemic encephalopathy/pericarditis\n• Dialysable toxin\n→ YES: initiate immediately", WHITE_BODY),
     Paragraph("• Trend of kidney function\n• Oliguria duration\n• Cumulative fluid balance\n• KDIGO AKI stage\n• Symptom burden (CKD)\n• Rate of eGFR decline\n• Patient goals of care", WHITE_BODY),
     Paragraph("• Stable → IHD\n• Unstable → CRRT or SLED\n• Home/chronic → PD\n• Toxin removal → HD\n• Liver failure → CRRT\n• Pregnancy → CRRT/IHD", WHITE_BODY),
     Paragraph("• Inform patient/family\n• Nephrology consult\n• Anticoagulation decision\n• Monitor K⁺, pH, UO, BP\n• Review medications (dose adjust)\n• Avoid nephrotoxins\n• Plan for long-term access", WHITE_BODY)],
]
fw_tbl = Table(framework_data, colWidths=[4.4*cm, 4.4*cm, 4.4*cm, 4.4*cm])
fw_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), DEEP_BLUE),
    ("BACKGROUND", (0,1), (-1,-1), MED_BLUE),
    ("TEXTCOLOR",  (0,0), (-1,-1), WHITE),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("RIGHTPADDING",  (0,0), (-1,-1), 7),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("LINEAFTER", (0,0), (2,-1), 1, WHITE),
    ("LINEBELOW", (0,0), (-1,0), 2, WHITE),
    ("BOX", (0,0), (-1,-1), 1.5, DEEP_BLUE),
]))
story.append(fw_tbl)
story.append(vspace(0.3))
story.append(callout_box(
    "Early vs. Delayed RRT — What the Evidence Says",
    [Paragraph(
        "ELAIN (2016): Earlier RRT improved 90-day mortality in one German centre (stage 2 AKI). "
        "<b>AKIKI (2016)</b> and <b>STARRT-AKI (2020)</b>: No mortality benefit from early RRT vs. watchful waiting. "
        "Two subsequent meta-analyses including ELAIN data found no overall mortality benefit. "
        "<b>Conclusion:</b> In the absence of emergent indications, withhold RRT and reassess frequently. "
        "Exposing patients who may recover to unnecessary RRT risks infection, bleeding, and haemodynamic instability. "
        "<i>(Brenner &amp; Rector; Harrison's 22e)</i>",
        BODY_SM
    )],
    bg=YELLOW_BG, border=YELLOW_BORD
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════════════
# 10. REFERENCES AND CONCLUSIONS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("10.  Key Takeaways &amp; References"))
story.append(vspace(0.2))

takeaways = [
    ("<b>1. Use the A-E-I-O-U mnemonic</b>",
     "Acidosis, Electrolytes, Intoxications, Overload, Uraemia — the framework taught in Davidson's "
     "and Archit Baloor that covers all emergency indications."),
    ("<b>2. Prioritise clinical indications over single lab thresholds</b>",
     "No single creatinine, urea, or eGFR value should automatically trigger dialysis. "
     "Integrate symptoms, trajectory, and overall clinical picture."),
    ("<b>3. Volume overload is the most common acute indication</b>",
     "Refractory pulmonary oedema and fluid overload top the frequency list in AKI "
     "— act before respiratory failure develops."),
    ("<b>4. Uraemic pericarditis/encephalopathy are late signs — don't wait for them</b>",
     "Modern practice aims to initiate dialysis before these develop. They indicate severely prolonged uraemia."),
    ("<b>5. Match modality to haemodynamic status</b>",
     "CRRT/SLED for unstable patients; IHD for stable; PD for home/chronic; "
     "intermittent HD for rapid toxin clearance."),
    ("<b>6. In CKD/ESRD, symptom burden drives timing more than eGFR alone</b>",
     "Prepare for dialysis at Stage 4 CKD. Early education improves outcomes and enables home dialysis."),
    ("<b>7. Individualise for special populations</b>",
     "Elderly (consider conservative care), pregnancy (lower urea targets, intensified schedules), "
     "liver failure (CRRT), critically ill (CRRT/SLED)."),
    ("<b>8. Early-start RRT has no proven mortality benefit (without emergent indications)</b>",
     "STARRT-AKI and AKIKI trials confirm: in the absence of A-E-I-O-U indications, watchful waiting is safe."),
]

for heading, content in takeaways:
    story.append(Paragraph(heading, H4))
    story.append(Paragraph(content, BODY_SM))
    story.append(vspace(0.1))

story.append(vspace(0.2))
story.append(rule(MED_BLUE))
story.append(Paragraph("<b>Primary References:</b>", H4))
refs = [
    "Harrison's Principles of Internal Medicine 22E (2025) — Chapter on CKD, RRT preparation",
    "Fischer's Mastery of Surgery 8e — Indications for Renal Replacement Therapy",
    "The Washington Manual of Medical Therapeutics — Nephrology section",
    "Brenner and Rector's The Kidney (2-volume set) — RRT in the ICU; AKI management",
    "Campbell-Walsh Wein Urology — Management of Acute Kidney Injury",
    "Sabiston Textbook of Surgery — Renal Failure chapter",
    "Rosen's Emergency Medicine — Dialysis/RRT section",
    "Comprehensive Clinical Nephrology, 7th Edition",
    "Morgan & Mikhail's Clinical Anesthesiology 7e — Table 31-7: Indications for RRT",
    "Maingot's Abdominal Operations — Perioperative RRT guidelines",
    "Davidson's Principles and Practice of Medicine (referenced framework)",
    "Archit Baloor's Medicine (referenced framework)",
]
for ref in refs:
    story.append(Paragraph(f"• {ref}", REF_STYLE))

story.append(vspace(0.3))
story.append(callout_box(
    "Disclaimer",
    [Paragraph(
        "This document is for educational purposes only. Clinical decisions must be based on "
        "real-time patient assessment, local protocols, current clinical guidelines, and "
        "specialist (nephrology/critical care) consultation. Drug doses, thresholds, and "
        "recommendations should be verified against current guidelines before application.",
        BODY_SM
    )],
    bg=RED_BG, border=RED_BORD
))

# ─────────────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print(f"PDF written to: {OUTPUT}")

cd /home/daytona/workspace/renal-dialysis-pdf && python3 build_pdf.py 2>&1

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/…