Discover and read the best of Twitter Threads about #Nephrology

Most recents (24)

Heads up to followers on twitter, will be virtually attending the #ESASRBANZBMS conference this week (21-24th Nov) so expect a bunch of tweets with a particularly heavy science bend. Disclaimer: this is by no means an extensive coverage & usually includes personal reflections. /1
So before continuing, I will try to...
- keep everything here in this thread
- share what I snippets I can
- add a number to keep tweets in some order
- respond where possible (but am also engaging in the conference spaces)
- link to papers when I can /2
Now a bunch of # in case relevant to these folks: #MedTwitter #Science #anzbms #biology #pharmatwitter #ortho #rheum #immunology
#arthritis #pathology #physicaltherapy
#pt #MSKRad #OccupationalTherapy
#physiotherapy

Anyone is most welcome to add relevant tags :D /3
Read 35 tweets
Be sure to join us TOMORROW here on @ckd_ce for our first ORIGINAL accredited content . . . from none other than @edgarvlermamd . . . whom you #kidney-oriented clinicians will know as a comforting and familiar presence and as an AWESOME teacher. He'll be talking about ...
...IgA nephropathy (#IgAN) from the ... perspective of the 2021 @goKDIGO #guidelines. Lots to learn about this common cause of #CKD worldwide! Free CE/#CME for #physicians #nurses #PAsDoThat #nursepractitioner @ANNAnurses @neph_PAs @pharmacists @nephondemand @IgAN_JBarratt
Read 35 tweets
#Nephrology #POCUS short story:
1/ Simple case, want to remind some pitfalls in routine practice.
There was a patient with orthostatic hypotension. Likely neurogenic secondary to amyloidosis.
Read the thread 🧵below:
#IMPOCUS #MedEd mini #tweetorial
2/ Physician A orders IV albumin q 6 hours and keeps continuing because:
1. 'Formal' echo from 4 days ago reported a RAP of 3 mmHg = not high
2. 'Documented' weight showed 3 kg drop since admission
Interestingly, documented cumulative fluid balance is +4 L!
3/ Physician B comes in and performs physical examination (#POCUS). Supine BP is relatively low (SBP ~103 mmHg) but nothing different compared to patient-reported figures at home. Pt feels OK, on midodrine.
Here is the IVC👇
Read 9 tweets
Happening now‼️
@NKFIllinois Controversies in #Nephrology #Nephpearls Image
Balanced crystalloids vs saline in critically ill & non-critically ill adult patients from @NEJM #Nephpearls
#VisualAbstract by @aakashshingada
👉🏼 SALT-ED pubmed.ncbi.nlm.nih.gov/29485926/
👉🏼 SMART pubmed.ncbi.nlm.nih.gov/29485925/ ImageImageImage
Urgent-start PD is defined as initiation of PD in patients w/ newly diagnosed ESKD who are not yet on dialysis and who require dialysis initiation < 2 weeks (as little as 24-48 hours) after PD catheter placement but do not require emergent dialysis #Nephpearls Image
Read 5 tweets
1/How can #POCUS #echofirst help in the evaluation of #hyponatremia?
#Nephrology consulted for low sodium. Pt received diuretic for shortness of breath (which was possibly due to hiatal hernia as shown on CXR).
2 physicians FELT patient was EUVOLEMIC
Small 🧵below 👇 #MedEd Image
2/Based on the above labs, it does look like euvolemic hyponatremia (Urine Na is high, Uosm >100 but not too high, BUN not high). BP was 150s systolic.
That's it? Give some salt tablets or UreNa etc.?
No; perform PHYSICAL EXAM (= #POCUS)
IVC was small - doesn't tell much 😬
3/ Next step? Look at the heart, assess stoke volume.
Recent echo LVEF>50%
LV contraction looks good visually
We measured LVOT VTI (couldn't measure LVOT diameter due to chest deformity precluding good PLAX view but its not a problem; VTI is generally enough)
#POCUS Image
Read 10 tweets
Every speciality who is on (or wants to be) the ‘Mucor’ team- how many are willing to admit a patient with Mucor under their care and manage (even after surgical debridement). How many were admitting before and will admit after the pandemic? (1/n)#Mucormycosis #COVID19India
Some hypothetical consultations in the emergency before and after the pandemic:

#ENT : We will operate and transfer back

#Ophthalmology : Call us during the Surgey, we will coordinate with ENT in the OT, if needed

#Neurology : Continue Amphotericin (2/n)
#Endocrinology : Send us a consultation after admission under primary, we will control sugars

#Neurosurgery :No active neurosurgical intervention required

#Nephrology :We will do renal modification of Amphotericin

#Medicine/ #Infectiousdisease Admit under any of the above
Read 4 tweets
Time to discuss some rationale/evidence behind doing #VExUS #POCUS #Nephrology
A short #tweetorial #MedEd 👇
1/ Is fluid overload harmful?
of course yes. Here is a recent meta-analysis.
2/ Does fluid administration affect renal venous flow in asymptomatic but vulnerable patients (#heartfailure)?
#POCUS #VExUS
3/ In fact, elevated CVP is associated with reduced GFR.
This 👇is a study in outpatients undergoing right heart cath (N = 2557). In CVP values >6 mm Hg, a steep decrease in GFR was observed.
Read 18 tweets
#POCUS #echofirst #MedEd case of the day.
Context: alcoholic liver cirrhosis with suspected #hepatorenal syndrome
Purpose: think about the underlying pathophysiology & seek expert input
1/ PLAX, PSAX, Apical views of the heart. Heart rate ~110-116 bpm
#VExUS images in 🧵
2/ overall, looks hyperdynamic. LA looks little enlarged on PLAX, visual TAPSE high on apical.
In cirrhosis, hyperdynamic circulation is expected because of splanchnic vasodilatation and 'relative' arterial under filling.
LV EF #POCUS obtained using @kosmosplatform 👇
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
Read 20 tweets
OK #VExUS #POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did.
1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd #Nephrology
2/ So, hepatic shows D-only pattern👆
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS 👇
3/ Renal parenchymal vein #VExUS #POCUS
It also demonstrates D-only pattern 👇
Read 15 tweets
#Nephrology #POCUS case of the day:
What do you think is this anechoic structure adjacent to liver?
See thread 👇 for the answer and more images. #MedEd #IMPOCUS
Let's start with a poll before seeing other images: ☝️? #POCUS
The answer is right renal cyst. Note how the kidney appears with fanning the probe. #POCUS
Is rest of the kidney normal? doesn't appear to be...🤔
Read 11 tweets
Renal #POCUS in a #dialysis patient: Looks fine at first glance (thin parenchyma as expected) but fanning anteriorly reveals a large cyst, which would have been missed otherwise. Labeled images and notes in thread 👇
#Nephrology #MedEd #IMPOCUS
Labeled first image #POCUS
Note: peri-renal fat (usually prominent in ESRD patients) can be confused with free fluid.
Labeled second image #POCUS (obtained with phased array probe)
Note: EKG is not needed 😀
Read 5 tweets
#Nephrology consult for worsening creatinine in the context of diuresis in a patient with #heartfailure
Documented weight 3 kg ⬇️ than the previous day. No accurate urine output. Pt feels OK (has some unrelated issue).
Question: over diuresis?
#POCUS #MedEd #VExUS see thread 👇
So, there is decreased LV systolic function and obviously diastolic dysfunction. Bi atrial enlargement. No significant pericardial effusion (there was trace on PLAX).
Next step in the hemodynamic circuit #POCUS assessment?
btw repeat weight was similar.
Next: IVC #POCUS assessment to assess right atrial pressure.
Here it is 👇
Big and plethoric (take it as 15 mmHg in a spontaneously breathing person - we get RVSP of ~41 mmHg based on the above tricuspid gradient)
Read 10 tweets
Do the benefits outweigh the risks in using MRI gadolinium-based contrast media (GBCM) in patients with kidney disease?

MAJOR new consensus statement from @RadiologyACR and @NKF published in @Radiology_RSNA at doi.org/10.1148/radiol…

A #RadInTraining #TWEETORIAL thread 👇
BACKGROUND:
GBCMs consist of gadolinium ions chelated with organic ligands to minimize toxicity from free gadolinium.

Which chemical class has a lower rate of free gadolinium dissociation?
Answer: Macrocyclic GBCMs are more stable (lower ratio of free gadolinium to complexed ligand). (Remember, 𝐋inear is 𝐋abile)

Macrocyclics form a complete ring, whereas linear agents form an incomplete ring.

Examples:
Read 20 tweets
Stimulated by the enthusiasm of #MedEd student and #nephrology fellow, did a small experiment to see how well #POCUS -determined blood flow in the continuous renal replacement therapy (CRRT) circuit correlates with the actual no.
1/ First, got a color #Doppler img. of the tube 👇
2/ How do you calculate flow? It is the same principle that we use to determine flow rate in an arteriovenous fistula 👇 #POCUS Image
3/ 2nd step: measured the diameter of the tube (double-lined structure) - 0.42 cm Image
Read 4 tweets
#POCUS Intra-renal vein Doppler waveform looking exactly like that of hepatic vein!
#VExUS obtained from a #nephrology clinic patient with pulmonary hypertension. #MedEd
Normal hepatic vein waveform #POCUS Image
Portal vein #POCUS in this patient - increased pulsatility. Image
Read 6 tweets
A #Tweetorial on Blood Gas Analysis (adapted from my WKRP in Cincinnati style method of teaching blood gases).
Blood gas interpretation is something that is initially very confusing, is usually poorly taught, comes up hourly in the #pedsICU and #ICU and will be on every exam for the rest of your life.
But it doesn't have to be that complicated and this method will get you through 99.99% of blood gas interpretation and serves as a good foundation to learn those exceptions. (So don't @ me!)
Read 27 tweets
(1/17)

Why does every BMP report show a GFR - African American and GFR - non-African American for the same Cr value?

Let's focus on #racecorrection in the estimation of GFR as part of our ongoing series on racial bias in medicine.
(2/17)

This #tweetorial is based on the work of Dr. Vanessa Grubs (@thenephrologist), Dr. Darshali Vyas (@DarshaliVyas), Dr. Nwamaka Eneanya (@AmakaEMD), Dorothy Roberts (@DorothyERoberts), and so many more. We encourage you to delve into the literature at the bottom.
(3/17)

MDRD (bit.ly/3euUMYg) and CKD-EPI (bit.ly/3ez1Cfb), 2 equations commonly used to estimate kidney function, make sizable adjustments to the estimated GFR (eGFR) based on a binary input term: black or non-black race.
Read 22 tweets
1/ #Nephrology #POCUS case study:
Dr. X is rounding on an ESRD pt who initially presented with dyspnea after missing a dialysis (HD) session; underwent dialysis in the hospital. Pt asymptomatic at the time of exam and lung #ultrasound revealed 👇 Further story in thread #MedEd
2/ Based on the 2-zone lung #POCUS, Dr. X orders for another session of HD. Notably, pt says he is at his 'dry weight' and HD nurse says they could only get 1.5L off during first session. Dr. X doesn't change his/her mind.
Info on various lung scan zones👇
3/ Patient becomes hypotensive during HD and only ~500cc fluid could be removed.
Why can't we get more fluid out of a hypervolemic patient? Dr. X is perplexed and decides to more #POCUS Here is the IVC
Read 16 tweets
#POCUS teaching case: #Dialysis patient c/o sob, reports weight gain. BP low to begin with (~100-110 mmHg systolic) & drops further during ultrafiltration. Dr. X performs IVC #ultrasound at the bedside and sees this 👇 - probably volume depleted? See #thread
#MedEd #nephrology
2/ Dr. X orders to stop ultrafiltration. BP stabilized a little bit.
All done?
Wait, something doesn't make sense. Why did the patient gain weight? (usually #dialysis patients know their dry weight well). Why sob?
In the meanwhile, radiology tech performs chest #X-ray 👇
3/ That's not good. Diagnosis is apparent but lets get Dr. Y who does more than just IVC #POCUS
Subcostal view 👇
Significant pericardial effusion
Read 12 tweets
#POCUS Here is the "story of Foley" #tweetorial about diagnosing misplaced Foley catheter using #IMPOCUS #MedEd #nephrology

1. Normal urinary bladder 👇
2. Urinary bladder decompressed by Foley catheter. As the Foley balloon is filled with water, it appears as a well-defined cystic structure on #POCUS
Asterisk (*) indicates the tiny bit of urine around the balloon.
3. The sonographic image demonstrates the transverse view of the bladder distended with urine(*) despite having a Foley in place. Indicates obstruction of the catheter by a blood clot or debris. Treatment is to flush the catheter, not page #nephrology for dialysis! 🤐
Read 9 tweets
We advise clinicians to do the following to improve patient safety:

1) Limit the volume of administered gadolinium-based contrast agents when used
kidney360.asnjournals.org/content/early/…

#gadolinium
☢️#radiology
#nephrology
🏥#patientsafety
#risk #management
#medical #ethics
#FOAMed
2) increase patient education, incorporate informed consent and shared decision making when GBCA administration occurs;

kidney360.asnjournals.org/content/early/…

#gadolinium
☢️#radiology
#nephrology
🏥#patientsafety
#risk #management
#medical #ethics
#FOAMed
3) maintain careful institutional records of administered agents along with the volume and frequency,

kidney360.asnjournals.org/content/early/…

#gadolinium
☢️#radiology
#nephrology
🏥#patientsafety
#risk #management
#medical #ethics
#FOAMed
Read 4 tweets
Time to follow up on #VExUS #POCUS
Today's images will demonstrate the improvement in congestion with IV diuretic therapy.
#tweetorial
1/ Portal vein - note the pulsatility is ~55% (<30% taken as normal) & the whole waveform is above the baseline now = improvement!! #IMPOCUS
2/ Also note the RAP meter in the above image with arrow pointing to current state.
Below is the side-by-side comparison between the initial #POCUS image and the current one.
3/ Hepatic vein waveform: Note the improvement; arrow points to current state on the RAP meter. #POCUS @ThinkingCC @ArgaizR feel free to comment if you don't agree with the labeling.
Read 10 tweets
On a  lonely morning when you are sipping coffee ☕and peeking at your tweeps🐦, you get a consult for acidosis
Wanna know what do #GI #Urology #Nephrology have in common?
#nephtwitter #urotwitter #medtwitter #FOAMed #theskeletonKG #NSMCinternship
Read our post @RenalFellowNtwk
1/ A 55 year old man👨🏻 with urothelial cancer
✂️transurethral tumor resection, radical cystectomy & neobladder reconstruction 3 mons ago
✂️B/L PCNs & ileostomy - postop (urinary and bowel leak)
2/ He was admitted🏥 6 days ago due to increased ostomy output💩🌊 (>4L/day) & dehydration, and has been receiving NS 💧@ 150mL/h
His BMP is-
Read 22 tweets

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