My Authors
Read all threads
To celebrate 1 yr of taking referrals as the renal registrar on-call, it’s time for some kidney-themed #tipsfornewdocs covering high K, AKI, “nephrotoxins”, medications, iv contrast, hypertension, & caring for kidney transplant & dialysis patients. #nephpearls (thread)
⬆️K - Renal #tipsfornewdocs 1/18

✅ Insulin-dextrose is not benign (⬇️BM risk) & does not get rid of K (only hides it), therefore rather than give round after round do phone us for help!
✅ Repeat ECG, re-bolus calcium gluconate if persistent changes
✅ Salbutamol dose = 10-20mg
⬆️K - Renal #tipsfornewdocs 2/18

✅ Get a bicarb level (correct acidaemia to help ⬇️K)
✅ No one who can’t name 3 side-effects of bicarb should decide to give bicarb (not a bad rule for any drug!)
✅ Review NSAIDs, ACEi, A2RBs, spironactone, beta-blockers, trimethoprim, diet
AKI - Renal #tipsfornewdocs 3/18

✅ Using eGFR in steady state CKD is fine but it isn’t helpful in AKI - use creatinine
✅ You can say you’ve sent “renal screen” but we’ll still ask what you’ve actually sent
✅ Avoid urinary catheters if bottles will measure urine output fine
AKI - Renal #tipsfornewdocs 4/18

✅ AKI doesn’t respond to giving litre upon litre of IVT to euvolaemic, normotensive patients
✅ It’s always obstruction in older men until proven otherwise
✅ In wet patients with AKI, continuing diuresis will almost always be our answer
AKI - Renal #tipsfornewdocs 5/18

At referral, we’re thinking 4 qs;
1. Differential diagnosis? Hence we need historical creatinines, volume status, urine dip, imaging results, all events & bloods this admission, new & prev meds
2. Patient safe to transfer? Need current obs, K, pH
AKI - Renal #tipsfornewdocs 6/18

3. Safe to biopsy? Correct coag, valid group & save, r/v anti-platelets, control ⬆️BP
4. Safe to dialyse? Urgent BBV serology = avoid dialysing in isolation = ⬆️efficiency of dialysis nurse time. Octenisan & naseptin = lines safer with ⬇️SA load
“Nephrotoxins” - Renal #tipsfornewdocs 7/18

❌ Most common reason for re-admission after AKI = pulmonary oedema
❌ Likely factor = ACEi and/or diuretics stopped (possibly appropriately in short term) but without review in patients who needed them going forwards
“Nephrotoxins” - Renal #tipsfornewdocs 8/18

✅ ACEi in heart failure with reduced ejection fraction (HFrEF) = one of most beneficial drugs known to man
✅ If you wouldn’t stop chemotherapy without review plan, don’t stop ACEi in HFrEF without one (benefit often many fold higher)
“Nephrotoxins” - Renal #tipsfornewdocs 9/18

✅ Don’t tell HFrEF patient “those ACEi drugs poisoned your kidneys” - creates massive headache when comes to restarting the life-saving drug
✅ Diuretics can actually can be good for the kidneys - especially if patient congested
Medications - Renal #tipsfornewdocs 10/18

❌ No clarithromycin for patients on tacrolimus
❌ Metformin is a “good day” only drug
❌ No baclofen in later stage CKD/dialysis
❌ Try to avoid trimethoprim / co-trimoxazole in AKI as pushes up creatinine (& ⬆️K) & muddies the waters
Iv contrast - Renal #tipsfornewdocs 11/18

☠️ If you or your reg are worried your patient with AKI or CKD could have ischaemic bowel then do the contrast CT scan - there’s no value protecting the appearance of the kidneys on autopsy.

(if iv contrast would have hurt at all....)
⬆️BP - Renal #tipsfornewdocs 12/18

✅ Think of asymptomatic inpatient ⬆️BP as a chronic problem = STAT doses of meds are rarely required (also, treat pain!)
✅ Amlodipine takes 8 hrs to reach peak concentration; lower re-check BP 30mins after STAT dose is regression to the mean
Transplant pts - Renal #tipsfornewdocs 13/18

✅ We want to know they’re in, esp if immunosuppression issue (NBM, infection - double pred!), or AKI (get urgent US for starters)
✅ Tacrolimus & ciclosporin at 10am & 10pm (gives phlebotomy time to take trough levels before AM dose)
Haemodialysis (HD) pts on wards - Renal #tipsfornewdocs 14/18

Let us know if they;
✅ Bleed; we’ll avoid heparin on HD
✅ Need surgery; need HD re-arranged
✅ Get sick; outpatient HD unit mightn’t be safest place for them
✅ Need routine bloods; easy on HD days, saves extra stab
Haemodialysis pts on wards - Renal #tipsfornewdocs 15/18

❌ Creatinine & urea build up again after HD; this doesn’t mean they need IVT
❌ Post-HD K often low; this doesn’t mean it needs replaced (K rapidly builds-up again)
✅ Renal pharmacists are great asset if can find them
Dialysis pts on wards - Renal #tipsfornewdocs 16/18

✅ If still pee, protect residual renal function
✅ If anuric, think of them like closed box - any fluid you put in has to get out somehow. Never for bag upon bag of “maintenance iv fluids”. If need bolus, 250ml & re-assess.
Renal #tipsfornewdocs 17/18

Things we’ll (almost) always say no to;
❌ “Can I take blood from the fistula?”
❌ “Can we use the tunnelled dialysis line as routine iv access?”
❌ “Do you want to see this patient with renal colic?”
❌ “Would EPO help with anything at 2am?”
Renal #tipsfornewdocs 18/18

Other way to save a life;
✅ If swapping to meropenum plus more IVT for a recurrent temp spike with worsening AKI, ask “Could this be vasculitis?”

Easiest way to save a life;
✅ Remember IVT is one of the most dangerous drugs you prescribe
Apologies if tone of above a bit negative at times!! We are nice and helpful really!

Would like to hear anyone else’s top tips too.
Missing some Tweet in this thread? You can try to force a refresh.

Keep Current with Jamie Willows

Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

Twitter may remove this content at anytime, convert it as a PDF, save and print for later use!

Try unrolling a thread yourself!

how to unroll video

1) Follow Thread Reader App on Twitter so you can easily mention us!

2) Go to a Twitter thread (series of Tweets by the same owner) and mention us with a keyword "unroll" @threadreaderapp unroll

You can practice here first or read more on our help page!

Follow Us on Twitter!

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3.00/month or $30.00/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!