✅ 1L 5% dextrose 12 hourly = 50g glucose = 55 skittles. Not same as feeding patient.
✅ “iv fluid for AKI plus furosemide to keep it off their chest” isn’t a thing - commit to goal of wetter or drier.
(specialist use only eg. ⬆️Ca, ⬆️K)
✅ In AKI anticipate accumulating meds (eg opiates,insulin) & ⬇️dose before complications
✅ Seeing unobstructed AKI pt, BP/K/pH fine but becoming oligoanuric at 1am despite euvolaemia? It’s OK to watch + wait. Trial by drowning not obligatory.
Ward nurses/HCAs;
✅ Meticulous input/output record in AKI is key aid in dialysis decisions
✅ For low K diet advice either ask dietitian (knows 50+ risky foods) or me (knows 🍌 = bad)
✅ Whoever writes dipstick result in medical notes = renal reg’s hero
✅ Half-life of iv hydrocortisone = 100 mins, so transplant pt on pred needs TDS/QDS dosing if NBM
✅ Continue MMF in the v well transplant pt with simple infection, suspend if v sick, inbetween talk to us 1st (talk to us anyway!)
✅ You won’t correct ⬇️K if you don’t correct ⬇️Mg first (distal tubule magic). Replace Mg slowly.
✅ Diarrhoea main side-effect of PO K/PO4/Mg sachets.
✅ Electrolytes don’t always need replacing just because they’re red on the screen
Some protection from DKA in ESKD as ⬇️insulin clearance, & less hypovolaemia as ⬇️osmotic diuresis with ⬇️nephrons
But if get DKA;
⬆️vulnerability to overload & hypos from Tx
❗️Time for individualised approach, NOT cookbook protocol❗️
DKA in ESKD 9/15
☠️ If anuric & hypervolaemic in DKA need unopposed iv insulin = HDU
Anuric pt;
⬆️sugars ➡️ osmotic shift H2O intra to extracellular but without usual ⬆️urine output (+ ⬆️thirst) = intravascular EXPANSION in DKA = iv insulin on own can reverse pulmonary oedema!
☠️ PD peritonitis the big concern with any of abdo pain, cloudy PD bags, GI upset. Needs PD fluid WCC & culture - phone renal unit for advice. Your iv abx are just as good as our intraperitoneal abx until transfer sorted.
‼️ Please take a sec to google what a PD catheter looks like versus a suprapubic urinary catheter - the absolute least fun conversation we can have is after a urometer has been attached to the sterile PD tube connection‼️
✅ Do urine ACR or PCR, no one does 24hr collection now
✅ Nephrotic PCR = >300mg/mmol
✅ Pt with “?1st presentation CCF” & ⬇️albumin - could all be nephrotic Sx, do uPCR
✅ ⬇️alb + oedema post-sepsis with PCR 35 = sick, not nephrotic
✅ Gabapentin in CKD = go so low & so slow eg. 100mg once daily for starters
✅ Aciclovir = must dose reduce in CKD to avoid encephalopathy
✅ Largest cause of “resistant hypertension” is nonadherence; simplifying the med schedule helps!
❌ Writing “GP repeat U&Es in 3 days” on discharge letter isn’t OK. Write why, 📞 to book.
✅ Self-discharge forms assess capacity to hold a pen, for capacity to self-discharge need to see pt & write in notes (also give meds & 🆘 advice).
Again, sometimes hard to give short tips you think are helpful that don’t all come across a bit negative - my apologies!
Some stolen following @CharlieTomson@HotKidneyAction@Yuv90@RenalMed on twitter.
Thanks Tim Ellam for input.
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1/20
Difelikefalin approved by NICE for uraemic itch in patients on haemodialysis! nice.org.uk/guidance/ta890
(on the same day I was offered a consultant job with a haemodialysis role - also exciting!)
Thread to learn everything you need to know about difelikefalin🧵👇
2/ Quick recap on uraemic itch that will surprise no one:
✳️ Common
✳️ Under-estimated by nephrologists
✳️ Many patients don’t report it unless you ask specifically
✳️ Associates with depression, poor sleep & reduced QoL
✳️ Patients state it’s a priority for research
3/ “But 39 therapies have been trialed for uraemic itch, why do you want another?!”
Indeed - that kinda tells you that none of them work great.
An 18 yr old man has missed his dialysis all week & today reports weak legs. The dialysis nurse snaps this ECG as he passes out.
What do you do? Is starting dialysis during CPR ever a thing?
A thread on hyperkalaemic cardiac arrest👇
1/ As you can imagine the evidence base for optimal management of hyperkalaemic cardiac arrest is fairly low quality.
Here’s some ideas (majority of which are based on fantastic UKKA 2020 review & algorithm👇), but every tweet comes with the “but no one knows for sure” caveat….
2/ Firstly – don’t wait for confirmation of ⬆️K
🚨With this history & ECG, the diagnosis = ⬆️K
🚨It is also largely accepted that ECG sensitivity is poor, & subtle or non-classical changes prior to arrest are possible, so even without this ECG starting ⬆️K treatment sensible
3/ Albuminuria quantification is useful prognostically (as well as clear diagnostic utility!):
❗️Independent risk factor for CV mortality
❗️ RENAAL showed higher uACR = higher risk of CKD progression in patients with type 2 diabetes
✅ Many potential factors;
✔️hypovolaemia due to fever / GI symptoms
✔️sepsis & cytokine release
✔️rhabdo, even without myalgia; check CK!
✔️direct viral tubule invasion?
✅ Low grade proteinuria & haematuria common
✅ Don’t miss ‘usual’ post-renal AKI; bladder scan +- US
Volume status
Assessment not easy at best of times!
Balance of maintaining volume to prevent AKI & avoiding hypervolaemia which impairs oxygenation in ARDS
🟠 UK Renal Assoc - “target euvolaemia”
🟠 Uptodate - “fluid goals conservative as per ARDS criteria” but individualise
✅ “stress hormones” rise
✅ blood glucose rises & because glucose is an osmotic diuretic, there is a huge, inappropriate urine output
✅ body makes ketones as alternative fuel, so pH falls
3/ Recap of normal DKA;
✅ patient symptomatic,extracellularly dry, 6 litres down & counting
✅ whole body K low due to osmotic diuresis, but often ⬆️K at first due to hypertonicity/ low insulin/ acidosis
- serum K then rapidly falls as INsulin drives K & glucose INtracellularly
KDIGO have just published their conference conclusions on managing acute #hyperkalaemia so I run through some learning points, some criticisms and the bits I’m not sure about as a renal reg.
Firstly, no one can even agree on the definition of hyperK. What’s up with the Swiss? 4.5mmol/l as the upper limit of normal? Compare this with some values used in research papers.....!