Jamie Willows Profile picture
Aug 25, 2019 17 tweets 7 min read Read on X
Last week twitter was unexpectedly keen for renal registrar on-call tips, so here’s round 2️⃣ of kidney #tipsfornewdocs covering iv fluids, AKI, “renal screen” bloods, immunosuppression, electrolytes, DKA in ESKD, peritoneal dialysis, proteinuria, meds & ⬆️BP (thread)
#nephpearls
Iv fluids; Renal #tipsfornewdocs 2️⃣ 1/15

✅ 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)
AKI; Renal #tipsfornewdocs 2️⃣ 2/15

✅ 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.
AKI; Renal #tipsfornewdocs 2️⃣ 3/15

AKI “renal screen” bloods MIGHT include;
✔️Myeloma screen (Igs, serum EP, SFLCs)
✔️ANCA(MPO & PR3), anti-GBM, cryos, autoantibodies, C3/C4, dsDNA, ASOT, (PLA2R)
✔️Blood cultures x3
✔️CK
✔️Eosinophils (serum, not urine)
✔️HIV/Hep/Adeno/CMV/BKV
AKI; Renal #tipsfornewdocs 2️⃣ 4/15

“Renal screen” cont;
✔️Haemolysis screen (film, ⬆️bili,⬆️LDH,⬇️hapto, DAT)
✔️STEC PCR / ADAMTS13
✔️ACE
✔️Paracetamol/salicylate/toxic alcohol, urine for illicit
✔️Other eg. Lepto PCR, legionella, oxalate

BUT which to send depends on the story!
AKI; Renal tips 2️⃣ 5/15

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
Immunosuppression; Renal #tipsfornewdocs 2️⃣ 6/15

✅ 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!)
Electrolytes; Renal #tipsfornewdocs 2️⃣ 7/15

✅ 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
DKA in ESKD; Renal #tipsfornewdocs 2️⃣ 8/15

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!
Peritoneal dialysis (PD); Renal #tipsfornewdocs 2️⃣ 10/15

☠️ 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.
Peritoneal dialysis (PD); Renal #tipsfornewdocs 2️⃣ 11/15

‼️ 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‼️
Proteinuria; Renal #tipsfornewdocs 2️⃣ 12/15

✅ 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
Meds; Renal #tipsfornewdocs 2️⃣ 13/15

✅ 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!
⬆️BP; Renal #tipsfornewdocs 2️⃣ 14/15

✅ Don’t keep ⬆️BP meds to aim great control while inpatient without gd reason & follow-up. Many take >4wks to max effect anyway (graph)

✅ HFrEF= bisop, metop, carvedilol
Portal ⬆️BP= propran, carv
Essential ⬆️BP= not BB 1st line (or 2,3,4)
Renal #tipsfornewdocs 2️⃣ 15/15

Bonus;

❌ 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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More from @jamiekwillows

May 19, 2023
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🧵👇 Image
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.
 
Gabapentin likely has efficacy, but no one is going to pretend the side-effect profile is ideal.
pubmed.ncbi.nlm.nih.gov/28720208/ Image
Read 20 tweets
Apr 22, 2022
You get called to the haemodialysis unit.

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
Read 20 tweets
Dec 3, 2021
1/
Nephrology:
“We will forever argue about validity of equations to convert serum creatinine to eGFR using age, sex etc”

Also nephrology:
“We will make no adjustment for muscle mass when using urinary creatinine within urine ACR”

A #tweetorial on two albuminuria paradoxes 👇
2/
Recap: why use early morning urine ACR?

✅Correlates well with ‘gold standard’ 24hr urine collection (pain to perform)

✅Creatinine in denominator corrects for urine dilution - works when creat excretion constant (but, note some daily variation)

ncbi.nlm.nih.gov/pmc/articles/P…
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

pubmed.ncbi.nlm.nih.gov/15302780/
Read 20 tweets
Apr 30, 2020
Do you manage the renal impact of #covid19 on general wards?

My summarised recommendations on;
✅ AKI
✅ Volume status
✅ ACEi
✅ Transplant & dialysis patients

taken from @RenalAssoc, #eraedta, #nephjc & @UpToDate

= lots of relevant info in 8 tweets👇

#medtwitter #covid4mds
AKI 1

✅ 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
Read 10 tweets
Mar 1, 2020
1/
#medtwitter is fairly comfortable managing “normal” DKA right? But how about in the anuric dialysis patient? The cookbook protocol can be deadly.

Read this #tweetorial to learn about how their DKA pathophysiology is fascinatingly different.

#meded #nephpearls #endotwitter
2/
Quick recap of normal DKA pathophysiology;

🔑 insulin requirement > insulin supply

✅ “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
Read 18 tweets
Jan 26, 2020
1/
Hyperkalaemia treatment

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.

#medtwitter #nephpearls #meded
2/
Before we start - why do we care?

Because hyperkalaemia associates with a large increase in risk of death in the next 24 hours.

☠️ mortality not necessarily caused by the hyperkalaemia itself, but can indicate that something bad is happening

ncbi.nlm.nih.gov/m/pubmed/19546…
3/
So, the KDIGO conference paper.

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.....!
Read 14 tweets

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