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Nayan Arora,MD Profile picture
@captainchloride
Nov 2, 2021 • 4 tweets • 2 min read • Read on X
Why are thiazides effective in augmenting natriuresis when added to loops?

We all know that exposure to loops➡️increase in NCC channels in the distal tubule

BUT there's more

Did you know that there's a mechanism for thiazide sensitive NaCl reabsorption in the collecting duct? ImageImage
Electroneutral NaCl absorption can also occur in the collecting duct through the parallel action of pendrin and NDCBE (Na-dependent Cl/HCO3 exchanger) which is upregulated by Ang II and mineralocorticoids (when Ang II present)
2 cycles of pendrin = 2HCO3- to the lumen for 2Cl-. 1 Cl- is recycled to NDCBE resulting in net reabsorption of 1 NaCl and 2 HCO3- (Cl- through CLCK2 and Na and HCO3- through AE4 in the basolateral membrane)

The whole mechanism appears to be thiazide sensitive Image
Maybe pendrin will be the target for the next diuretic??

Good articles regarding the above here:
pubmed.ncbi.nlm.nih.gov/20389022/

and here:
pubmed.ncbi.nlm.nih.gov/25794953/

#diuresisjedi

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More from @captainchloride

Nayan Arora,MD Profile picture
Jul 31, 2023
As a Nephrologist, why do I love vasopressin? Particularly when I see patients in the CCU?

My ode to vasopressin in a 🧵

#medtwitter #cardstwitter #nephtwitter @MedTweetorials
Right off the bat let's acknowledge that the following trials show no mortality benefit in critically ill patients with vasopressin. But that's not the point - we only care about the kidneys right now because I'm a Nephrologist.
Before we get to hearts we need to borrow from the sepsis literature.

First a small study from 2002
💥24 pts w/septic shock
💥vasopressin v norepinephrine x4 hrs, titrated to BP
💥Vasopressin group = better UOP and CrCl

https://t.co/ExHaUdwfEGpubmed.ncbi.nlm.nih.gov/11873030/

Image
Image
Read 13 tweets
Nayan Arora,MD Profile picture
Jun 7, 2023
The conventional diuretic treatment of ascites in patients with cirrhosis is high doses of spironolactone w/furosemide (classic 100/40 ratio). This was also mentioned recently on @thecurbsiders. Where does this come from and is it true? A quick🧵. #MedTwitter #nephtwitter
In 1981 Fogel et al compared 3 diuretic strategies in 90 patients w/cirrhosis

1.spironolactone + lasix prn
2.lasix alone
3.spironolactone + lasix

🔥Furosemide alone appeared to perform worst for weight loss though not statistically sig. Required sig up-titration and massive KCl Image
In 1983 Perez-Ayuso et al: lasix v spiro. in 40 pts w/cirrhosis and nml kidney function

If🚫response (UNa excretion <50mmol/d) alt. tx given

🔥Lasix grp: 50% response
🔥90% of non-responders responded to spiro.
🔥spiro. grp: 95% responded: 1 non-responder🚫response to lasix Image
Read 10 tweets
Nayan Arora,MD Profile picture
Sep 20, 2022
Diuretic management in decompensated heart failure has been stagnant for years but recently we have some new tools to help us out.

Let's review the Rise of the Proximal Tubule Inhibitors in preparation for the #nephjc discussion on ADVOR tonight.

#MedTwitter @MedTweetorials
First, it's important to recognize how crucial adequate decongestion is.

👇study: pubmed.ncbi.nlm.nih.gov/29544928/ which assessed pts in the PROTECT trial showed lack of decongestion was a predictor of mortality and HF re-hospitalization

Another one by Metra: pubmed.ncbi.nlm.nih.gov/22167320/
Only a minority of patients in the DOSE trial, which used high dose diuretics were free from congestion at 72 hours

nejm.org/doi/full/10.10…
Read 16 tweets
Nayan Arora,MD Profile picture
Jun 17, 2022
Great case of hypokalemia presented by chief fellow @Laurenaring yesterday.

60 y/o woman with a h/o nasopharyngeal cancer, nephrology consulted for hypokalemia.

Sk 2.5, bicarb 30, normal kidney function. No diuretic use, denies vomiting or diarrhea. #nephtwitter #medtwitter
She was on pembrolizumab, which is a/w tubulointerstitial disease and subsequent hypokalemia d/t an RTA, however this was just started 5 days ago and her urine was bland.

Next step? As Nephrologists we want to know urine composition. In this case I would want a Uk, UCr and UCl
Spot values are sufficient and hers were Uk 43, UCr 18 and UCl 50

If you live in the US then you have to deal with unit conversions: discussed here pbfluids.com/tag/potassium/

Her Uk/Ucr ratio was 27 (>2.5 is c/w renal K wasting)
Read 9 tweets
Nayan Arora,MD Profile picture
Apr 29, 2022
Should you give albumin with loop diuretics to augment diuresis?

I've been asked this three different times today so a quick🧵of my thoughts

#nephtwitter #MedTwitter @MedTweetorials
First, edema formation. Starting with Starling's forces that govern fluid exchange between the plasma and interstitial space

Net filtration=LpS x [(Pcap-Pif)-s(Picap-Piif)]

(Pcap/Picap = hydrostatic pressure plasma/interstitium and Pif/Piif = oncotic pressure)
It would make sense that⬇️plasma oncotic pressure (Picap) with hypoalbuminemia would = fluid from plasma➡️interstitium.

HOWEVER what really matters is the oncotic gradient between plasma and interstitium (Picap-Piif)

With nephrotic syndrome (NS) Piif⬇️parallel to a⬇️in Picap
Read 17 tweets
Nayan Arora,MD Profile picture
May 18, 2021
How does increasing dietary potassium improve blood pressure?

I’ve heard this, even recommended it. But how does this really work? Grab some prunes and follow along this Tuesday morning tweetorial.

#Nephtwitter #cardstwitter @MedTweetorials
Let’s establish that potassium does appear to have an inverse relationship with BP

In a meta-analysis of 22 RCTs ⬆️ K+ intake⬇️BP by an average of 5.3/3.1 mmHg

💥greatest benefit seen in hypertensive patients who ⬆️potassium intake to 90-120mEq/d

👉pubmed.ncbi.nlm.nih.gov/23558164/
This study showed a ⬇️need for antihypertensives if dietary K+ was ⬆️
💥RCT 47 pts w/ htn
💥⬆️ K+ vs usual K+ diet
💥45% ⬆️ in dietary K+ in ⬆️ K+ group
🔥Hypertensive therapy ⬇️by at least 50% in 81% of intervention group v 29% in control group at 1 yr

👉pubmed.ncbi.nlm.nih.gov/1929022/
Read 15 tweets

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