I'm putting together a lecture on AKI for emergency medicine doctors. Here is my outline. What am I missing? #AskRenal
I wanted to be practical and stick with the realities of AKI management today rather than forward looking technologies that may be impactful in the future.
Since the pretest probability that fluids will help AKI, physicians should not try to find volume depleted people, but should give fluids to everyone unless the fluids would be harmful.
How do you uncover urinary obstruction?
The FENa and FEUrea are “An Elegant Weapon for a More Civilized Age.” but are not very helpful on the routine evaluation of AKI.
Urine eosinophils, please tell me your still not doing this and hopefully not teaching students to do this.
If ~90% of AKI is fixed with a foley and some crystalloids, what about remaining 10%? Most of that is ATN and you just need to be patient. But be careful of the "Do not miss diagnosis." These require intervention.
On to cardiorenal syndrome in a few slides. The last two show that bumps in Cr (worsening renal function if you are a cardiologist) while treating CRS do not cause kidney biomarkers to go up. MORE DIURETICS.
STARRT, AKIKI, and IDEAL-ICU in a GIF. TL;DR: no dialysis until they need dialysis.
Furosemide stress test as GIF
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Next session started by Rovin to talk about IGAN pathophysiology and the selection of therapeutics
4-hit model 1. formation of IGA galactose deficient 2. formation of autoantibodies against these IgA 3. Formation of circulating IgG-IgA1 immune complexes 4. Deposition of the immune complexes in the kidney
#RKDSummit
1st case
Hematuria on U/A
Gross hematuria after covid vaccine
10 RBC/HPF, no casts
Scar 0.9 mg/dl, 24-hr urine 750 mg of protein
#RKDSummit
A bit “Juicy”
Mesangial expansion (arrows, fig 1)
Mesangial hypercellularity (circle, fig 2)
Biopsy has no chronicity (fig 3)
Lights up with C3 and IgA (fig 4)
When we published our study <> of ODS and hyponatremia we were pummeled for including people at low risk of ODS because we included Na levels between 120 and 130. They said it is well known "that ODS is incredibly rare/non-existent at those levels." 1/4evidence.nejm.org/doi/10.1056/EV…
Of course one of the reasons it was thought to be incredibly rare was that no one looked for CPM in patients with Na from 120-130. We found a fair number (≤5 of 12). 2/4
Our findings are replicated in a study from Australia. The authors took a different approach to investigating ODS. Instead of starting w/ hyponatremia and working forward to ODS, they started with a dx of ODS and worked backwards
3/4ncbi.nlm.nih.gov/pubmed/35717664
Gadolinium in dialysis patients.
What's up with that?
#Tweetorial
1/11
Nephrogenic systemic fibrosis (NSF) is an iatrogenic disease that presents with hardening of the skin and other organs. It is often lethal. I treated 5 people with this condition (including one with AKI). Terrible.
2/11
The etiology of NSF was unknown and there were many theories. In 2006, Thomas Grobner published a small case series showing 5 patients developing NSF within weeks of receiving gadolinium contrast for MRI.
3/11pubmed.ncbi.nlm.nih.gov/16431890/
I just recently recommended the Renal Physiology book by Bruce Koeppen and Bruce Stanton. I thought it was a good medical student level text book: pbfluids.com/2023/08/ouwb-s…
But I came across this question in Chapter 8 Regulation of Acid Base. It is a straight forward question asking the learner to interpret simple acid-base cases.
But the question falls apart when you look at the answer...