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Joel M. Topf, MD FACP

Follow @kidney_boy

Jul 9 • 11 tweets • 6 min read

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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More from @kidney_boy

Joel M. Topf, MD FACP

@kidney_boy

Jul 7

"The treatment of anuria should be conservative. If circulatory failure is present, appropriate steps should be taken to correct it. Otherwise, therapy is limited to the balanced maintenance of the patient until the kidneys have a chance to affect recovery."

Homer Smith 1951

71 years later and the most significant advance is replacing anuria with acute kidney injury.

A policy of fluid restriction was therefore adopted empirically, with the triple objective of avoiding edema (especially renal), of resting the kidneys, and of avoiding an overload of the circulatory system with fluid which had no escape.

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Joel M. Topf, MD FACP

@kidney_boy

Jun 19

He seems nice

And Doc Hudson showed up! #eyesondesign

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Joel M. Topf, MD FACP

@kidney_boy

Jun 14

I was on call last night and the ER called with a case hyperkalemia. The ER was crazy (literally there was an active shooter in the ambulance bay moments before I received the call clickondetroit.com/news/local/202…)

So you need to be quick and precise with your questions.

How high is the potassium and is it confirmed on the EKG? It is always helpful to quickly establish that this is not pseudohyperkalemia. It was not.

https://twitter.com/kidney_boy/status/1536690291356352520?s=20&t=l-L0vZQ3hvbg--YjYzvNzQ

Does the patient have a foley and are they making urine? Quickly correct urinary obstruction which can cause hyperkalemia and determine if you can use the kidneys to clear the potassium.

Yes on foley, no on urine.

Read 10 tweets

Joel M. Topf, MD FACP

@kidney_boy

May 22

Every person who ever had a high potassium on labs was told to adopt a low potassium diet. Recently, a meta-analysis and systematic review looked into the data to support this. jrnjournal.org/article/S1051-…

Regarding the question of dietary restriction of potassium to lower serum K, there were 2 studies. TWO. And take a look at the weight of the two studies, Cockram has 90%. So in essence this meta -nalysis can just be replaced by looking at Cockram alone.

And Cockram is a weird study. It is all dialysis patients that were placed on liquid feeds and nothing but liquid feeds for two weeks. 🤮

And this is the "science" that ubiquitous recommendation of "low potassium diet" rests on. sciencedirect.com/science/articl…

Read 4 tweets