Aisha Shaikh Profile picture
Division Chief, Nephrology @ VA| Nephrologist @ISMMSKidney|Interest in Dialysis Vascular Access| Tweets & RTs are not medical advice| Opinions my own
Kingston Profile picture Reza Hosseini ⚕️ Profile picture DickP Profile picture Shanil Keshwani Profile picture conorjudge Profile picture 20 added to My Authors
2 Aug
💥 A ‘Stuck’ Hemodialysis Catheter
- A Tweetorial

⚡️What is a ‘Stuck’ HD catheter?
⚡️What are the risk factors?
⚡️How to manage it?

@ASDINNews
#VascualarAccessPearls

1/
💥What is a ‘Stuck’ Hemodialysis Catheter?

⚡️Commonly referred to as a ‘Hemodialysis catheter that won’t come out’

But there is more to it...

2/
💥A ‘Stuck’ or ‘Tethered’ Tunneled HD CVC is a catheter that cannot be removed after dissection & release of the catheter cuff

⚡️It likely occurs due to fibrin sheath formation around the CVC & subsequent adherence of the sheath to the vessel wall

3/
Read 19 tweets
25 Jul
💥 A Case of Hyponatremia

⚡️It is cool to see the ⬆️ in Plasma Sodium be close to the predicted value based on our calculation

⚡️Let’s review the case

💥An elderly man with metastatic cancer presents with Hyponatremia
1/
💥Hyponatremia work-up is consistent with SIADH due to the malignancy

⚡️⬇️ Plasma Osmolality
⚡️Euvolemic
⚡️⬆️ Urine Osmolality
⚡️⬆️ Urine Na
⚡️Normal Uric Acid, TSH, Cortisol
⚡️On no medications that ⬆️ ADH
2/
💥Day # 1
⚡️Plasma Na =124 mEq/L
⚡️Urine Output/24 hrs = 1 L
⚡️Urine Osm. = 604 mOsm/kg
⚡️Wt = 59 kg
⚡️TBW = 35 L (0.6 x 59 kg)

💥Urine Osmolality x Urine Volume = Urine Solute Excretion
⚡️604 mOsm/L x 1L= 604
⚡️Pt’s daily solute excretion is 604 mOsm
3/
Read 12 tweets
18 Jul
💥How to use Urine Electrolytes for assesment & diagnosis of Kidney Disorders?

A great article in @CJASN
👉🏽 cjasn.asnjournals.org/content/14/2/3…

⚡️Summary of the article is in this🧵
#MedEd
#FOAMed
#NephPearls
💥Urine Na is used for:

⚡️Assessment of effective circulatory volume
⚡️Differentiation of Pre-renal Azotemia vs. ATN
💥Spot Urine Na

⚡️Urine Na < 15 mEq/L suggests ⬇️ effective circulatory volume BUT the caveat is:

‼️Spot Urine Na is dependent on the amount of ‘water’ in the urine

⚡️Hence spot Urine Na can be ⬇️ in the setting of water diuresis & ❌ always mean ⬇️ volume
Read 25 tweets
26 Jun
📚 New Nephrology Fellows - Here are some Tweetorials that will help you with Nephrology ‘Consults’

📟 PICC line placement in a CKD Patient👇🏽
1/
📟 Hemodialysis Catheter-Related Bactermia: Management👇🏽
2/
📟 Dialysis Nurse pages you about having issues with AVF cannulation👇🏽
3/
Read 8 tweets
22 Jun
💥”Can’t Cannulate a Dialysis AV Fistula - How to Troubleshoot?”
#Tweetorial

⚡️Difficultly in AVF Cannulation can be due to:

☄️Stenosis
☄️AVF Depth
☄️Collateral Veins
☄️Tortuous & Aneurysmal AVF
☄️Cannulation-related Pain
☄️Skin conditions

@ASDINNews
1/
💥AVF infiltration causes:

⚡️Pain
⚡️⬆️es CVC dependence
⚡️Results in additional interventional & surgical procedures
2/
💥So how to troubleshoot?

⚡️Think of AVF as a circuit & NOT just an anastomosis b/w an artery & vein
⚡️ Problems anywhere in👇🏽 circuit can cause cannulation problems

⚡️Circuit:
☄️Heart (Pump)
☄️Artery (Inflow)
☄️Body of AVF (Conduit)
☄️Vein (Outflow)
3/
Read 21 tweets
23 May
💥SGLT2 Inhibitors as Diuretics:
Tweetorial

⚡️SGLT2i: how is it’s diuretic effect potentially different from the Loop Diuretics?
1/

@RenalFellowNtwk
@NephJC
#NephJC
#SGLT2i
💥Let’s start with a Poll:

⚡️Loop Diuretics inhibit ❌ the Tubuloglomerular Feedback & ⬆️ Renin secretion
2/
💥Diuretics are used for Heart Failure therapy

⚡️The goal of diuretic therapy in Heart Failure is to achieve:

☄️Negative Na, Cl & Water balance
☄️⬇️ ECF volume
3/
Read 23 tweets
26 Mar
💥Can PICC Use be Avoided in CKD?
Tweetorial

Let’s review the following:
⚡️What is a PICC?
⚡️Indications for PICC use?
⚡️Complications associated w/
PICCs?
⚡️How can PICC use be avoided in
CKD patients?

#NKFClinicals
@RenalFellowNtwk
1/
💥What is a PICC?
⚡️Peripherally Inserted Central Catheter
It is a Central Vein Catheter‼️
⚡️Inserted into the peripheral veins of the upper arm
⚡️It passes thru the central veins
⚡️Tip of the PICC resides at the SVC/atrial junction or in the Right Atrium
2/
💥PICC use has been growing for reasons stated below👇🏽

3/
Read 21 tweets
26 Jan
💥’Endovascular AVF for Dialysis’ -
Tweetorial

⚡️What is an Endovascular Arteriovenous Fistula?
⚡️How is an EndoAVF different from a surgically created AVF?
⚡️EndoAVF Outcomes?

@ASDINNews
#EndoAVF
#VascularAccessPearls
1/
💥First a poll:
In the next few years, Endovascular AVF will completely replace the Surgical AVF for hemodialysis
💥Let’s first briefly review the Surgical-AVFs

⚡️In 1966, Brescia & Cimino described the creation of the Radial-Cephalic AVF in the distal arm👇🏽

⚡️This proved to be revolutionary & AVF became the dialysis vascular access of choice

2/
Read 23 tweets
21 Oct 19
💥’Dialysis AV Fistula & the Heart:
Friend or Foe?’ - Tweetorial

⚡️Let’s review the following:
☄️Hemodynamic effects of an AVF
☄️Impact of AVF on Cardiac Structure
& Function
1/
@ASDINNews
@RenalFellowNtwk
#VascularAccessPearls
💥Why is it important to understand the impact of AVF on the heart?
⚡️Because AVF use has ⬆️ in 🇺🇸
⚡️Cardiac disease is highly prevalent among ESRD pts.
⚡️50% of all ESRD deaths are due to
a CV-related cause👇🏽
2/
💥What causes cardiac disease in ESRD patients?
⚡️Many factors contribute to it - as shown below👇🏽
⚡️In this tweetorial, the focus will be on how the AVF affects the heart
3/
Read 20 tweets
24 Sep 19
💥 Dialysis Access Associated Venous Thoracic Outlet Syndrome (VTOS) is a rare but under-recognized cause of central vein stenosis in dialysis patients
⚡️Tweetorial on Dialysis Access Associated VTOS 👇🏽
1/
@ASDINNews
@MedTweetorials
#VascularAccessPearls
💥Venous Thoracic Outlet Syndrome
is due to:
⚡️Subclavian Vein stenosis caused by
it’s compression in the thoracic
outlet
⚡️Thoracic outlet is formed by the 1st
Rib, Clavicle & Subclavius
muscle👇🏽
2/
💥 Subclavian vein stenosis due to thoracic outlet compression can occur in healthy individuals & can present with:
⚡️Intermittent positional venous obstruction (McCleery Syndrome)
⚡️Venous thrombosis (Paget-Schroetter Syndrome)
3/
Read 10 tweets
30 Aug 19
💥Current American Diabetes Association guidelines recommend Metformin as the 1st line therapy for all T2DM patients👇🏽
⚡️But should Metformin be the 1st line therapy in T2DM patients with cardiovascular disease?
1/
#Metformin
#endotwitter
#cardiotwitter
💥Let’s review the following about
Metformin:

⚡️Mechanism of action
⚡️Safety profile
⚡️Cardiovascular benefits
2/
💥How does Metformin work?

⚡️It inhibits gluconeogenesis in the liver by mitochondrial inhibition & by ⬆️ activation of AMP-kinase👇🏽
⚡️It ⬆️ insulin sensitivity
⚡️It may have additional pleiotropic
effects👇🏽
3/
Read 12 tweets
9 Aug 19
@robshahverdyan @wasse_m @zayb_khawaja @nick_inston @alexmallios @SocietyAccess @VASAMD @Vascupedia_com Not aware of vascular access study in scleroderma but a few things:
-it may be reasonable to stay on a perm cath for a few months as Renal recovery has been described in up to 1/4th of pts. after dialysis initiation
Any chance of doing PD?
References 👇🏽
1/
1/
@robshahverdyan @wasse_m @zayb_khawaja @nick_inston @alexmallios @SocietyAccess @VASAMD @Vascupedia_com 2/ AV access can be challenging is Scleroderma due to:
-skin issues
-poor surgical wound healing
-Raynaud’s causing hand pain
-Pulmonary htn
My experience: Have had only 1 ESRD pt. with scleroderma who did PD before getting a transplant
Another reference 👇🏽
Read 2 tweets
3 Aug 19
💥Teaching point re: Rx of dialysis catheter related bacteremia
⚡️IV antibiotic alone is NEVER the correct Rx choice
Rx options are:
☄️IV antibiotic + CVC antibiotic
lock solution
OR
☄️IV antibiotic + CVC exchange
@ASDINNews
#VascularAccessPearls
1/
💥The reason IV antibiotic alone is not the correct choice is because it does not eradicate the bacteria in the CVC lumen biofilm
⚡️For effective clearance of bacteria from the biofilm you have to use CVC antibiotic lock solution or exchange the CVC
2/
💥The choice of antibiotic for catheter related bacteremia is listed below👇🏽
⚡️How to prepare the CVC antibiotic lock solution?👇🏽
@RenalFellowNtwk
3/
Read 4 tweets
7 Jul 19
💥’Physical Examination of the Dialysis Vascular Access’ - Tweetorial

Let’s first review the:
⚡️Anatomy of the Vascular Access
⚡️Vascular Access-related
complications
1/

@ASDINNews
@RenalFellowNtwk
#VascularAccessPearls
💥 A dialysis vascular access is a ‘circuit’ and NOT just a ‘connection’ between an artery & a vein

⚡️The circuit consists of:
☄️ Pump (heart)
☄️ Inflow (artery)
☄️ Conduit (body of the access)
☄️ Outflow (vein)
2/
💥 There are 3 basic types of vascular access:
⚡️AVF (arterio-venous fistula)
⚡️AVG (arterio-venous graft)
⚡️CVC (central venous catheter)

☄️AVF: created by a direct connection b/w an artery & a vein
☄️AVG: graft is interposed b/w an artery & a vein👇🏽
3/
Read 19 tweets
15 Jun 19
💥HeRO Graft Tweetorial

⚡️’HeRO’ stands for ‘Hemodialysis
Reliable Outflow’
⚡️What Nephrologists need to know
about HeRO👇🏽
⚡️HeRO graft: Indications, Outcomes
& Complications
1/
@ASDINNews
@SocietyAccess
@RenalFellowNtwk
#HeRO
💥What is a HeRO Graft?

⚡️It is half graft + half catheter
⚡️Fully Subcutaneous

⚡️Graft-component is connected to the artery at one end & to the catheter at the other end

⚡️Catheter-component serves as venous outflow w/ it’s tip @ SVC/R. atrium
2/
💥Is any part of the HeRO graft exposed externally?
⚡️No

⚡️Graft-part is subcutaneous just like the conventional AVG

⚡️Catheter-part traverses the central veins BUT instead of sticking out through the skin it connects subcutaneously w/ the graft👇🏽
3/
Read 21 tweets
29 Apr 19
💥 Hydroxychloroquine - is an
Anti-malarial drug that also has immunomodulatory properties
⚡️It is used to Rx auto-immune conditions
⚡️The origin and history of this drug is as fascinating as it’s benefits
1/
@RenalFellowNtwk
#Lupus
#medtwitter
💥 Quinine was 1st found in the bark of the ‘Cinchona’ tree by the Inca in Peru to Rx ‘shivering’
⚡️It is believed that the tree got its name ‘Cinchona’ after it was used to treat the ‘Countess of Chinchon’ for a febrile illness in the 1630s
2/
💥 In the early days, the Cinchona bark tree powder was called the ‘Jesuits Powder’ (and not Quinine)
⚡️However, this 👆🏽is why side effects from quinine - such as tinnitus, headaches and poor vision are referred to as ‘Cinchonism’
3/
Read 19 tweets
24 Apr 19
The #CREDENCE Trial was discussed @NephJC last night. We were fortunate to have the lead author of the paper @VladoPerkovic join in. He took questions from the participants. Here is the summary of his responses 👇🏽
#CREDENCE
#NephJC
@hswapnil
@kidney_boy
Q1: Why was the 100 mg dose of Canagliflozin used in #CREDENCE and not the 300 mg dose?
VP: We were anxious about the toxicity as seen in some previous trials, & we wanted to minimize that risk
#NephJC
Q2: Why did centers from Germany have a lower HbA1C cut off for inclusion in the study compared to the centers from other parts of the world - 10.5% vs. 12%?
VP: That was a regulatory request from Germany 🇩🇪
#NephJC
Read 24 tweets
22 Apr 19
💥How do SGLT2 Inhibitors work?
💥How does an anti-diabetic drug improve Renal & Cardiovascular outcomes?
💥To understand this let’s first review:
⚡️Renal handling of glucose
1/
@RenalFellowNtwk
#NephJC
#SGLT2
#CREDENCE
💥Renal handling of glucose:
⚡️180 g of glucose is filtered thru the glomeruli every day
(180 L x 100mg/dL)
⚡️But all the glucose is completely reabsorbed
⚡️Renal reabsorption of glucose occurs thru transporters in the proximal tubule called SGLT
2/
💥Sodium-Glucose Co-transporters (SGLT)
⚡️There are many 👇🏽
⚡️Not all of them are located in the kidney👇🏽
3/
Read 24 tweets
18 Apr 19
💥Why is the #CREDENCE Trial such a big deal for the Nephrologists?
⚡️It is the first ‘positive’ trial in CKD DM pts. in two decades!
1/
@RenalFellowNtwk
@VladoPerkovic
@georgeinstitute
#NephJC
#Nephpearls
The last positive RCTs in CKD-T2DM were RENAAL & IDNT & those were published in 2001....19 years ago!

💥RENAAL Trial: Losartan ⬇️ CKD progression & ⬇️ risk of ESRD by 28% compared to placebo, but it did not lower CV mortality
2/
💥IDNT Trial: Irbesartan ⬇️ CKD progression & risk of ESRD by 23% compared to the Amlodipine and Placebo, but it did not lower CV mortality
3/
Read 17 tweets
17 Mar 19
💥Tweetorial on ‘Are AVF’s the best dialysis vascular access?
⚡️Do AVFs have better long term patency than AVGs?
⚡️Impact of vascular access type on clinical outcomes?
⚡️Are AVFs cost effective in all pts?
@RenalFellowNtwk
#VascularAccessPearls
💥Do AVF’s have better long term patency than AVGs?
⚡️Observational studies have shown that AVFs have better cumulative access survival than AVGs but...👇🏽
💥Why is it important to look at the cumulative AV access survival from the ‘Time of AV access creation’ and NOT from the ‘Time of successful AV access use’?
⚡️Let’s take a look at this study which compared the cumulative survival of AVF vs. AVG 👇🏽
Read 18 tweets
28 Feb 19
💥Tutorial on ‘Dialysis Adequacy’
⚡️Is Urea a good solute to assess Adequacy ?
⚡️Is Kt/V urea a good Adequacy test?
⚡️Should ‘time on dialysis’ be an independent measure of Adequacy?
⚡️Should ‘UF rate’ be a measure of Adequacy?
@RenalFellowNtwk
#NephPearls
Urea is not the perfect uremic solute to assess dialysis adequacy, in fact it is far from perfect👇🏽
Kt/V urea is a measure of the dialysis dose
‘K’ is the dialyzer clearance, ‘T’ is the time on dialysis and ‘V’ is the volume of distribution of urea (which = Total Body Water)
Familiarize yourself with spKt/V, eKt/V and stdKt/V 👇🏽
Read 25 tweets