Jamie Willows Profile picture
Renal/GIM SPR - many more questions than answers. Dad. LTFT. Runner. Poker player. POCUS amateur. Twitter for medicine only.
30 Apr 20
Do you manage the renal impact of #covid19 on general wards?

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

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

= lots of relevant info in 8 tweets👇

#medtwitter #covid4mds

✅ 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
1 Mar 20
#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
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
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
26 Jan 20
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
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

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
25 Aug 19
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)
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.
Read 17 tweets
18 Aug 19
To celebrate 1 yr of taking referrals as the renal registrar on-call, it’s time for some kidney-themed #tipsfornewdocs covering high K, AKI, “nephrotoxins”, medications, iv contrast, hypertension, & caring for kidney transplant & dialysis patients. #nephpearls (thread)
⬆️K - Renal #tipsfornewdocs 1/18

✅ Insulin-dextrose is not benign (⬇️BM risk) & does not get rid of K (only hides it), therefore rather than give round after round do phone us for help!
✅ Repeat ECG, re-bolus calcium gluconate if persistent changes
✅ Salbutamol dose = 10-20mg
⬆️K - Renal #tipsfornewdocs 2/18

✅ Get a bicarb level (correct acidaemia to help ⬇️K)
✅ No one who can’t name 3 side-effects of bicarb should decide to give bicarb (not a bad rule for any drug!)
✅ Review NSAIDs, ACEi, A2RBs, spironactone, beta-blockers, trimethoprim, diet
Read 20 tweets