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;
✅ AKI
✅ Volume status
✅ ACEi
✅ Transplant & dialysis patients

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

= lots of relevant info in 8 tweets👇

#medtwitter #covid4mds
AKI 1

✅ 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
1/
#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
2/
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
3/
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
1/
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
2/
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

ncbi.nlm.nih.gov/m/pubmed/19546…
3/
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)
#nephpearls
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