Jamie Willows @jamiekwillows Twitter profile

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Jamie Willows

@jamiekwillows

5 years

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)

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Jamie Willows

@jamiekwillows

2 years

You get called to the haemodialysis unit. An 18 yr old man has missed his dialysis all week & today reports weak legs. The dialysis nurse snaps this ECG as he passes out. What do you do? Is starting dialysis during CPR ever a thing? A thread on hyperkalaemic cardiac arrest👇

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Jamie Willows

@jamiekwillows

4 months

The UK has the best hyperkalaemia guidelines in the world, and they’ve just been updated. No one can cover all 171 pages, but here are 3 quick important bits in a thread👇

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Jamie Willows

@jamiekwillows

4 years

New NICE guidance on contrast-induced nephropathy released. ✅ Well enough to be outpatient = well enough for oral hydration ✅ iv fluid for high risk inpatients (eg eGFR <30) ✅ There’s no renal reason to delay emergency imaging (though discuss if you must) #medtwitter thoughts?

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Jamie Willows

@jamiekwillows

4 months

1️⃣ Key thing in this flowchart = a well outpatient without AKI who has potassium 6.3mmol/L on routine bloods can be managed as an outpatient (yes they need prompt review, repeat bloods and some thought - but what they don’t need is a repeat test in ED at 3am)

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Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

2 years

1/ Nephrology: “We will forever argue about validity of equations to convert serum creatinine to eGFR using age, sex etc” Also nephrology: “We will make no adjustment for muscle mass when using urinary creatinine within urine ACR” A #tweetorial on two albuminuria paradoxes 👇

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Jamie Willows

@jamiekwillows

1 year

1/20 Difelikefalin approved by NICE for uraemic itch in patients on haemodialysis! (on the same day I was offered a consultant job with a haemodialysis role - also exciting!) Thread to learn everything you need to know about difelikefalin🧵👇

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Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

5 years

Iv contrast - Renal #tipsfornewdocs 11/18 ☠️ If you or your reg are worried your patient with AKI or CKD could have ischaemic bowel then do the contrast CT scan - there’s no value protecting the appearance of the kidneys on autopsy. (if iv contrast would have hurt at all....)

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Jamie Willows

@jamiekwillows

2 years

1/ As you can imagine the evidence base for optimal management of hyperkalaemic cardiac arrest is fairly low quality. Here’s some ideas (majority of which are based on fantastic UKKA 2020 review & algorithm👇), but every tweet comes with the “but no one knows for sure” caveat….

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Jamie Willows

@jamiekwillows

1 year

Pleased to see that our post on how to manage DKA in patients on dialysis has >10,000 views on the great @RenalFellowNtwk - things just ain’t the same when there isn’t an osmotic diuresis. @simonjsmiths

DKA in Patients on Dialysis and Anuria: Pathophysiology, Pearls, and Pitfalls

Simon Smith, MDInternQueen Elizabeth Hospital, Gateshead, UK Jamie Willows, MDRenal fellowFreeman Hospital, Newcastle Upon Tyne, UK Diabetic ketoacidosis

www.renalfellow.org

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Jamie Willows

@jamiekwillows

5 years

Apologies if tone of above a bit negative at times!! We are nice and helpful really! Would like to hear anyone else’s top tips too.

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Jamie Willows

@jamiekwillows

4 months

2️⃣ Treating hyperkalaemia in hospital, they lean in more to Lokelma over Patiromer as adjunct binder: ✔️faster onset ✔️greater effect within timeframe ✔️pending further evidence, e.g. 🚨More importantly, please forget that calcium resonium ever existed🚨

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Jamie Willows

@jamiekwillows

6 months

Very exciting flozinating times in the UK! 🔥Soon getting official go-ahead to slow CKD progression by prescribing SGLT2i if eGFR 20-45, even if no albuminuria🔥 See draft NICE guidelines published today (official due December), and UKKA flozin update - links in next tweet👇

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Jamie Willows

@jamiekwillows

2 years

3/ Start usual advanced life support algorithm, plus: 👉 Get calcium in via good access ✅ 10ml calcium chloride 10% recommended, as doesn’t need hepatic metabolism like calcium gluconate ✅ repeat at 5-10 mins if no ROSC If you do get ROSC, you still need to get the K down….

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Jamie Willows

@jamiekwillows

5 years

“Nephrotoxins” - Renal #tipsfornewdocs 8/18 ✅ ACEi in heart failure with reduced ejection fraction (HFrEF) = one of most beneficial drugs known to man ✅ If you wouldn’t stop chemotherapy without review plan, don’t stop ACEi in HFrEF without one (benefit often many fold higher)

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Jamie Willows

@jamiekwillows

5 years

⬆️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

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Jamie Willows

@jamiekwillows

5 years

⬆️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

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Jamie Willows

@jamiekwillows

1 year

NICE guidance on finerenone now out (photo👇) ✅ Can use in patients with T2DM if albuminuria & eGFR 25-60 ✅ Should be on max ACEi/ARB and SGLT2i already (if tolerated) @NephJC on Fidelio trial (note little antihypertensive effect, need to monitor K🍌)

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Jamie Willows

@jamiekwillows

5 years

⬆️BP - Renal #tipsfornewdocs 12/18 ✅ Think of asymptomatic inpatient ⬆️BP as a chronic problem = STAT doses of meds are rarely required (also, treat pain!) ✅ Amlodipine takes 8 hrs to reach peak concentration; lower re-check BP 30mins after STAT dose is regression to the mean

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Jamie Willows

@jamiekwillows

5 years

“Nephrotoxins” - Renal #tipsfornewdocs 9/18 ✅ Don’t tell HFrEF patient “those ACEi drugs poisoned your kidneys” - creates massive headache when comes to restarting the life-saving drug ✅ Diuretics can actually can be good for the kidneys - especially if patient congested

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Jamie Willows

@jamiekwillows

5 years

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

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Jamie Willows

@jamiekwillows

2 years

17/ Summary for ⬆️K cardiac arrest: ✅ Aggressive calcium ✅ Early adrenaline ✅ Insulin-dex bolus �� iv 8.4% bicarb ✅ Plan ahead for dialysis during CPR (+-ECMO) if appropriate & practical ✅ If you’re the renal reg on-call, go find out if your HD machines are defib-proof?

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Jamie Willows

@jamiekwillows

5 years

AKI - Renal #tipsfornewdocs 4/18 ✅ AKI doesn’t respond to giving litre upon litre of IVT to euvolaemic, normotensive patients ✅ It’s always obstruction in older men until proven otherwise ✅ In wet patients with AKI, continuing diuresis will almost always be our answer

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Jamie Willows

@jamiekwillows

5 years

AKI - Renal #tipsfornewdocs 3/18 ✅ Using eGFR in steady state CKD is fine but it isn’t helpful in AKI - use creatinine ✅ You can say you’ve sent “renal screen” but we’ll still ask what you’ve actually sent ✅ Avoid urinary catheters if bottles will measure urine output fine

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Jamie Willows

@jamiekwillows

2 years

I confess I chuckled a bit when the NICE CKD guideline said “advise patients not to eat meat before their blood test” as I didn’t realise the size of the effect - serum creatinine almost doubled from 87umol/L to 163umol/L at 3 hours after eating 300g boiled beef!

Tony Breu

@tony_breu

2 years

Heating meat can lead to conversion of creatine to creatinine. As a result, eating cooked meat has been shown to cause an acute rise in serum creatinine. This isn't seen with raw meat.

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Jamie Willows

@jamiekwillows

2 years

2/ Firstly – don’t wait for confirmation of ⬆️K 🚨With this history & ECG, the diagnosis = ⬆️K 🚨It is also largely accepted that ECG sensitivity is poor, & subtle or non-classical changes prior to arrest are possible, so even without this ECG starting ⬆️K treatment sensible

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Jamie Willows

@jamiekwillows

2 years

6/ Sodium bicarb isn’t used in 'routine’ arrests BUT is for ⬆️K 🟢 Give 50ml iv NaHCO3 8.4% ⛔️ via different access to iv calcium ⁉️Conundrum: does the hypertonic sodium cause more stablisation of the cardiac membrane than the bicarb-driven ⬇️ionised calcium destablises it?⁉️

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Jamie Willows

@jamiekwillows

5 years

Medications - Renal #tipsfornewdocs 10/18 ❌ No clarithromycin for patients on tacrolimus ❌ Metformin is a “good day” only drug ❌ No baclofen in later stage CKD/dialysis ❌ Try to avoid trimethoprim / co-trimoxazole in AKI as pushes up creatinine (& ⬆️K) & muddies the waters

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Jamie Willows

@jamiekwillows

11 months

Strong from the RCEM & RCR: ✳️If a CT with contrast is needed in an emergency, there is no reason to delay it✳️ (the kidneys do much worse with a missed diagnosis than a bit of iv contrast)

Royal College of Emergency Medicine

@RCollEM

11 months

🚨We have published a new statement with @RCRadiologists on 'Emergency Computed Tomography scans and the use of Intravenous Iodinated Contrast Agents' See the joint statement and recommendations here:

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Jamie Willows

@jamiekwillows

2 years

@kidney_boy Nice BP chart! Good reminder not to uptitrate meds too quickly: sometimes people seem to think of antihypertensives like lightswitches, but the time lag til max effect concept is solidified in my head by this graph👇

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Jamie Willows

@jamiekwillows

2 years

8/ If patient was already dialysing does this change things? Yes! Most machines NOT shock-proof in UK ✳️Patient needs disconnected prior to shocking ✳️These stickers identify defib-proof machines👇 Survey in 2007 = 25% UK renal units unaware of above

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Jamie Willows

@jamiekwillows

3 years

This week @Nephjc will be discussing CONFIRM - the largest ever trial of patients with type 1 hepatorenal syndrome, examining terlipressin versus placebo. This is no niche renal paper - hope to see lots of specialities joining the discussion! #nephjc

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Jamie Willows

@jamiekwillows

5 years

Renal #tipsfornewdocs 18/18 Other way to save a life; ✅ If swapping to meropenum plus more IVT for a recurrent temp spike with worsening AKI, ask “Could this be vasculitis?” Easiest way to save a life; ✅ Remember IVT is one of the most dangerous drugs you prescribe

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Jamie Willows

@jamiekwillows

2 years

12/ Hesitancy to start dialysis during CPR is inevitable, probably due to expectation of failure. To quote Dr Annette Alfonzo (author UKKA guidelines) on the issue: “like most things in life, you may not always succeed, but failure is usually guaranteed if you do not try”

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Jamie Willows

@jamiekwillows

5 years

Haemodialysis pts on wards - Renal #tipsfornewdocs 15/18 ❌ Creatinine & urea build up again after HD; this doesn’t mean they need IVT ❌ Post-HD K often low; this doesn’t mean it needs replaced (K rapidly builds-up again) ✅ Renal pharmacists are great asset if can find them

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Jamie Willows

@jamiekwillows

5 years

Renal #tipsfornewdocs 17/18 Things we’ll (almost) always say no to; ❌ “Can I take blood from the fistula?” ❌ “Can we use the tunnelled dialysis line as routine iv access?” ❌ “Do you want to see this patient with renal colic?” ❌ “Would EPO help with anything at 2am?”

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Jamie Willows

@jamiekwillows

5 years

“Nephrotoxins” - Renal #tipsfornewdocs 7/18 ❌ Most common reason for re-admission after AKI = pulmonary oedema ❌ Likely factor = ACEi and/or diuretics stopped (possibly appropriately in short term) but without review in patients who needed them going forwards

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Jamie Willows

@jamiekwillows

2 years

5/ Does iv insulin work? No one knows, but will take 15+ mins to even start. UKKA recommend: ✔️Give 10 units iv insulin with 25g glucose (e.g. 125ml of dex 20%) via iv bolus ✔️If pre-treatment sugar on low side give additional dextrose infusion, aiming to avoid hypoglycaemia

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Jamie Willows

@jamiekwillows

1 year

1/9 The satisfaction I get from swapping bendroflumethiazide to indapamide (while trying to sound clever by muttering something about longer half life) may be coming to an end. Sigh. A reasonably niche 🧵 about thiazides for hypertension in the UK.…👇

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Jamie Willows

@jamiekwillows

5 years

Dialysis pts on wards - Renal #tipsfornewdocs 16/18 ✅ If still pee, protect residual renal function ✅ If anuric, think of them like closed box - any fluid you put in has to get out somehow. Never for bag upon bag of “maintenance iv fluids”. If need bolus, 250ml & re-assess.

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Jamie Willows

@jamiekwillows

4 years

THREAD 1/15 The monthly @TheSkeletonKG case has dropped: ‘Hypercalcaemia – chasing horses, finding zebras’. Read on for hypercalcaemia pearls #medtwitter #nephtwitter #endotwitter #FOAMED

Renal Fellow Network

@RenalFellowNtwk

4 years

Skeleton Key Group Case 13: Hypercalcemia - Sometimes, is *is* a zebra! The Skeleton Key Group @TheSkeletonKG reviews a much less common cause of hypercalcemia @jamiekwillows @CTeodosiu

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Jamie Willows

@jamiekwillows

2 years

4/ Does giving iv adrenaline (epinephrine) earlier than usual ALS protocol help? Some experts say give it immediately as it’s fast acting & should hide K intracellularly - that’s what I’d do (but even if just giving it as per usual ALS algorithm, the delay will be minimal)

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Jamie Willows

@jamiekwillows

5 years

Very nice summary slide of hypertension management in CKD. It’s nicer to be alive with a slightly worse eGFR than die from a CV event with a good eGFR - accumulating evidence for more aggressive BP targets to protect the heart/brain, even if not the kidneys. #ERAEDTA19

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Jamie Willows

@jamiekwillows

2 years

7/ Any drug effectiveness studies? None without limitations. Largest: 👉retrospective look at 109 arrests with ⬆️K 👉suggestion if both iv Ca & bicarb used can sometimes get ROSC up to K=9 👉No survivors when K >9.4 However, no patients were dialysed.

The effects of calcium and sodium bicarbonate on severe hyperkalaemia during cardiopulmonary...

The use of calcium and SB might be effective in the treatment of severe hyperkalaemia during cardiac arrest. The efficacy of SB/calcium correlated with serum potassium level. However, because the...

pubmed.ncbi.nlm.nih.gov

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Jamie Willows

@jamiekwillows

5 years

Haemodialysis (HD) pts on wards - Renal #tipsfornewdocs 14/18 Let us know if they; ✅ Bleed; we’ll avoid heparin on HD ✅ Need surgery; need HD re-arranged ✅ Get sick; outpatient HD unit mightn’t be safest place for them ✅ Need routine bloods; easy on HD days, saves extra stab

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Jamie Willows

@jamiekwillows

5 years

AKI - Renal #tipsfornewdocs 5/18 At referral, we’re thinking 4 qs; 1. Differential diagnosis? Hence we need historical creatinines, volume status, urine dip, imaging results, all events & bloods this admission, new & prev meds 2. Patient safe to transfer? Need current obs, K, pH

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Jamie Willows

@jamiekwillows

4 months

3️⃣ I have covered their fantastic hyperkalaemic cardiac arrest guidelines before (without getting too much abuse from medtwitter for inaccuracy) - link here 👍

Jamie Willows

@jamiekwillows

2 years

You get called to the haemodialysis unit. An 18 yr old man has missed his dialysis all week & today reports weak legs. The dialysis nurse snaps this ECG as he passes out. What do you do? Is starting dialysis during CPR ever a thing? A thread on hyperkalaemic cardiac arrest👇

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Jamie Willows

@jamiekwillows

2 years

11/ Points from table: ✳️Mean K at arrest = 9.2, mean K at ROSC = 6.1 ➡️ very hard to achieve this drop with drugs alone ✳️Mean dialysis time until ROSC = 50 mins ✳️Weak evidence that, even in extreme ⬆️K, outcomes can be good when dialysis used (in contrast to tweet 7 study)

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Jamie Willows

@jamiekwillows

2 years

Fin 2/ The case was purely fictional. ECG courtesy of Simmer, Wilde & ECGpedia. For reference: The fantastic 161 page UKKA hyperkalaemia guideline European resus guideline “for special circumstances”

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Jamie Willows

@jamiekwillows

5 years

Transplant pts - Renal #tipsfornewdocs 13/18 ✅ We want to know they’re in, esp if immunosuppression issue (NBM, infection - double pred!), or AKI (get urgent US for starters) ✅ Tacrolimus & ciclosporin at 10am & 10pm (gives phlebotomy time to take trough levels before AM dose)

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Jamie Willows

@jamiekwillows

2 years

14/ How is HD done? ✅ Low K dialysate ✅ Use existing access or insert femoral line (easier site during CPR) ✅ Bolus 250ml fluid at start of dialysis, give anticoagulation ✅ Initial pump speed 100ml/min, aim to gradually increase to 200ml/min Lots more tips from UKKA👇

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Jamie Willows

@jamiekwillows

2 years

9/ And if not dialysing? Can consider STARTING during arrest when K refractory to medical therapy as: 1️⃣ ROSC unlikely unless get K controlled 2️⃣ Logical to use most effective treatment to ⬇️K, esp when very high 3️⃣ Case reports show feasibility & efficacy of dialysis during CPR

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Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

5 years

CKD is not a diagnosis - keep thinking #rcpeRenal19 @CharlieTomson

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Jamie Willows

@jamiekwillows

2 years

10/ These case reports collated by UKKA demonstrate some good outcomes using IHD, CVVH, & even PD in prolonged cardiac arrest (though the publication bias must be huge - one wonders how many unpublished poor outcomes there are for every one reported success)

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Jamie Willows

@jamiekwillows

5 years

AKI - Renal #tipsfornewdocs 6/18 3. Safe to biopsy? Correct coag, valid group & save, r/v anti-platelets, control ⬆️BP 4. Safe to dialyse? Urgent BBV serology = avoid dialysing in isolation = ⬆️efficiency of dialysis nurse time. Octenisan & naseptin = lines safer with ⬇️SA load

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Jamie Willows

@jamiekwillows

5 years

Average CREDENCE patient age 63 with eGFR 56; IF projected effect on eGFR holds true, this average patient would delay developing eGFR 10 by over 15 years by taking SGLT2i! #ERAEDTA19

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Jamie Willows

@jamiekwillows

5 years

If serum PLA2R positive and eGFR>60 retrospective review of 60 nephrotic patients showed that renal biopsy did not alter their management - all had membranous nephropathy, no other relevant pathology found, & all to play for given maintained eGFR. #eraedta19

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Jamie Willows

@jamiekwillows

4 years

4/ A pearl in diagnosis - suspect pseudohyperkalaemia in patients with very high WCC or platelet counts. Prove it by taking a VBG straight to the gas machine (no time for K release from cells so you’ll get the true K value and avoid the harms of unnecessary treatment)

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Jamie Willows

@jamiekwillows

4 years

13/ If you’ve made it this far you may be the type of person to wonder if KDIGO had anything good in their supplementary material. Well, this is as thorough a list of hyperkalaemia risk factors as I’ve ever seen....

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Jamie Willows

@jamiekwillows

3 years

Major take home point - patients on dialysis who never pass urine should not be given DKA treatment as per the cookbook guideline! Was a pleasure writing this with @simonjsmiths , & thank you to @docanjuyadav @Elena_Cervants @amyaimei @Nephro_Sparks for the edits! DKA pearls👇

Renal Fellow Network

@RenalFellowNtwk

3 years

DKA in Patients on Dialysis and Anuria: Pathophysiology, Pearls, and Pitfalls @simonjsmiths @jamiekwillows @NSMCInternship

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Jamie Willows

@jamiekwillows

4 years

Fin/ Here’s the paper. Would love to hear other people’s opinions (or disagreements).

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Jamie Willows

@jamiekwillows

2 years

16/ However, obviously prevention is better than cure… I wrote a not great, non-exhaustive thread on some pitfalls of inpatient ⬆️K management a few years ago, though I suspect anyone making it this far will know plenty about this already (maybe not about the dried toad skin…)

Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

4 years

7/ KDIGO hyperkalaemia treatment algorithm Key message #tipsfornewdocs ✅ Don’t use potassium-hiding therapies (iv insulin/dextrose and neb) but do nothing else as it’ll just rebound. You must address the underlying cause and consider potassium-eliminating treatments.

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Jamie Willows

@jamiekwillows

2 years

Fin/ As ever, I’m a trainee mostly putting this together just to teach myself, so I welcome any tips/corrections from the more experienced. The concept of HD during CPR sits uncomfortably with me, but better to mentally prepare in case a v rare scenario presents itself I suppose

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Jamie Willows

@jamiekwillows

3 years

Thrilled to be on the team, thank you! Looking forward to a big year of learning in 2021 with the @NSMCInternship

Matthew Sparks, MD

@Nephro_Sparks

3 years

Excited to welcome the @NSMCInternship class of 2021 (the 7th) These 35 individuals will make a big impact in medicine and nephrology #FOAMed #NephForward Read out them and follow them here 👇👇

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Jamie Willows

@jamiekwillows

2 years

15/ What else? ✔️Consider ECMO ✔️Mechanical chest compression device if prolonged CPR ✔️Given often refractory to shocks until K controlled, some experts advocate to keep going until K normal (if appropriate) ✔️If get ROSC obviously ensure you clear K & monitor for rebound….

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Jamie Willows

@jamiekwillows

2 years

13/ Who might you consider for dialysis for ⬆️K arrest? Patient selection: ✔️Suitable for prolonged attempt at CPR (you’ll have your own thresholds) ✔️Medical treatment alone unlikely to be effective (based on severity of hyperkalemia & treatment response over first 15 mins)

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Jamie Willows

@jamiekwillows

3 years

@SkylerLentz @PulmCrit Agree the usual DKA protocol recipe is disastrous in ESRD. Often the hypertonicity has made the patient very thirsty leading to hypervolaemic DKA - creates an unusual situation in which iv insulin alone can reverse pulmonary oedema! My deeper dive thread on the topic below 👇

Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

4 years

THREAD 1/13 We hope #medtwitter liked our latest case from @CRRTiff & @TheSkeletonKG on high anion gap metabolic acidosis (HAGMA) - here’s the link if you’re late to the #FOAMed #tweetorial #nephtwitter

TheSkeletonKeyGroup

@TheSkeletonKG

4 years

Hello #medtwitter ! We’re back with a new case “An Unexplained Acidosis” 😎🤩 #MindTheGap #Nephtwitter #FOAMed 🌟Can you explain what’s going on in this case?! @RenalFellowNtwk

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Jamie Willows

@jamiekwillows

2 years

How much incidental serum MPO or PR3 antibody positivity is there in the general population? If you take blood from 1000 adults at random, (assuming none have clinical vasculitis) how many would test positive for MPO or PR3? #askrenal @GlassockJ

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Jamie Willows

@jamiekwillows

6 months

Strong agree - diabetes emergencies in patients on haemodialysis cannot be treated with the ‘usual’ protocol. Deep dive here at this link:

DKA in Patients on Dialysis and Anuria: Pathophysiology, Pearls, and Pitfalls

Simon Smith, MDInternQueen Elizabeth Hospital, Gateshead, UK Jamie Willows, MDRenal fellowFreeman Hospital, Newcastle Upon Tyne, UK Diabetic ketoacidosis

www.renalfellow.org

IMCrit

@IM_Crit_

7 months

9. Patients on dialysis who present to the emergency room in diabetic ketoacidosis need to be treated with some tweaks in the usual hospital DKA protocol. Others have commented on this (I think @pulmcrit ). Just don’t follow the protocol blindly...

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Jamie Willows

@jamiekwillows

5 years

Newcastle represented at #eraedta19 - @johnasayer focussing on cystinuria Tx; ✅ High fluid intake (there’s an app for that) ✅ Low animal protein / low Na diet ✅ Alkalise urine with K citrate ✅ Tiopronin (though high freq of side-effects) #eraedta19 @NewcastleHosps

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Jamie Willows

@jamiekwillows

3 years

What differing physiology explains why we give IV albumin when we do an ascitic drain for patients with liver cirrhosis but not when when the ascites is due to malignancy? And what would people do if the ascites aetiology was CCF (with low BP)?? #askliver @LiverQs @ebtapper

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Jamie Willows

@jamiekwillows

2 years

We’re in the Cambridge Room at #UKKW2022 all day Wed & Thurs too - point of care ultrasound, TNL insertion model, renal biopsy model (it’s a sight to see a chicken with 4 kidneys in it), AVF ultrasound & intervention, medical Tenchkoff insertion and more. All free, just drop-in!

Sarah Gleeson

@sarah_gleeson_

2 years

Learning about VexUS and point of care ultrasound at the interventional nephrology workshop at #UKKW2022

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Jamie Willows

@jamiekwillows

4 years

Acute interstitial nephritis secondary to #SGLT2i - inevitable as prescription number increases, still SGLT2i for the win in #nephmadness #nephtwitter #endotwitter

Acute interstitial nephritis due to sodium-glucose co-transporter 2 inhibitor empagliflozin

Abstract. Biopsy-proven acute interstitial nephritis (AIN) secondary to sodium-glucose co-transporter 2 (SGLT2) inhibitors has not been described previousl

academic.oup.com

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Jamie Willows

@jamiekwillows

4 years

12/ Sigh. Don’t think most in UK renal would refer well CKD outpatient to ED because K 6.2 in clinic - ⬇️ACEi - K wasting diuretic - discuss diet - PO bicarb - arrange repeat - don’t send to ED at 11pm Also don’t forget to r/v ACEi again asap. If unwell, it’s a different story.

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Jamie Willows

@jamiekwillows

11 months

New UKKA guidelines: to consider specialist SGLT2i use in people with type 1 DM (photo 1), I assume partly as EMPA-KIDNEY had n=68 with T1DM (photo 2 from @NatalieStaplin ) & logical that it could protect heart/kidneys if safely used. Anyone doing this yet?? #askrenal @endo_kerri

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Jamie Willows

@jamiekwillows

4 years

Links to my renal medicine tweetorial threads👇 1. Tips from Renal Reg on-call 2. Extra tips 3. Hyperkalaemia treatment 4. DKA in ESRF 5. Renal COVID guideline summary for medics

Jamie Willows

@jamiekwillows

4 years

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

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Jamie Willows

@jamiekwillows

4 years

9/ Phenotype 3 (most interesting) intracellular to extracellular water movement (>2L) due to ⬆️⬆️extracellular glucose & tonicity + huge THIRST due to same + zero osmotic diuresis = extracellularly HYPERvolaemic DKA (with associated hypertension++ and pulmonary oedema)

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Jamie Willows

@jamiekwillows

4 years

Thread/ Do you look after patients with HHS? UK guidelines use calculated osmolality = 2Na + Glucose + Urea “What’s the problem?” Including urea lowers the diagnostic threshold in patients with CKD - a group at ⬆️risk of treatment harm But it gets much worse 👇 #medtwitter

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Jamie Willows

@jamiekwillows

2 years

Def the scariest nephrology journal club of recent months - RCT evidence that paracetamol worsens hypertension 🤯 Our summary of the trial in @KidneyMed below, great fun to write with 6 authors from 6 different countries, brought together by @NSMCInternship & @NephJC

Momen Abbasi

@Momen_Abbasi

2 years

Check out the Latest @NephJC Editorial on PATH-BP Trial Published in @KidneyMed @NSMCInternship @hswapnil @JMTeakell @jamiekwillows @drpriyajohn @NephroSeeker

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Jamie Willows

@jamiekwillows

4 years

Fin/ As ever, I’m a trainee so any disagreements / criticism / sharing experience much appreciated. References;

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Jamie Willows

@jamiekwillows

4 years

11/ And because I’m often asked - the iv isotonic sodium bicarb checklist for acute hyperkalaemia ✅ an adjunctive treatment, never by itself ✅ acidaemia due to AKI or normal anion gap metabolic acidosis ✅ room for volume ✅ patient can ⬆️RR to blow off CO2 ✅ no hypocalcaemia

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Jamie Willows

@jamiekwillows

2 years

Have thoroughly enjoyed my time as an intern with @NSMCInternship & would thoroughly recommend to anyone thinking of applying - quick run through of the highlights for me 👇

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Jamie Willows

@jamiekwillows

4 years

8/ Algorithm problems IMO ✅ default = iv insulin/dex AND salbutamol ✅ repeat ECG at 5 mins & re-bolus calcium if ECG changes persist (they do mention this in text) ✅ Sodium bicarb 8.4% doesn’t work (solute drag moving K out of cells cancels out benefit of improving pH?)

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Jamie Willows

@jamiekwillows

2 years

10/ It’s because uACR is a bipolar tool – it captures ⬆️protein leak AND ⬇️muscle mass, & both are negative prognostic factors. This is an occasion when ‘surrogate test' performs BETTER than ‘gold standard’ test. Can anyone think of other examples of this in medicine? I can’t

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Jamie Willows

@jamiekwillows

5 years

TRANSFORM - largest trial in kidney transplant; higher dose CNI and MMF (standard care) 🆚 lower dose CNI and everolimus. ✅ No difference at 2 yrs in eGFR, rejection rates or de novo DSAs ✅ Significantly more CMV in high risk groups and more EBV with standard care #eraedta19

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Jamie Willows

@jamiekwillows

1 year

@ED_PharmD21 Forgive the self-promotion, but we tried to cover the salient issues about insulin infusion rate & need for fluids (or not) here👇

DKA in Patients on Dialysis and Anuria: Pathophysiology, Pearls, and Pitfalls

Simon Smith, MDInternQueen Elizabeth Hospital, Gateshead, UK Jamie Willows, MDRenal fellowFreeman Hospital, Newcastle Upon Tyne, UK Diabetic ketoacidosis

www.renalfellow.org

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Jamie Willows

@jamiekwillows

4 years

“Though Hartmanns does contain 5mmol/L of potassium & 0.9% saline none, it is still better fluid in hyperkalaemia as a) RCTs show saline worse b) hyperchloraemic acidosis is detrimental and c) you simply cant worsen K=7mmol/L by adding a K=5mmol/L fluid”

Dr. Glaucomflecken

@DGlaucomflecken

4 years

“The active ingredient in Visine is Tetrahydrozoline, which is a vasoconstrictor, so yes it decreases redness but doesn’t treat the underlying reason you have redness, so you end up using more and more of it without actually getting better.”

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Jamie Willows

@jamiekwillows

4 years

6/ HyperK severity depends on absolute value & ECG appearance. In the text they rightly point out that normal ECGs are common even in severe hyperkalaemia, so don’t use ECGs diagnostically. (however again the cut-offs for what deserves to be ‘mild’ or ‘moderate’ are debatable)

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Jamie Willows

@jamiekwillows

8 months

I enjoyed helping to write this - if you ever see patients on haemodialysis in your practice, please give it a read 🙏

Renal Fellow Network

@RenalFellowNtwk

8 months

Tricky Testing in the Patient on Hemodialysis @jamiekwillows James Bannister

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Jamie Willows

@jamiekwillows

5 years

Study on left showing why patients do not get RRT modality they want. In UK it’s not down to different patient populations, it’s down to variations in how we deliver care. @NUTHRenalNP #eraedta19

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Jamie Willows

@jamiekwillows

4 months

@DrBenLovell And their response would be 100% reasonable - they’re expected to know 50 times more guidelines than I am in speciality & the logistics will be difficult in most areas. Do you think using Amb Care resource is a good fit to avoid the 3am ED sit (assuming not under renal/cardio)?

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Jamie Willows

@jamiekwillows

5 years

Different definitions of “moderate hyperkalaemia” - 7.5-10mmol/l really?!?!? #eraedta19

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Jamie Willows

@jamiekwillows

4 years

9/ Further #tipsfornewdocs that is often mismanaged; the dose of B2-agonist is really big compared to COPD/asthma dose

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Jamie Willows

@jamiekwillows

4 years

10/ ❗️This is a rather unusual type of pulmonary oedema - it is reversible with iv insulin alone ❗️ (when insulin drives glucose into cells water follows from interstitium = less extracellular water = resolution of pulmonary oedema)

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Jamie Willows

@jamiekwillows

4 years

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

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