Makindo Medical Notes.com

Renal Tips

• Insulin-dextrose is not benign (hypo 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 (Albuterol) dose 10-20mg
• 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, spironolactone, beta-blockers, trimethoprim, diet
• 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
• ? AKI doesn’t respond to giving litre upon litre of IVT to euvolemic, 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
• At referral, we’re thinking 4 qs;
  • Differential diagnosis? Hence we need historical creatinine, volume status, urine dip, imaging results, all events & blood this admission, new & previous meds
  • Patient safe to transfer? Need current obs, K, pH
  • Safe to biopsy? Correct coagulation, valid group & save, r/v anti-platelets, control BP
  • Safe to dialyse? Urgent BBV serology = avoid dialysing in isolation = ??efficiency of dialysis nurse time. Octenisan & naseptin = lines safer with ??SA load
• 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
• 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 the patient is congested
• Medications: 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
• IV Contrast: 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....)
• Hypertension: 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
• Transplant pts - Renal: We want to know they’re in, esp if immunosuppression issue (NBM, infection - double pred!), or AKI (get the urgent US for starters)? Tacrolimus & ciclosporin at 10am & 10pm (gives phlebotomy time to take trough levels before AM dose)
• Haemodialysis (HD) pts on wards: 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 the safest place for them? Need routine blood; easy on HD days, save extra stab