30 June 2021 - Renal & Urology
Teaching this week will begin in the Conference Room in the Education Centre on Level 3 of Building C (Healy Wing).
Program
1000-1100: Renal Q&A — David Goodman
1100-1140: NIV Workshop — Alex Handrinos
1140 — Give Sarah Ward your coffee orders and she will deliver
1140-1150: Recap — Sarah Simons (with coffee)
1150-1200: ECG & Image of the Week — Mim Scharkie
1200-1210: Reflections for ITA — Sarah Ward
1210-1240: Urogenital Infections — Stuart Howard
1240-1300: Lunch
1300-1500: Small group rotations
CVC Insertion & LUCAS Device (Teaching Lab)
Renal Sim — Stuart Dilley
NB: 1300-1430: Fellowship Exam Break-out Groups — Written with Alex Handrinos & OSCE with Brendan Morrissey
Summary
Thanks Ezra for the study notes from this week’s session.
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Renal Q&A
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Code blue to dialysis pearls:
- Likely hypotension from fluid removal.
- 2-3L removed each visit.
- Rule out MI (possibly silent) and infection.
Hyperkalaemia
- there is no cardiac telemetry on lvl 10
- plumbed telemetry beds where dialysis can be performed: ICU, Bed 3 ED, CCU.
After hours overloaded/hyperkalaemic patient?
- initiate temporizing measures
--- if passing urine, renal dose frusemide (eg 250mg PO).
--- insulin glucose,
- call renal registrar to expediate treatment early morning in-hours.
- a/h dialysis only in extreme circumstances.
PD pt with abdominal pain?
- Peritonitis until proven otherwise.
- "Newspaper test", place bag on newspaper - should be able to read large print.
- Cloudy filtrate can also be fibrin, but pts are educated regarding this. Rx is heparin in the fluid.
- Order:
--- Cell count and MCS.
--- Dont forget TB in vulnerable cohorts (eg migrants.). False negative AFB tests are common, but order anyway. Needs peritoneal biopsy!
- Avoid peritoneal antibiotics until instructed by renal team, as MCS is critical.
The Legend of Contrast Nephropathy.
- yes it does exist, in patients with other severe comorbidities (eg. Cardiac pt on multiple renal toxic drugs)
- manifests as a slow rise in Cr as opposed to loss of UO the following day. Takes weeks to reach ESRF.
--- Pearl: Urinary sodium < 10. Loss of concentrating ability.
--- NaCl preloading can prevent it.
- do what needs to be done.
--- if eGFR ~30, likely ok.
--- if approaching dialysis / predialysis - Renal Replacements, TL;DR
- CVVHDF. The mild gentle one.
- Tunneled Permacath (subclavian) - temporary. High rate of complications.
- Peritoneal dialysis - avg one ep peritonitis every two years! Good for QOL.
- Haemodialysis
--- vigorous. rapid correction over 5 hours. must be stable.
--- dont touch the fistula. dont touch the fistula arm. (prone to clotting off)
Islet Transplants
- severely immunosuppressed (high dose tacrolimus and mycophenolate)
- call any time of day.
- steroids can wipe out their transplant.
Post Transplant complications:
- first week - common post op / hospital infections. (IDC UTI, HAP, thrombophlebitis)
- first few months - viral
- after a few months - atypical organisms (PCP, cryptococcus) can present.
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UTI
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- "simple" cystitis +/- urethritis VS Pyelonephritis
- risks (physical): stents, idc, obstruction
- medical risks: PKD, DM, immunocompromise, male, prolonged symptoms.
- GNB (e. coli, klebsiella, proteus, pseudomonas.). Staph saprophyticus <5%
Asymptomatic bactenuria
- no symptoms + single pathogen on 2 successive cultures + NOT PREGNANT.
- 10% of all women.
Dysuria without pyuria!
- prostatitis
- STI
- renal stones
-
FWT:
- bacterial contaminants double every 30 mins at room temp (send to lab immediately)
- Nitrites: 90% specificity (rule in) w E.Coli.
- Leukocyte esterase ~50% sens and spec.
--- TL;DR - negative test doesnt mean anything. Positive meaningful only with symptoms.
- "epithelial cells" = contaminants
- Pyuria = > 5 cells per HPF, or >10k per ml.
Rx:
Female simple - Trimethoprim 300mg 3/7
Female pregnant / allergies - Nitrofurantoin 100mg QID
Second line - Cefalexin 500mg BD (also treats Staph Saprophyticus.
Male
- Extended course of trimethoprim 7-14 days
- Ciprofloxacin if prostatitis suspected.
Nitrofurantoin and Fosfomycin for treatment resistant UTIs.
ECG of the Week
45yo man presents with 3 episodes of syncope and a history of chest pain.
ECG findings:
- Normal axis
- Rate- 66
- Sinus rhythm
- Narrow QRS complexes
- TWI 1, and lateral leads (inferior and lateral leads)
- Biphasic TW V3
- LVH by voltage criteria
This patient has apical HCM.
Apical HCM
- Variant of Hypertrophic cardiomyopathy- 10% of all HCM
- More sporadic, more common in Asian HCM (25% ) but up to 1% of non Asian HCM
- Less likely to have family history
- Non Asian Apical HCM- higher incidence of sudden cardiac death
- Increase risk of AF
- More common in males 1:6 ratio
- Average age presentation 41 years
- 0.5-5% risk of Sudden cardiac death
- Apical wall thickness >13mm
Image of the Week
77yo man presents intoxicated complaining of left shoulder pain. Denies history of fall.
The xray shows a dislocation of the glenohumeral joint, with inferior displacement in keeping with an anterior dislocation. No discernible fractures.
Anterior/ inferior subglenoid dislocation (5% of all anterior dislocations) - a distinction should be made with a true ‘inferior shoulder dislocation/ Luxatio erecta, which this is not.