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so Hi, guys. Work again for the second lecture of the medicine for Finals and foundation Doctor Siris today we've got a doctor in the past 70 who's gonna be covering the first of two part webinar lectures on nephrology and the skin being a former Gee, part one. Um, no. Just infuses a little bit right there. My name's in a hurry. A minute. Three in court. What's the moment? I was pretty lucky and got to do eight months of renal ascent F one because we didn't get rotate to. Since then, I've been really interested in it, So I was more than happy. When they ask me to do the renal teachers like I said, his part one part too will be in two days time. Um so if if we move onto the next light and airy and so, as usual, if you haven't done so already, please join our Instagram Facebook and Twitter page. 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So if you join that, or if you want to join the QR code in the bottom right, you can also get a freebie. So just a pocket prescriber book at the end of your vision cards, which I have used previously on this one. Is that the foundation program hand booklet as well on without further ado I believe from this point onwards, I will leave it to hurry. Think e ads. Okay, so just just about what we talked about today and then if you teach So I'm going to start off with the, you know, tract infections, even though it's not quite renal, it comes up a lot in GP and hospital when it comes up on the movement. Move on Teo properly. No medicine and talk about a K. We'll talk about the definition, how you classify it, how you find the cause and a bit about how you manage it. We're going to stick with fundamentals today on the basic principal, just so we get a good idea of that first, before we fix on specifics, which we more in the next teach. And then we'll finish off just on a bit about dialysis. We've got lots of questions throughout, so just message on the group with your on the chat with the answers. And if you have any questions at any point in just for is well, last question 66 year old lady who attempts her GP. So let's pretend that your GPS she's been complaining of burning while passing urine And while you're waiting for, she's already gone to the toilet three times to pass urine in the last hour. You think that she has a UTI? What would be the most appropriate course of action in this scenario? So a to do a urine dip it. If it's positive nitrites, then you start into politics. Option B, you said at MSU and wait for the results come back before starting antibiotics. Option three is you prescribe a three day course of antibiotics and said it MSU anyway. But without waiting for the results on Option D is you admit the patient and because you think they need some IV antibiotics. I think if you just message on the shop well, no, I just launched a pool. Thanks. Have you been taught himself with this? Looks like these people want it. Yeah, looks like everyone's answered now. So it's quite oh, no hernias Well, but no one's picked up. Theanti, sir, is Option C. So I think there's a bit of a mix going. One of the answers day with Option A and see So talk about you tears and explain why that is correct. The UTI was a urinary tract infections. It just means an infection of some where in the urinary tract we divide into lower and upper UTI. So no UTI is just means an infection of your bladder. So what happens is the bacteria in your feces move from your Sinus. Your urethra is up to a bladder, and cause an infection is much more common in women because that distance is a lot shorter azelas urinary tract being a lot shorter. And if that infection travels further up into your bladder, I mean to your kidney. Sorry. It causes an upper UTI or pilot if rightist, most common causes of a colitis. And that happens in about 80% of all beauty eyes are the causes of things like clubs. The other pneumonia. Proteus Mirabelle S, which exam pressure is associated with renal stones and staffs that because it is, um, seen and lots of people young people who are sexually active so most common in women because it's shorter urethra is in terms of cystitis or no UTI or some of the what this lady presented with says she had this urea pain when passing urine frequency as well. But you can have nocturia going more often at night to pass urine or honey pains, usually super pubic or never abdomen. It's and tenderness. You might have some blood in your urine or hematuria as well. Uh, if this lady has any science in this red box for symptoms and you be thinking about up the UTI. So things that would suggest up the UTI or pyelonephritis would be things like fever, bridles, nausea, vomiting, flat paid or cost of virtual and renal angle tenderness. So those would point you away from cystitis into more pyelonephritis type. It is really important to know the difference because you managed them differently. So this will bring up some of the answers that I offered to you in that first question. So a lot of you did put Option A, which was to do a urine dip. Actually, nice guidelines say that urine dipstick is unreliable in the diagnosis of UTI is in anyone over the age of 65. So I sneak, he put This lady is aged 66 just a cheap that the cutoff is 65. Mr Same with any patient who's catheterized a urine dipstick again, in this scenario, isn't that reliable in this lady was a young young patients it and and you were questioning the diagnosis. You had some of the symptoms, but you weren't quite sure. In that scenario, Beat would be appropriate to do a urine dip first, and you're looking for things like white cells and blood or nitrites that would point towards the diagnosis. MSU is an appropriate thing to do, definitely. But in this scenario, because it's clearly a UTI, I just got the classic symptoms of dysuria and frequency. You don't need to wait for the result, but nice guidelines do see that in this this list of people you should definitely send in a mess you. So that's any male with the UTI. Any women over the age of 65 Anyone who's pregnant catheterize was history of recurrent UTI is who has any blood in their urine. Those scenarios you really should send in a mess. You just cause that will help you identify organism. Is there a especially if there's any resistance and things like that that can help you. Antibiotic choice. The most common antibiotics and nitro friend women and try a method been, But obviously you need to look at your local guidelines when you're prescribing and just remember natural thing to do and you can't give it your age. If I less than 45 trimethoprim you shouldn't use in the first trimester of pregnancy, women get a shorter course. This because the really common infection have a shorter urethra. It's easier to treat. You need to give them three days of antibiotics, which was option three. So in this case, you give that and then send them issue and then alter your antibiotic choice if needed, depending on the result you get. If this lady was younger, was pregnant or had a catheter, and he'd want to give her a longer course of antibiotics seven days and with any male with the UTI, give him seven days. A swell, a specific scenario where you have a bacteria in your urine, but you're completely asymptomatic would be in pregnancy because they screened them routinely. If you do find that you should treat it in pregnancy is one of the few scenarios where you do have to treat asymptomatic bacteriuria so back to you in your room just because there's a higher risk of it becoming pyelonephritis If that happens, there's a really high risk of preterm labor. So because of this need to treat that probably the difference between cystitis pilot right, as I mentioned earlier, and this because it affects the management. The main differences are matter what age and what category for into you always need to send in a mess. You you don't need to wait for the result again. You start on it, but it's probably, and this might be IV IV rather than aural, depending on how unwell they are. And usually the first choices Kapidex in, and you should look at your local guidelines to see what's appropriate. Give a slightly longer course of antibiotic um, 7 to 10 days. And then you should really think about referring the speech. A patient who has pilot if I just. If the president in expressed have any structural abnormality in the urinary tract, think of just some questions coming up onto them. Once I finish this topic so I'll answer a few ounces, says Nitric. Yet not yet for Interval is contraindicated in the third trimester is well, so I think a good option in pregnancy would be things like amoxicillin. But local guidelines advise you on what safer to give in pregnancy when they're trimester. So, yeah, I think I am spanked. Really? Answer about my friend so you can use it in the gym process of 45 so we'll move on to the next part of the topic. So I'm going to talk about a K. I can also keep kidding. Laundry got to very sad looking kidneys because in simple terms, an A k I, um, is just unsalted your kidneys that causes a drop and your kidney function The question coming up. So the kidney disease improving global outcome guidance is probably the most up to date and most commonly used definition of an A k I. Okay, according to this, which is the statements is true. Option A. Which means that a K I was defined as getting in greater know equal to 26 and micro millimeters, but liter and this happens within 48 hours, or is it be your creatinin rice is 20% or greater, and this happens by their known or presumed in the last seven days, and option C is you drop your urine out, but less than no 70.5 mL per kilogram per hour. And this has happened over 24 hours. So I think I am going to create a pole. See which of these is correct? Give you a few more minutes. Oh, sorry. I just showed the results. Oh, touch. That's why. So, yeah. So this is quite a mean question for me to pick is a little with the numbers, but is a really important definition to learn. So actually, statement is the one that's correct. So is that probably easiest one to learn is an A K. I E is when your creatinine rice is more than or equal to 26 micromoles in 20 and 48 hours. The others are just tweet slightly. So Option B is that you need at least a 50% rise in the Syrian tap creatinine in in the last seven days. So not their answer I put was 20%. Some people room, remember, has to be at least 1.5 times the baseline, and then option c of just tweet the time. So it's when your urine up is less than no 0.5 mL per kilogram per hour for more than six hours. there's a really important definition to learn, just forms the basis of everything but are working hospital. Thankfully, the computer's just do this for you. They're moving on to kind of. I'm saying the bait, the basis of this as we do deal with an a k. I don't just cools of it or to classify it in. I think you probably hear this definition many, many a time. So it's just a constipation, which is pretty renal, renal impaired street. Oh, you know just means that the blood supply to your kidneys has been affected. Your option and request the filtration arena on intrinsic calls just means that something actually going on within the kidneys themselves and then post renal just means the blood supplies find the kidneys are working fine, producing urine. Fine, but the urine can't actually flow out of your body's. There's an obstruction at something. It's called his backflow Hydronephrosis is and then causes an A k I. It will just got some examples of each of these categories and feel free to message. If you know any said, you guys know what the most common causes of a pre arena, a K I might be exactly so someone just put high. Probably not exactly like so That's, um, most common core. So things like dehydrations what you see most of the science of pre we know. Okay, I was the majority of AKI that you will see in hospital, and this was called like I said, Just disrupts the blood supply to your kidney, but no alternative cause of things that we know artery stenosis that comes up not on exam. So just remember those as well as type of anemia. Well, and then in terms of post renewing Okay, I've got Do you think the most common causes are that you'd see EPH is one of them? That's correct and then stayed? Yep, there's two of the most common things that you'll see between like a I. So these causes a normally reversible, you know, for hyperbole. Me? A. Just give fluids, correct it stones. Just mind the stone BPH and catheterize and simple things that you can do that mean that the a k i e. Is it reversible? Well, obviously, if you don't treat those problems, the's can progress into a renal a care and actually cause damage to your kidneys. and we've got more interesting or complicated causes of which are real or intrinsic. Course is the things like acute tubulin, a process that's the most common cause of Marino AKI. You got much rarer things like the merrier nephritis interest in the brightest and rubbed it. Marchioness is. We'll talk about those more in the next teach. Once you kind of categorize these into your head, you to try and figure out how you put them into those what's in front of you. So like everyone goes on about, it's always about history. So if you can't get a history, get a collateral history called GP. But you need to know what's been going on, especially times of how long things have been going on for a big part of that history is the medication history. So you're looking for any drugs nephrotoxic that might be involved to things like me, See antibiotics and says insight that definitely ask about. And then, in terms of the exact thing examination the main thing, you need to focus on the fluid status, which is why I've got a big cup of water there. Anyone know what kind of features you'd look for when you're trying to assess one's fluid status and things that you look for, just you've got mucus membranes, skin. Turgeon's refill time yet is a look. Great answers. Yeah, yeah, I just started the top of the body and you work your way down so you look at their lips, their tongue. Look at the mucous membranes. You look at the upper it perfusion, so it could be a refill Time that someone said JVP is really useful. Listen to the lung basis. There's any signs of hypoc. See how you might want to get a chest X rated little palmar you Dema. Then he looked for peripheral edema. So look at their legs like they're back for any dependent edema on the little BP and heart rate that I think is one of the most useful things you can do. And that will really help you, especially if you're thinking about three vehicles. So hyperbole. Mia. By doing that fluid status, you basically have your answer. And another thing. I guess you could look forward rashes on my point. Two more renal course once you kind of got a good history, looked medications assess, then by examining. You need to move onto investigations. Patient coming up so and all patients should have what? A soon as an a K I diagnose was suspected according to the nice guideline. So they've just been in the blanks. What should patients out? So the options are a IV fluids. Be a urine dip, see a renal ultrasound d catherization and see a renal referral. So your pole coming up? What should holding too. Nice guidelines. Nice people. Uh huh. So you got quite a mix of answers, but I think everyone surprise. The actual answer is urine dip. So I think that might got the lowest results. So I found this quite surprising as well. But urine dip is according to Nice. And I think in real practice, one of the most important test that you can do to classify an A k. I was really cheap really easy to do. You get the results straight away, and what you're looking for is protein and blood. It is not like for a UTI assessment. We shouldn't do it. And that will be anyone any age should have any have a urine dip down a soon as possible and that nice guidelines. Actually, you should do it within six hours as well. So why is this so really helped you differentiate between the cause so classically and in textbooks world previa or post renal achy. I shouldn't have any blood or protein because there's no actual damage to the kidneys themselves. Because if you're thinking of a real cause, so in entrance it cause there should be some blood or protein or both. I'm on that urine dip cases that you're and it might not be useful Is a patient is catheterized because of the troll mother. Probably be some blood in there. Isn't that CKD need to be careful when you analyze it Just because you might have protein urea just from longstanding CKD on. Then there's always exceptions. And this is not always that you get nothing. So no blood or protein in your urine dip. See if it isn't other causes other than a key IVs. For example, if the cause is renal stones, probably gonna have quite a lot of blood in that urine dip. So we move on to some other investigations. They definitely remember I would always do a urine dip, other things you need to consider is to do about out other scan. So when I was in, he di, I try to do those owners. Many patients is possible, especially older people that come in with an A k I. They might be passing urine, but that doesn't mean they're not in retention about doing about can Simply executed. Retention is one of the causes that's such a simple being to treat with a catheter but improves their renal function. People said a renal ultrasound was one of the answers. Actually, you don't need to do with you understand if things start to improve and you think it's a preview AKI. But nice guidance says that everyone who suspected obstruction and so a posting like, Yeah, you should do an ultrasound to look for how to reverse is and you should do it if things aren't improving. So if it's a previous okay, are you giving them fluids? They're not getting better, you think. Is there something else going on? We should do an ultrasound and then on that urine dip and on your history and examination, you're suspecting a real cause, so something weird and wonderful. There's lots of different tests that you can do this stuff here. I went going to much detail about them away because we'll talk about them. And we talked about renal pauses later on. But there's some of the things that you might want to think about. There are a bit more and niche take a little break in. Then I'll read through, I think a businessman, thankfully answering my questions, they can't seem to focus on both. No, this is This is so good. Uh, I'm just trying to hunt some facts. And that has love would have, uh, no, we didn't good on time, but it I think I just want a library one point, because when if he was asking about imports Jaeggi in sort of a k. I say what I want to say was, So is a new thing. So they raised It is improved. So fluid, overloaded patients. Good example that I could think of is the fault of symptoms you get in the mail or more simply, patients with sort of acute heart failure. You are fluid, overloaded can also get a k I. So what sort of explaining was that? You know, we know that for Rooster might, you know course is sort of a k I see, but sort of contractor normal for, you know, in these fluid, overloaded patients where they could get swollen kidney capsules because, remember, in the mode doesn't just isn't just in the skin and go to the organs on the kidneys. It can make you a damn it Scott, which makes adoption pull. It can make a tentative skin's, which would cause a K i E and those sorts of patients with sort of hyperbole me a sense, causing that a k I sort of control to normal. Four Feruzzi might can actually sometimes help when you fluid off, load them at the kidneys, go back to their normal sort of shape and the world, and you can actually improve the AKI. But it's not a decision that you make yourself, is why so I hope that makes sense in ER Yeah, definitely. I think it's those people think, you know you shouldn't give diuretics or someone has an A k. I really denarii. It's seen with giving the IV fluids. You wouldn't give someone overloaded IV fluids, so yeah, definitely right. So when you are, yeah, so another question Now think yourselves in admitting F one patient's been clocked in, but you're looking at the drug chart and all we've got the information we have is that a k I query calls looking through the drugs. Any wandering which drugs you should continue is a a naproxen. Be metformin. See lisinopril d candesartan or a warfrin. Which of these is safe to continue when you have a patient with an achy I without no known cause? Okay, lets people stopped answering. Yeah, so yeah. So I think most people got the right answer. For some reason, it is in a different color, but, um, I have given it away. Yeah. So warfarin is the one that's safe to continue to stop through why the others aren't safe. Really nice. Guidance is really clear on what drugs you need to hold during make a I. And this is n said son approximates. And so I stopped that a snip it is or ARB so And you tens and receptor blockers like lisinopril and candesartan. They should be held on Ben Metformin. I think some people put that as of right answer. So unlike the others, it's not actually in effort off toxic, but it is excreted through the kidneys. So if your renal function drops, there's a risk of that. You have. You have lactic acidosis is which is one of the side effects. So that's why it should be held and then warfarin and isn't mean excreted, so it's safe to continue. But you might want to think about other drugs that are nephrotoxic as well, so things like gentamicin really common cause of acre as well. So you suspend that as well. Who just recaps if it's definitely suspend, Any answered is inhibitors nephrotoxic six and then think about drugs that are like to molecular things are cleared by the kidneys, such metformin and more fully morphine that can build up. You get more side effects of those medications. You should also think about drug dozing, especially antibiotics. Want me to reduce the dose? Really good example is insulin that's really excreted, so if your kidney function drops, you actually need less insulin. In the months it starts to recover, you need more insulin, so it's a bit to keep an eye on the sugars and take your patients on insulin. Always consult, you know, drug database that VNF Isn't that useful? Actually, about specific guidance. And if in doubt, always contact Pharmacy said. Nice guidance. Specifically, says an a k I. When you're being medications, it's going to involve the pharmacy tea. Let's talk a bit about the physiology now, just to explain why NSAID's and 80 didn't be used naked. Eye especially preview AKI. So you've got This is my basic drawing is a glomerulus. We've got the Afrin arterials on the left hand side, going into supply the movements and effortful different arterial going up. And there's our is just represent the kidney. Just producing urine starts here in being filtered down. So what happens normally in the kidney, that's right for is that they can compensate for any reduction in blood flow. So, for example, in the previous a k, I will get reduced blood supply going into the kidney going into the arterial. So what can happen is your effort. Arterial constricts, and that increases the pressure in that America less by keeping it high, because actually, there's less more resistance going out on what happens with age, and if it is is that they inhibit this vasoconstriction. So you're trying to compensate and you can't so that it can really. Eight inhibitors can make prerenal make a I much, much worse. That's what happens. It is really common exact exam questions. 18 and it is. They prevent the effort arterial from vasoconstrictor and the opposite really happens with NSAID. But it wasn't the same effect. So another compensate three mechanism is that that after you're going into the glomerulus, there conveys er dilate, so that becomes bigger. So there's more blood flow going into that REM very less so. That helps again the filtration pressure so you can continue to produce urine. But what happens when you take ends? It's because they inhibit prostaglandins. Is that these in stop that vase? A dilation of that Afrin arterial because of that and said also make Previnaire achy eyes much worse. I know it's quite technical, really good to get a good understanding of those things and how they work. So entered is they prevent African are two really busy dilation hit these diagrams? Be guys going to see that? Because I did a long time to get to grips with that. They're moving on that also, we've kind of taken a good history trying to find the cause. I done some investigations, but it's really important to keep monitoring the patient. It's always you need to keep monitoring their renal function on a good week. To do that is that created in is much more useful than the Jeff on there. Keep setting need to keep an eye on their potassium. Gilenya is really common in a K. I need to keep it. I am the urea, and especially symptoms of high urea as well. On their bicarbonate as well. Get metabolic loses in a care as well, and then keep going on about fluid balance. But it really is one of the most important things in a K. I say you just need to know, but clinically keep assessing them. Keep a really strict in for outfit. Chart might be hate helpful. Doing daily rates, especially in the Demadex patients, was a bit dot and not assist of help. Things are going and then, just in terms of going further forward, and I'm management, might need to involve urology, especially they're supposed to, you know, take a I kind of the plumbers and they deal with distractions much better. The kidney doctors and then you need to think about whether you need to involve read. Also nice garden, very specific when it's appropriate. Teo. Refer them. So any renal transplant patient should be referred just because it in a K are in a reading transplant patient. Could be a sign of rejection is really important. And then anyone with the achy I stage three So that's a severe form of a K I basically they should be referred. Anyone that's not responding to your treatments. You think of the purine awake a Are you giving him fluid there? Not getting better? I need to refer. You don't know what's going on. You should refer. Or if you're thinking about any intrinsic renal cause that might needs and specialist management to those things of things like raspy like this. The merrier. Nephritis, interested or nephritis or myeloma, The definitely to involve renal like you need to send specialist medications and management. Think about biopsies and things like that. It slide. Just on the stage is a bakery X I mentioned in a K I three you should refer to. The first stage is basically just the definition of an A k I stage two. The creatinine just goes almost up to three times the baseline, 83 just more than three times a baseline. It could do it and you're up well when you talk about it too much. But just one of those things, unfortunately, do you have to learn for exams? Has come up now the question. So we've got an 89 year old man now. It's quite sad. He's been found on the floor, but his son, he thinks he's been there for two days. He's complaining of muscle pain, tiredness, and he says his urine looks like Coca Cola. So which of these features is least associated with? The likely diagnosis is a bit of a two part. Question is, I'm giving you the diagnosis. Is it hypophosphatemia race? Creatine kinase is 80 I or hyper clean? Yeah. So looking for the one that's least associated with this. Thank you. No longer. Yes. I think most people got that one right. Does anyone know what the condition is? Exactly? So Mars is Your majority of people are right. It's I pay for it with the media and the condition is rubbed of violence. This is one of my favorite. Okay, The rhabdomyolysis just means muscle in the crisis of breakdown of muscle. So most common scenarios where this happens is after you fall and have a long life. It happen after prolonged seizure. Much rarer causes the things that ecstasy can cause it crush injuries and feel especially to take a combination of statins and clarithromycin together that can precipitate rhabdomyolysis is a swell. What happens is basically get damage to your muscle cells or your myositis, and they release for the contents inside before you get a lot of complications to get a C. M and phosphorous that leak out So you get hyper clean. Me a hyper for protein, you know, hypophosphatemia get in. Kindness is an enzyme of muscle breakdown, so that'd be really high at least five times the normal limit. And it's a really good indicator of how severe rhabdomyolysis is, and it's a good way to monitor it as well to see if patients are getting better or worse. And the cells also contained my globulin. That's release out of the cell, and this is what gives the urine that particular color. If you did, the patient's urine with rhabdo actually comes positive for blood, so is useful in this case to do. Urine dip is well, but sometimes you're in conflict. Quite duck on people, pages that dehydrated. You just want to check that it's my A globulin in that urine well, and then the hin pigment in my globulin itself is actually what's directly toxic to the tubules of the kidneys, so it causes a renal, um, intrinsic picture. But there's also partly kidney injury because of hypovolemia and third spacing going on as well on you conform costs in your urine that block the tubules that also add to the achy I picture as well. So the main management of this is IVF. What you're trying to do is reduce the concentration of myoglobin that he pigment in your tubules, the trying to prevent them damaging the kidneys again. You need to really keep it close on the fluid balance system to make sure that it become overloaded and you should always try to create Sorry, correct. There any electrolyte abnormalities, particularly hyperkalemia, is really common in quite a nerve sign and rhabdomyolysis as well. I really like it just cause patients get really poorly that it would get really too achy eyes. But once you treat them with something so simple is IV fluids they get they can get better and says, I mentioned Hyperkalemic as one of the things that you need to treat. So this question just asks about kind of a month about works. So which of these drugs helps you remove potassium from your body? So is a calcium gluconate be insulin and dexterous? Is it C salbutamol? D calcium was only, um, e sodium Cicconi. Um, psycho. Since be more it looks like you've got quite a mix of answers for this one, and it's a bit you give me because to the answer is actually correct. A calcium was only, um and sodium's a Coney in both removed from the body. Just go through the others cause they are ultradian. It's of hypo a couple of the authority. Yeah, it just means your potassium is high gives really classic PCG signs that you do actually see in real life. And it's a really common exam question. Does anyone know this PCG would show in hyperkalemic 80 ways? It's really obvious on this. I don't know any anything else yet. We got wide QRs. That's correct. Exactly. Perfect Says area is a really common example Western. And you do see them. You you know, we do a lot of e c gs in our practice where someone's potassium is high. It doesn't quite meet that threshold treatment. You do any See? I have to look for these things. So you look in the tour 10 t waves loss of people. Aves brought you rs on then a sign pattern on the waves as well. And the treatment? The first thing that you want to do is try and stabilize that cardiac remembering. Because of this risk of arrhythmia, you give shots and you can I be 10%. Actually, that treatment doesn't lower the potassium in your blood, which is stabilize your cardiac membrane. So you need to give something global that potassium in your blood. So the most common thing we use is into dextrose infusion. On what? This does it shift the potassium from extra saline left interest so it will lower your potassium. That way you can give salbutamol nebulizer a swell. But in practice, I've not really seen that done, but it is an option. And then lastly, you need a way to get rid of the potassium from your body so the other treatments don't actually do this on. But we the what we used to use quite earlier is calcium a Zuni, um, so it's very non, not well tolerated medication. Give it or or an animal, and it binds potassium new bird. But it takes quite a long time to work. It's not used, but sodium's a Coney, Um, or like Elma is a new wonder drug that works really well on that again finds potassium in your blood to get rid of it when you when you about it's really the drug that gets and gets rid of that potassium from your body. Because if you're not peeing, there's no other way to get rid of that from your body. The your hospital will have its own guidelines on the management of hyperkalemic. In practice, I always consult this, and this is our guideline. It's really helpful. Tells you when to do any See gi what changes to look for on the management so you don't have any questions about yeah, maybe one to question. I think this might be our last question. So you've been managing this patient with an a k I treating them for what you think is rhabdomyolysis. And But when you look at the Bloods today and you think he's getting worse, which of the findings would indicate that you might need to think about starting dialysis in this because Option eight urea 48 b E D. F r. Four C 5.8 on de appear to 7.2. So which of these would you have to call the renal consultant but and say, Oh, a better thing about starting dialysis? You get? Think everyone's answers. So I think Option B seems to be the most popular. The correct answer is actually auction D. This is indications, for diet is the really common example. Asian and the renal consultants love. This question is really important that you get to grips with it. So we're talking about acute dialysis in an unraveling patients and not kind of long term dialysis, any patient. So you have time to come put fistula is in and things like that. This is kind of in the middle of the night. It's patients on Well, they need dialysis. Does anyone know what indications these are So does it really good afternoon? A. I you that helps me remember them acidosis. Just perfect. That's the A symptomatic uremia. That's great. Dema refractory topically meal intoxicated Perfet. Exactly. Yes. So just remember er, you say is acidosis. So ph of less than 7.2 normal special that they used electrolyte imbalances. Hyper clean me A. That's refractory to treatment. So one of the answers was, was a hike. How's how potassium Sorry, but you tried to treat that medically give kind of all the great treatments. It's only if it's not coming down and it's dangerously high. But you think about dialysis in this case and then really use. But it is one of the indications Asian by certain drugs that otherwise can't be cleared on a Dema. So again, that's we refractory demon. You try to treat it, but it's not getting better. And your palm you Dema, then it's no uremia itself. See, jury is conjugate really high, but and you should become symptomatic with it. So they need to have you make pericarditis or you're anemic and careful itis These are the kind of indications really important to let so yeah, just a summarize what we've been doing less. Anyone has any questions, So just talk briefly about ET eyes on. But management and castigation took about a k I had to classify them. Wouldn't cause on Doc about the investigations and management that's required. Talked a bit about rhabdomyolysis distance by easy to treat as well as hyper clena is really important and then just gone over. The indications for dialysis you take him message is, is that you're in debt is really, really important in a k I. You're looking for blood and protein is not that easy for your UTI xray, really, especially in patients who are over 65 then fluid balance is involved in fair anyone Okay, I need to keep on the trend, then keep a really accurate idea of whether they're usually not hyperbole. Nickel hyperbole make lucky with the cause and the management on. Then you really need to know when she should refer to renal. So we've talked about a lot of basic things. It be really helpful for renal team. If you do those first things like urine dip assess The fluid status is look at the medications. Then if you don't know what's going on, they're not getting worse. I mean, they're not getting better. If you think that's something intrinsic renal going on, then you should call the renal team, which is what I will talk about in my next to. Each of it is coming up in two days. So we'll talk about the renal causes of achy I especially or the groin area and nephritis a Z masculinity us. And then we'll talk about CKD, the complications off CKD and how you manage it. And we'll talk about kind of the principles of dialysis in that as well. And I think there's a few questions on there are These are the resources you so basically used. Nice guideline. So up to date, really good resource is to go for their reliable. Yeah, say the QR code, the feedback and I think a it's just put a link in the messages. Well, so please leave, Please. Please. Complete feedback for jury is such a fantastic teach. She's gonna have a pot to Yes, the recording on the slides with you on that also makes your son from metal account the feedback Your codes in the left Facebook page. So Instagram page girl comes on the right Onda while we're in there. Would you mind if I, uh, just putting towards a couple questions to ask? Yeah. So one of the questions was how this ecstasy cause rhabdo. So I know a lot of the drugs can cause patients have longer lives and be out for four period of time, and then you don't mind the muscle. Is there another mechanism by which exceed? Those are high before meal? What about? I know, I don't actually know, but I think it's not the fact that you get in talks getting any pass out drug itself is. But I don't actually need the mechanism and find out until you guys next time if you tune in. Yeah, it's a joint next time. And another question was, uh, let's see. Don't quite remember what it was. Uh, but that's a little look. Why did you get a third spacing in rhabdo? Yeah. Is what was asked. Mm. Um, explain this. That Whoa, I'm just having a little thing for myself. Is it because all the patients that I've seen their intravascularly dry but peripherally overloaded, you need to give them my refill. It's but they're still kind of proof that probably a dermatitis. I'm just one I just wanted. It might. It might. So I'm going to take it until I'm going to take a punch here. So I'm guessing if you release. So if you imagine there's, you know, intravascular basis, extra associates, that sort of interesting spaces and it's sort of extra baskets place. Got the cells there. If the 1000 being destroyed, their sort of contents, including sorts and everything, are being released. I guess which kind of makes makes that area more PSA was multiple active. If those things are there, it gets pretty much dream and in special space. And I'm guessing because the cells are mostly there, more fluid will shift. Was the spaces, of course, that space. That's my best guess. I just lift it up as well. So it just says you get influx of you extracellular fluid into the muscles that goes into the damage muscle. See what the fluid goes? Yeah, so just cooking. Why was the pH of 7.2 over use? So we use the gym for suggesting. Question is, what were you asking? Nicholas is about some indications for acute dialysis. Sooner you can can erect if I'm wrong. But in an acutely sort of acute presentation of a patient with an a K, I want whatever it is on urea is this Elijah, you know, going to forward. It is not a indication for patient in the four for dialysis in a patient here, something with acute kidney injury. I either not producing urine on this. That's where you're from. Too low G f r A. While the pH is because in acidosis, that's refracturing. If you remember acidosis, meaning or pay our pH. You know cells function in a *** hate to limit is a certain limit homeostasis something to five to seven point. So I sent a free 5 to 7.45. If it's outside that range and then acidotic and we can't resolve it, it's gonna cause said in the habit all over the body and, you know, cause organs to sort of, you know, not where you fail and the cells to be really dodgy. And that's why, in the acute setting on, I'm not talking about chronic horrible, the chronic setting Ramone more about that. But in the acute setting and urea is an indication. But the above of hyperkalemia, which contain a patient as noses, which could get patients severe demon because of you know which can cause respiratory failure tickets, lungs can court or an organ. Multi organ dysfunction can tell a patient toxins can. Can a patient because again, again, multi organ failure if you know if you're not excreting it on symptomatic uremia again. That's because affecting orders like like pericarditis whenever again can be two organ failure. So that's why those and you keep something or exactly So it's things that will kill if you don't have dialysis is you know I because of these things. So those are the things that would indicate you need acute dialysis, but like it is difficult. But I always see if your age, if I is for your probably going to have most of those other things. But it's not kind of an absolute GF are reading on absolute urea doesn't mean that you need dialysis now, but yeah, it's complete different picture in the in the chronic settings and once you eat, if our starts getting kind of less than 10 less than 15, then you start planning to dialysis? Um, and then you please clarify we should hold the forefront in a patient. So wolf want Muslim Publix by the liver, Not the kidneys. Yeah, so yeah. Yeah. Right now, I just picked a random drug. Basically, that's safe. It's got nothing to do, is it's not accumulated. It's not really cleared. And it's not nephrotoxic. It's all the other drugs are the nephrotoxic or their be excreted. So the chemo today. So that's why, uh, could you explain what is metabolic acidosis in taking multiple reasons, guys. So multiple reasons. So kidney metabolizes lactate. So if you get these are awfully lacked, it's an increased metabolic customs from that. If you're a A, increases your area is also can be some increased short sort of decrease your pH doubles. That's another one. What else am I thinking about? The lose you lose. Bicarb is well in my kidneys, so that's another reason to be in a lot of having main reason is the toxins. I mean, the urea as they build up they affect the pH is all you know, your kidneys clear a lot of toxins from the body that you're going to get rid of them. They just develop acidosis. And you could try and treat that with IV bicarb first. So that's That's why if it's not working and you need dialysis, don't make sense. It does, yes. Um, so multiple reasons, guys. It's not once imprisoned area said it, but yeah, bicarb, urea, lactate all those things. And if you miss past sessions, will they be used in the final? So, yes, according will be on that. Also, if you make a matter account next slides and the recordings on, will you be doing any extra key sections? Yes. If you follow us along for timetable, we will do SJC sessions closer towards sort of the STD time. But yes, there will be actually 80 sessions. Um, brilliant. I think we'll leave it at that. Thank you so much for joining us, guys. Thank you for a fantastic teacher. Very opposed to feed back link again. Guys, please. The only thing that we ask once again it's Zeus fall towards all of operators. Please fill out the view back. That's the only thing that we ask for a half. When we provide his teacher has a lot of our own time world. Pretty busy, but you can see time and effort and, um, you get people like a nerve. It's also gonna teach someone that will really help me get in Torino. Which is the Enbrel guys interacting and answering the questions. Thank you for your comments. Is are we in a couple of days? Fantastic On? I guess we will leave it at that and see tomorrow for another sort of session on the keep medicine. And I'll be there again. Thanks a lot of See you. Just take a