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Scleroderma Renal Crisis: ACE Inhibitor First, Steroids Out
Scleroderma Renal Crisis (SRC) is a life-threatening complication of systemic sclerosis (SSc), classically presenting wi...
Hypokalaemia With Normal-Anion-Gap Acidosis: RTA vs Diarrhoea
Hypokalemia with metabolic acidosis is a challenging clinical scenario that requires a systematic approach to uncover th...
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Cinacalcet versus etelcalcetide: how do you choose, prescribe and switch in dialysis secondary hyperparathyroidism?
Oral daily versus IV after HD: both activate the calcium-sensing receptor and lower PTH; etelcalcetide gives supervised...
Kidney-transplant recipient, 6 years out, graft stable: what late complications do you screen for and how do you reduce his cardiovascular, cancer and diabetes risk?
Bottom line: late care is surveillance: the graft (creatinine, proteinuria, DSA, adherence), cardiovascular risk (statin...
Man who donated a kidney ten years ago: creatinine now 1.3 mg/dL (was 0.9), blood pressure 145/92 and urine ACR 50 mg/g. How do you interpret this and what do you do?
Bottom line: a modest creatinine rise alone is expected after donation, but new hypertension plus albuminuria is not rea...
Kidney-transplant recipient 15 years out with months of diarrhoea and weight loss: causes, work-up, and how do you decide that it is CMV colitis rather than mycophenolate?
Bottom line: split drug from infection. Mycophenolate is the commonest drug cause; C. difficile is the commonest bacteri...
A 52-year-old on haemodialysis is offered a deceased-donor kidney from a donation-after-circulatory-death donor with a high KDPI: how do you decide whether to accept it?
Bottom line: I classify the donor (DBD or DCD, controlled or uncontrolled), quantify donor quality with the KDPI (0 best...
A patient's creatinine has risen after starting a new medication: how do you decide whether it is a harmless haemodynamic effect, true drug-induced AKI (tubular injury or interstitial nephritis) or a pseudo-rise, and what do you do in each?
Bottom line: sort the rise into four mechanisms — haemodynamic (ACE inhibitor/ARB, NSAID), tubular toxicity (ATN),...
A PD patient has a purulent, red exit site with no peritonitis: how do you treat it, and when does the catheter come out?
Bottom line: swab the infected exit site, start an anti-staphylococcal antibiotic (usually oral) for at least 2 weeks, w...
A woman with diffuse scleroderma on prednisone 20 mg has BP 210/120, blurred vision and creatinine rising from 100 to 250 umol/L: what is the diagnosis, what do you start, and what is the role of steroids?
Bottom line: this is scleroderma renal crisis (SRC) — abrupt accelerated hypertension with rapidly progressive AKI...
A 54-year-old non-adherent hypertensive has BP 240/130, headache, blurred vision, papilloedema and creatinine up from 90 to 250 umol/L: what is this, how fast do you lower the pressure, and with what?
Bottom line: severe BP plus acute target-organ damage (papilloedema, encephalopathy, AKI) is a hypertensive emergency: I...
An anuric haemodialysis patient arrives in acute respiratory distress with BP 220/120 and pulmonary oedema on the chest film: immediate management, and how do you choose between nitrates, diuretics and ultrafiltration?
Bottom line: in an anuric patient diuretics cannot work, so the order is sit up, oxygen if hypoxic, non-invasive ventila...
A haemodialysis patient develops fever and rigors during the session: catheter infection, pyrogenic reaction or dialyzer reaction - what do you do first and how do you tell them apart?
Bottom line: fever on dialysis is infection until proven otherwise (catheter, access, distant focus) or a pyrogenic reac...
Long-term haemodialysis patient with stuttering speech, bone pain and microcytic anaemia: do you suspect aluminium toxicity, how do you confirm it and what do you do?
Bottom line: suspect aluminium when a dialysis patient has encephalopathy (stuttering speech), osteomalacia or adynamic...