Juan Carlos Q Velez
@VelezNephHepato
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Academic Nephrologist @OchsnerNephro | @OchsnerHealth | Ochsner Clinical School- @UQMedicine Faculty
New Orleans, LA
Joined April 2017
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Do you ever wonder how come vasoconstrictors revert renal vasoconstriction in
#hepatorenal
syndrome? Found it counterintuitive? Here is a 30 sec animation:
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1/n adult arrives with sudden on onset of weakness, inability to stand. Complaints of muscle tenderness. CPK 11,000. Cr 2.0 mg/dL(baseline 0.9), Phos 7.6. AKI due to toxic ATN/rhabdo. All clear. But, K 2.1 mmol/L! Not the expected hyperkalemia…
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Today, I was asked by a
#medicalstudent
what are the most exciting developments in nephrology in the last few years, things that have affected the way I practice. Gave a 60 sec answer. But this is what I really wanted to say:
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Wonder why
#nephrologists
order that crazy 240 mg dose of IV Lasix for patients in
#AKI
? Here is a 30 sec animation, go:
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When the hyponatremia rapidly corrects but at the end the outcome is favorable.
#nephrocentric
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Nephrologist calmly handling being showered with irrational requests for urgent dialysis
#nephrocentic
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Nefrólogo y Cardiólogo manejando satisfactoriamente un paciente congestionado en equipo
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Ladies & gentlemen of the
#nephtwitter
world, let me introduce you the absolutely longest white blood cell cast of all time
#UrinarySediment
#PisseProphet
#UrineMicroscopy
@OchsnerNephro
#glomerulonephritis
#nephrocentric
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1/n Hyponatremia in cirrhosis rounds: case 1: ESLD 2/2 ETOH. Admitted at OUH 2/2 abd distension/lethargy w/sNa 133. Kept on spirono + furosem + lactulose. Gradual ⬇️in sNa in 10 days. Transferred 4 ⬆️level of care. Arrives with sNa 125, sCr 0.8. Alert, jaundice, ascites, no edema
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Ciprofloxacin crystal in the
#UrinarySediment
, appearance of a flaming asteroid under polarized light. Suspected toxic ATN.
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Sweet
#Xmas
present from my daughter. Carbon drawings over 2 of my publications. They’re going straight to my office wall.
#nephroart
#bestdaughterever
#papiestafeliz
#whattapresent
#feelingspoiled
#buddingartist
#glomerulus
#reinsarethebrains
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Fellow: memorize the guidelines
Junior faculty: question the guidelines
Mid career: ignore the guidelines
Senior faculty: call your buddy and ask him/her to rewrite the guidelines
Stages of residency:
Intern: figure out how to do stuff. PGY 2: figure out why we do stuff. PGY 3: realizing you know nothing
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When you give 20 mEq of KCl po qd to a patient with diarrhea on IV Lasix
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Nephrology team’s reaction when the primary team orders a PLA2R ab before placing the consult for nephrotic syndrome
#nephrocentric
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1/n My family and I recently visited my home country Peru. Thrilling experience to take the kids to see Machu Picchu for the first time 🇵🇪
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ICU and Nephrology teams running into each other and touching base about a few pts in common
#nephrocentric
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1/n SIADH is the FSGS of electrolyte disorders. Why? because it represents a pattern of disorder of water regulation (⬆️uOsm, ⬆️uNa) that can be triggered by different mechanisms of disease, like FSGS is a pattern of injury that can be the result of various glomerular hits.
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updating my CV mode
#milestone
#academics
@UQMedicine
#GratefulToMyParents
#bigdeal
#VamosPorMas
@OchsnerNephro
@CayetanoHeredia
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Diagnostic work up for nephrotic syndrome? Just some advice to medical trainees
#MedEd
#InternalMedicine
#Nephrology
@OchsnerIMRes
@OchsnerNephro
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Nephrology fellow walking to the cardiac ICU the morning after a heated argument about dialysis vs diuretics that ended up in 5 L of UOP
#nephrocentric
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Reflection on the days of iMedicine: Respect the senior physician. They may take their time, but their judgment and astuteness is to be admired and emulated
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SGLT2 inhibition restores NCC activity and TRPM6 expression via CaSR stimulation, a potential mechanism for its therapeutic benefit against hypoMg. Bam! The kinda education I love getting at
#KidneyWk
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Pathophysiology of Hepatorenal Syndrome
@NephRodby
@Nhepatic
@akdhjournal
@HrsHarmony
#HRS
@serenellaavelez
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Another fantastic
#KidneyWk
on the books, but this one, in particular, will always have a very special meaning for me 💙
#ProudPapi
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1/n a case of hypomagnesemia: pt sent to clinic 2/2 incidental finding: serum Mg 1.0 mg/dL. Not on diuretics, no diarrhea. Yep, common suspect is present: omeprazole, PPI-induced hypoMg is well-reported. First in 2006, this is an early case series
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CKD clinic visit. CO2 ⬇️ from 19 to 14 despite NaHCO3
Doc: “were u able to take Na bicarb tabs?”
Pt: “yes, 3 tabs twice a day”
Doc: “maybe skipped some days?”
Pt: “not at all”
Doc: “hmmm, strange...”
Pt: “yes doc, matter of fact, have the bottle here, wanna see it?”
#MedReview
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1/n new consultation to nephrology: young adult pt arrives to the ED with Na 125, K 2.5, Cl <70, CO2 45, BUN 49, Cr 2.4, Gluc 121. Pt had been hospitalized the month prior with a similar set of labs. At that time Gitelman syndrome was entertained as a diagnosis.
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Always cool to see a new paper in press version. But this is special. The most meaningful acknowledgement I’ve ever typed in a paper, so proud of my 16 yr-old daughter
#ProudPapi
#Priceless
#WomenInMedicine
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Have you ever heard that hypercalcemia is like Lasix to the loop of Henle? Well, hyperkalemia is like Thiazides to the DCT. Bam.
#KidneyWk
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1/n Sharing one more case before I go full force into
#KidneyWk
mode. Middle-aged Pt presents to clinic for flank pain and gross hematuria for 4 wks. Normal kidney function. Treated for UTI, no change. Seen by urology: cysto: no stones, no tumor, just clots. Urine like red wine
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Asterixis (flapping tremor) in a patient with AKI, azotemia and confusion = uremia. Immediate RRT planned. (Posted with permission)
#physicalexamination
#MedEd
#medicaleducation
#semiologia
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Ok this one wins as the most impressive poster at
#NKFClinicals
Sadly, reflection of how dangerous can misinformation be
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My “only
#COVID19
PUI ICU renal” rounding list today. We are close to maximizing CRRT capacity. This is Armageddon. But we are all in.
#WeAreInThisTogether
@OchsnerNephro
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Kidney cake, status post kidney biopsy at its lower pole, brought by
@SwethaKanduriMD
#NephCake
#NephMadness
@OchsnerNephro
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Why are you ordering ANCA and anti-GBM titers when the patient was 4+protein and no blood in the urine?
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Maybe this is how pulmonary edema can hide an underlying parenchymal lung disease
#hypervolemia
#fluidwars
#Nephrocentric
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I’m not a fan of algorithms, at all, but in the liver AKI space, the abundance of articles with simplistic 3-way algorithms (prerenal, ATN, HRS) pushed me to construct this phenotype-based framework that is intentionally depicting the complexity of establishing a diagnosis
Diagnosis and management of AKI in patient with liver cirrhosis from
@VelezNephHepato
@HrsHarmony
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1/ Patient with cirrhosis and worsening
#AKI
c/w
#hepatorenal
syndrome (HRS-1), not responding to midodrine/octreotide. Starts norepinephrine, MAP pushed up from 65-75 to 85-90...
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When I hear “volume depleted” instead of “dehydrated”, it’s music to my ears, so they go like this
#nephrocentric
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This stunning trophy arrived at my door a few days ago, rest assured that it’ll b strategically displayed in my office, to show off, just a little. So thankful to the entire
@NephJC
crew for the kind recognition. It’s almost 5 yrs on this
#NephTwitter
adventure, pumped 4 more 💪
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@tony_breu
23/23 the hypoMg could have played a role too. Pt was sent home on KHCO3 50 mEq/KCl 20 mEq + amiloride. 2 wks later K 5.8. One month later, pt off everything, K 4.6. Not drinking coffee nor Coke more than 1/wk. this case reminds us the forgotten value of history taking/ the end
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When URINE a mood for a good day at work, ready to debate POLARIZED opinions. Showing off a generous gift from
@jrseltzer
during
#KidneyWk
#UrinarySediment
#crystalluria
🔬
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Hyperleukocytosis-induced pseudohyperkalemia. No insulin, no albuterol, no Lokelma, no Lasix, no dialysis. Just an ISTAT K from an ABG.
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Floor team: “hi, is it OK to give 20 mg IV Lasix for this pt in AKI?”
Nephrology fellow: “20 mg? You could give that to me if you want, how about 200 mg for the patient, please?”
#DiuresisJedi
😏
@ashraf_dwal
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Historical moment of an executive order to ban ordering a FENa in patients with acute kidney injury before obtaining a good ol’ urinalysis
#nephrocentric
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Nice example of a hyperechogenic kidney. Biopsy showed C3-GN with only 5% IFTA & zero obsolescent gloms; “echogenic kidneys” in isolation is never a contraindication for kidney biopsy.
#renalimaging
#NephPOCUS
#renalultrasound
#kidneyimaging
#nephropic
@OchsnerNephro
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Acanthocyturia detected in
#UrinarySediment
of a patient presenting with new-onset gross hematuria and increased serum Cr. Dark field view (40x objective).
#glomerular
@OchsnerNephro
#PisseProphet
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1/11💧 Urine albumin-to-creatinine ratio (UACR) testing in type 2 diabetes (
#T2D
) – a brief tutorial
👉 What is it?
👉 Why it’s an important complement to eGFR 💉 testing to identify chronic kidney disease (
#CKD
) in
#T2D
COI:
#BayerPartner
#ItstheKidney
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When a nephrology fellow walks into the ICU and the requests for dialysis start coming at her/him
#nephrocentric
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New consult in clinic: hematuria/proteinuria, Cr 0.9
#UrinaryMicroscopy
performed STAT. Image should speak 4 itself. Messaged urologist 2 consider cancelling scheduled cystoscopy. Kidney biopsy now planned
#PisseProphet
#acanthocytes
@OchsnerNephro
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1/n young adult presents to the ED with weakness, fatigue & LE edema. Cr 2.8 (base 1.0). Reports tarry stools. Initial clinical impression: ischemic ATN 2/2 GIB.
#UrineMicroscopy
is performed: crisp RBC casts and acanthocytes are identified in
#UrinarySediment
. Time to regroup.
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In the midst of the
#COVID19
epidemic, even these monkeys take only 1 roll of toilet paper at a time. Let’s stay civilized
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Uric acid crystals. Urine pH 5.0. AKI CRS-1. Incidental finding, not clinically significant.
#UrinarySediment
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Which of the following is the biggest nephro fallacy? Vote and say why
CKD from chronic NSAIDs
219
AKI from IV contrast
1225
HypoNa from hypothyroid
330
CKD from chronic PPIs
493
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Just because a patient is on Lasix, it doesn’t mean that Lasix gotta be the cause of the AKI
#nephrocentric
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Eternally vilified
Never glorified
Ripped apart for my flaws
Shredded in bylaws
Blame the muscle
Not a puzzle
Tubular secretion
Perfect ammunition
You will whine til the end
But will order me again
Coz u know it’s a fact
I’m the best that u got
Ode to creatinine
#NephPoetry
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“They are going to call you with an “AKI” w/o baseline Cr, with a Na 112 after 2 L NS w/o urine values, with a pH 6.9 on 3 pressors, for a PICC in a CKD-4, for diuresis with no Is/Os. It’ll be alright. I got your back. We are family.”
#nephrocentric
#renalfellows
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Nephrology journals got it right this month with their pics for cover art
#UrinarySediment
#UrineMicroscopy
@ASNKidney360
@NDTsocial
🙌💪🔬
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My take on these complex
#CardioRenal
scenarios
Simple Q, hard to answer:
When SCr rises with diuresis in an overloaded state, does it represent lower GFR, or just concentration of SCr w lower plasma volume?
I’m sure “it depends”- but I’ll bet the later scenario happens more often than we think 🤔
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Cr trending down nicely from 4 to 2 in 4 days…
“AKI resolving but want you guys to take this consult and give us some recs”
- “your team is providing great care. Do you have any specific question?”
“We are hoping to discharge soon, but want your blessing”
- 👇🏼
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A 3D printed glomerulus. Even if it doesn’t evolve into a useful research tool, it’s pretty cool.
#nephrocentric
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We went from RRT to KRT, and now it’s KST? how about we just call it dialysis? advancing medical science shouldn’t require changing terminology every 2 yrs. Nothing against the high caliber authors. It’s just a rant/call to rethink the constant name changes in our field
Review by Josée Bouchard and
@RavindraLMehta1
:
Timing of Kidney Support Therapy in Acute Kidney Injury: What Are We Waiting For?
(FREE)
@ucsdnephrology
#AKI
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Writing CRRT orders, nephrology fellow on first month of fellowship and on last month before graduation
#nephrocentric
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When you are postop from orthopedic surgery and the nurse requires micturition before discharge and you deliver as a
#nephrocentric
patient w/850 ml despite preOp Celebrex (me, I gave myself permission to post; don’t mind the foam, dipstick neg prot)
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1. FENa: <1%? who cares when pt has abundant granular casts
2. Urine Eos: really? No WBCs in UA so...
3. 25-Vit D level: zzzz...🛌
4. TSH: trust me, the hypoNa? Not 2/2 myxedema coma
5. Ferritin: just give me the TSAT plz
What are your top 5 most hated labs? (inspired by
@IAmDrIbrahim
!)
Lactate: don't need it to tell me who's in shock
ESR & CRP: often a fishing expedition
BNP to figure out HF - check the JVP!
Troponin w/o symptoms- see fishing expedition, above (dedicated to
@cardiojaydoc02
)
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2/n immediate reminder that while rhabdomyolysis CAUSES hyperkalemia, hypokalemia may CAUSE hypokalemia: K depletion causes muscle ischemia by preventing normal release of K from myocytes during contraction. Couple of case reports:
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“bank” of bacteria flowing down a river surrounding a pseudo WBC cast “island” (phase contrast microscopy). Reminiscent of
@RiverMonstersUK
Case of
#AKI
in the context of suspected pyelonephritis
#UrinarySediment
@OchsnerNephro
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“You have to love teaching. You have to know the field. And you have to be able to explain it so that others can understand.” Burton Rose. On the Narins Award.
#KidneyWk
@BookBurton
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5 yo daughter: “Papi, a flamingo!!”
Me: (thinking: is that a loop of Henle?)
Yeah, something Is wrong with me
#nephrocentric
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1/7 pt develops precipitous AKI on the fourth day of hospitalization (for orthopedic surgery). Cr rose from 0.8 to 3.3 mg/dL in 24 hrs. Had received 11 g of vancomycin 48 hrs prior to the bump (weight 141 kg). Classic presentation of precipitous
#AKI
due to
#vancomycin
.
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This is how useful I find HTN guidelines in my day-to-day practice as a
#nephrologist
#NephMadness
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Embracing our procedure in nephrology: ultrasound-guided percutaneous kidney biopsy; direct inspection of tissue cores essential for specimen adequacy, iphone zoom adapter works well, 3 cortical cores visualized. Strong work by
@OchsnerNephro
fellow
@TJ_Wickman
💪
#PatientCare
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Impressive contrast CT images illustrating R renal infarction affecting half of the parenchyma, pt had flank pain & normal Cr, as it is usual in these cases. 10 yrs later, affected parenchyma is atrophied, Cr remains unchanged.
#renalimaging
#nephropic
#nephronmass
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While you might think that we are looking at 2 versions of a gas grill, old and modern, the top image is one of the first rotating drum artificial kidneys, invented by Willem Kolff 🇱🇺in 1943. Yep, top device to remove urea, bottom device to generate urea 🥩
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Full-blown tenofovir-induced Fanconi syndrome. HypoK, NAGMA, +UAG, phos wasting. Lacking glucosuria.
#electrolytes
#acidbase
@OchsnerNephro
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Real-time US-guided kidney biopsy (left lower pole). Immediate microscopy-based confirmation of adequacy of the retrieved specimen is critical to optimize histopathological examination. Note the visible glomeruli in the biopsy core
@OchsnerNephro
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Nephritic-Nephrotic syndrome captured in this
#UrinarySediment
video. Note the numerous acanthocytes (nephritic) in dark field and how the fatty cast (nephrotic) lights up under polarized light
#glomerular
#PisseProphet
@OchsnerNephro
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When the bicarb drip is prescribed at the correct rate and the right number of amps per liter
#nephrocentric
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I knew I would see this headline at some point. Oh my. 😆😆😆😆 this is absolutely a disgrace.
@rheault_m
@vipvargh
@hswapnil
@scoca1
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