A famous nephrologist getting ready to go see the most famous guy who plays a nephrologist @glaucomflecken.bsky.social @stanforddeptmed.bsky.social Grand Rounds!

We are thrilled to announce that we have generously received funding for a one-year hypertension fellowship, and we are recruiting now for a candidate to start fellowship July 1, 2026 . med.stanford.edu/hypertension/e… -Jehan Zahid Bahrainwala HTN Fellowship Program Director

Go to Stanford and learn from the best for hypertension! #NephSky

Secondly, loop diuretics act as venodilators, which means if you look at vena cava shortly after a diuretic dose, vena cava (and RAP/CVP for that matter) may suggest normovolemia even if the patient is still volume overloaded. www.ahajournals.org/doi/10.1161/...

First of all, I think it’s well overdue that we abandon the use of vena cava size (or at least downgrade it). It’s the poorest parameter! Vena cava circularity/sphericity is much better! pubmed.ncbi.nlm.nih.gov/28065586/

Some thoughts on this study on using vena cava to guide in-patient treatment of deconpensated heart failure and why it will not change the way I diurese (I use vena cava wisely). #emimcc #cardiosky

☝️DIGIT trial shows benefit from digitoxin in HFrEF (even in context of reasonable GDMT) numerous limitations but consistent w/ the seminal DIG trial (👇 hospitalizations) digitoxin is hepatically metabolized making dosing easier (not available in USA) #1/2 #EMIMCC www.medscape.com/viewarticle/...

for those of you worried about the safety of PPIs among critically ill patients: this RCT evaluated the effect of using insanely ridiculously ginormous mega-doses of esomeprazole in septic patients and... ...absolutely nothing happened. #EMIMCC journals.lww.com/ccmjournal/f...

Case in point: vasopressin is probably only a wise choice if EF is supranormal pubmed.ncbi.nlm.nih.gov/37030157/

Extremely striking difference in utilisation of Impella in the US vs UK and Canada. #cardiosky #cccsky #emimcc jamanetwork.com/journals/jam...

P-values are fraught with hazard, but SO IS BAYESIAN STATISTICS the Achilles heel of Bayesian stats is that someone determines a pre-test probability distribution (usually arbitrarily) The pre-test probability is often too high This inflates the final posterior probability 🧵 #1/4 #EMIMCC

assessing the severity of methemoglobinemia: people get too hung up on % methemoglobin *functional hemoglobin level* is more important 30% MeHb is OK if total hemoglobin is 15 mg/dL, but a big problem if total hemoglobin is 7 mg/dL same idea as O2 saturation vs. O2 carrying capacity 👇 #EMIMCC

technically this is true “up to 40%” my bank account contains “up to 10 billion dollars” the words “up to” are doing a lotta work here 😆

Myth busting: Antibiotics don't reduce mortality in variceal hemorrhage! I updated the IBCC & explained what happened here emcrit.org/ibcc/gib/#va... We probably don't need antibiotics at all🤦‍♂️ Nice illustration of how meta-analyses can be fragile (even Cochrane) emcrit.org/pulmcrit/meta/ #EMIMCC

Convoluted RBC cast; case of endocarditis-associated crescentic necrotizing glomerulonephritis #UrinarySediment #UrineMicroscopy #PisseProphet #OchsnerNephrology #Glomerular #GN #AKI

I will never get over how creepy it is how the NIH X account is a full time propaganda machine now

The Maltese Cross 🇲🇹🛡️sign is not unique to lipids, other structures can manifest it under polarized light (eg, starch, leucine crystals). Here, a rare sighting of a cast containing suspected ciprofloxacin crystals. #UrinarySediment #UrineMicroscopy #PisseProphet

We use aminoglycosides widely, and gentamicin specifically, in Norway. Only case of clear ototoxicity I’ve encountered was in an endocarditis case with overdose over many days (after weeks of therapy, medical error).

we're under-utilizing aminoglycosides for urosepsis in patients with good renal function rising % ESBL is pushing us to use carbapenems for empiric therapy... leading to more resistance (CDiff, CRE) aminoglycosides have minimal gut penetration = low CDiff risk & protect microbiome 🧵 #1/4 #EMIMCC

I made some improvements to my Stewart acid-base calculator, I think some of you might find it useful as well: medischesnippers.nl/stewart/ Let me know if you find any bugs or errors. @pulmcrit.bsky.social @kidneyboy.bsky.social

8/10 #NephJC Quote of the fortnight @hswapnil.medsky.social‬ and @christosargyrop.bsky.social ‬ quickly agreed on new treatment goals for DKD #ZeroAlbuminuria

Guidelines no longer recommend holding typical first-line antihypertensive meds since renin will most often still be suppressed despite being on them in true PA. Growing evidence supports proceeding with screening Hot off the press from the Endo Society: www.endocrine.org/clinical-pra...

What is at the top of your differential in a patient with a positive SPEP (IgG kappa) and the immunofluorescence finding below? (hint: lambda is negative) #DiagnoseThis #pathology #renal #kidneypath

this would be lovely in the ICU, to avoid excess sedation. when we have patients on propofol sedation who happen to be on EEG monitoring, I’m often shocked by how completely flat the EEG is. (it’s not normal or beneficial to have a totally flat EEG - makes it harder to wake up 😩) #EMIMCC

amiloride - allows large volume diuresis without needing to give the patient potassium every 5 minutes and without risking the potassium going to zero if nobody is paying attention seriously I'm pretty sure it improves safety (less hypoK) and saves money (less IV potassium infusions)

Interesting that when Renal Guard was double blinded (sham controlled) it stopped working 🤔 pubmed.ncbi.nlm.nih.gov/31120108/

Great article on dogma in ID (with parallels to critical care) We have HUGE problems re: guidelines making recommendations & *redefining* entire diseases based on minimal data. Gov't metrics exacerbate this further. @bradspellberg.bsky.social @absteward.bsky.social @drtoddlee.bsky.social #EMIMCC

Nice commentary explaining this in the setting of inaccuracy of TR gradient for estimating SPAP, but the same applies to aortic stenosis of course. journal.chestnet.org/article/S001...

This is what we were waiting for. A direct comparison between apixaban and rivaroxaban for the treatment of acute VTE. Apixaban reduces bleeding risk in the first 3 months by >50%! Practice changing investigator-initiated RCT. #ISTH2025

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early MAP support w/ norepi in septic shock 😄 this was edgy around ~2012-2015 I feel like most people are on board with it now (🤞) TLDR: even if the patient looks peachy, pls still support the MAP 2014 blog: emcrit.org/pulmcrit/ear... new meta: ccforum.biomedcentral.com/articles/10.... #EMIMCC

Today's Paper of the Day is: Challenge of tracheal extubation and tube exchange of a difficult airway: a narrative review https://criticalcarereviews.com/latest-evidence/paper-of-the-day Join us to read 1 paper per day and stay up-to-date as we cover the spectrum of critical care across 2025

Cascade reporting involves the lab only reporting the most narrow-spectrum antibiotics that a pathogen is sensitive to (and intentionally HIDING the results for broader spectrum agents) It's designed to push us towards choosing narrower antibiotics but it's a disaster... rantorial #1/7 #EMIMCC

new IBCC chapter: constipation! most ICU patients are constipated, so we manage this on a daily basis. but our approach is often super random ("I was taught this in residency") so I tried to create an evidence-based treatment strategy for constipation...🧵 #1/7 #EMIMCC emcrit.org/ibcc/constip...

Absolutely fascinating! We know the heart switches to lactate as energy substrate in shock, could there be a clinical benefit from lactate infusion in human cardiogenic shock? #emimcc #cccsky

Latest meta comparing continuous feeding vs. intermittent feeding among intubated patients: it doesn't matter. Continuous feeding seems horrifically aphysiological to me, but I guess it's allright. (ongoing theme: nutritional details don't matter) www.sciencedirect.com/science/arti... #EMIMCC

What are the restrictions on SGLT2is in NZ? #ERA25

The Australians with a clear recommendation to use balanced solutions (they don’t specify Plasmalyte) in kidney transplant www.kireports.org/article/S246... in @kireports.bsky.social #NephSky #Transplant #EMIMCC

A great review discussing the use of #POCUS in the four phases of shock BTW, nice blend of (patho-)physiology references & bedside applications!

Sarcoidosis like hypercalcemia with dabrafenib/trametinib (BRAF/MEK inhibitors) - case report www.kireports.org/article/S246... in @kireports.bsky.social #NephSky

neurologists when the patient was previously healthy and now has a sudden onset tremor of the left pinky: this could be a rare genetic disorder of neurotubular synaptotectin receptors of small muscle fibers neurologists when the patient has ESRD and a BUN >30: it’s metabolic, they need dialysis

Amiloride was noninferior to spironolactone in lowering home systolic blood pressure at 12 weeks. https://ja.ma/42XMGD9

Fascinating that the U-shaped relationship seen between LVEF and outcomes is not seen for RVEF #echosky #emimcc #cardiosky academic.oup.com/eurheartj/ar...

Procalcitonin- the more we learn, the less we love it 💔 ▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT ▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️ “Pct in pts with AKI/ESRD should not be measured” #EMIMCC ccforum.biomedcentral.com/articles/10....

I was skeptical about percutaneous mechanical aspiration for tricuspid valve endocarditis, but it apparently can work. Look at this picture of a vegetation that was fished out of a patient I was involved with. Only after removal was he able to achieve negative blood cultures.👇 #EMIMCC

I’m obviously a bit biased, but I believe there is greater danger in misclassification of non-septic shock (especially cardiogenic) as septic shock than from delayed recognition of septic shock. #emimcc #cccsky

I don’t usually post around this time—unless something 🔥 drops. Time zones don’t matter when it’s this good Worth breaking the pattern #IDsky #EMIMCC

cosign: hyperinsulinemic euglycemia is unlikely to help CCB overdose patients with vasodilatory shock & preserved/hyperkinetic EF. #EMIMCC

Yup. We discussed the JASN study from @scoca1.bsky.social et al on #NephJC here www.nephjc.com/news/hyperna... Podcast: www.nephjc.com/freelyfilter...

Three Cases of Red Yeast Rice–Containing Supplement-Induced Acute Kidney Injury and Fanconi Syndrome bit.ly/3C813tp #OpenAccess