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Even when nephro orders CRRT, it's not that hard. I ordered a couple on my last nephrology rotation as a resident and there were only a few parameters that actually needed to be picked, everything else was by protocol. Actually being the one taking care of the ICU patients and putting in all the lines, adjusting vent settings, and otherwise keeping them alive was much more difficult 😛
P.S. how drunk is JDH?
At my hospital, HD has a protocol, but not CRRT. The serum concentrations of sodium, potassium, bicarbonate, and calcium change constantly with CRRT, because it extends over a long period of time, like 12-24 hours, so you frequently have to adjust the baths. Furthermore, you don't always order the same bath for a given concentration of a particular electrolyte. For instance, for a potassium of 4.8, in some cases you might order a 4 K bath, in others you might order a 3K bath. The 3K bath might be ordered in a patient who is more acidotic, has rhabdomyolysis, is hypotensive, etc.. For a patient who does not have any of these things, a 4K bath should work just fine. And if you order a 40 HCO3 bath on a patient with a serum bicarb of 7, you have to be careful not to overshoot or you will cause the patient to be alkalotic. And you have to tailor your ultrafiltration rate to the individual patient. Even if the patient looks very volume overloaded, that doesn't mean you can run the UF at 500 ml/hour if s/he is becoming tachycardic or hypotensive! You calculate your UF based on what they're getting in and what you think they can tolerate. Even the decision of when to do HD or CRRT isn't always clear cut. For instance, even if you have a patient who only put out 200 cc of urine yesterday and has a rising BUN/creatinine, that doesn't necessarily mean you need to do HD or CRRT at that point. You base the decision on how the patient looks, how unstable electrolytes like the potassium and bicarbonate are, and how likely they are to become unstable (i.e. sepsis, tumor lysis, etc...). As for intensivists doing CRRT, I've heard of that happening at other hospitals, but it certainly doesn't happen in mine.
And its not like HD or CRRT are the only things we do. There is a lot more to nephrology than that. We diagnose causes of acute kidney injury, which usually involves taking a detailed history and physical, and then deciding on appropriate tests, depending on the cases. A lot of times, it might be ATN, but sometimes we have to look for the zebras like anti-GBM antibody disease, membranous nephropathy, amyloidosis, etc... And based on results, we determine how to manage it. And for some of those conditions, the treatment is not always clear-cut. For instance, the RAVE trial showed that for ANCA-associated vasculitis, rituximab was non-inferior to cyclophosphamide. You have to determine the appropriate treatment based on the patient's characteristics. There are always clinical trials going on in nephrology. For instance, you know that even the appropriate target for BP control is controversial? There were two different trials, the SPRINT and ACCORD trials, which drew different conclusions as to appropriate target BP.
So yes, nephrology may not require the intellectual capacity of a rocket scientist, but it does require at least some thinking. And we do have to know our stuff.
