In this episode of Clinical Conversations, Dr Marilena Giannoudi discusses cardiorenal metabolic disease with Dr Andrew Frankel. Their discussion provides an overview of this common cause of chronic kidney disease (CKD) and they focus on the management of cardiorenal metabolic disease, with Dr Frankel highlighting the importance of lifestyle management and patient education and engagement, and the pharmacotherapy 'four pillars' of RAAS inhibition, SGLT2 inhibition, blood pressure control, and MR antagonism. Explore this and more in this episode.

Dr Andrew Frankel has been working as a consultant nephrologist at Imperial College Healthcare NHS trust since 1995 and works at the Imperial Renal and Transplant Centre, which is one of the largest kidney units in Europe catering for a population base of over three million. He has experience in managing all aspects of kidney disease but has a particular interest in relation to the management of kidney disease in the context of diabetes, cardiac disease and obesity.

Dr Marilena Giannoudi is a cardiology registrar based in Leeds. She is Co-Chair of RCPE's Trainees and Members' Committee.

-- Links --

NICE Guideline (NG203) - Chronic kidney disease: assessment and management

https://www.nice.org.uk/guidance/ng203

2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/CVD-and-Diabetes-Guidelines

For Kidneys Sake Podcast - By Dr Andrew Frankel and colleagues

https://www.forkidneyssake.com/

Recording date: 24 November 2025

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This podcast is from the Trainees & Members' Committee (T&MC) of the Royal College of Physicians of Edinburgh (RCPE).

In this episode, Dr Kat Ralston speaks to Professor Edwin Jesudason about how his experience of whistleblowing as a paediatric surgeon changed his practice. They reflect on the importance of listening and creating a shared dialogue with patients, discuss how experiencing moral injury can help clinicians better understand and navigate patient suffering and explore the art of being human in medicine.

Professor Edwin Jesudason is a Consultant in Rehabilitation Medicine in NHS Lothian.

Dr Kat Ralston is a geriatric medicine registrar in Edinburgh. She is also the Education Co-Vice Chair and the joint Podcast Lead for the RCPE Trainee & Members' Committee (T&MC).

Recording date: 24 July 2025

-- Useful Links --

Jesudason, 'The 4D Model: Rehabilitating Unrealistic Medicine', BJHM (2025) https://doi.org/10.12968/hmed.2024.084

Jesudason, 'Manufacturing safer medics', J Med Ethics (2022) https://doi.org/10.1136/jme-2022-108581

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In this episode, Dr Kat Ralston speaks to Dr Jane Rimer about a challenging clinical case which had an unexpected outcome. They discuss the importance of reflection with trusted colleagues and consider systems to help us cover the basics well. They explore how we can reduce the sense of isolation and vulnerability that is often encountered when we have to navigate complaints, adverse event reviews and legal processes, as illustrated by the title 'Defence against The Dark Arts'.

Dr Jane Rimer is a Consultant Physician and Geriatrician in NHS Lothian. She is also Associate Postgraduate Dean for Medical Training in South East Scotland.

Dr Kat Ralston is a geriatric medicine registrar in Edinburgh. She is also the Education Co-Vice Chair and the joint Podcast Lead for the RCPE Trainee & Members' Committee (T&MC).

Recording Date: 29 July 2025

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In this episode, Dr Marilena Giannoudi hears about a case that changed the practice of Professor James Dear.

They discuss the challenges of caring for a patient without a diagnosis, who to talk to if you are feeling uncertain in how to treat a patient, and how you can own up to and move on from mistakes you may make.

Professor James Dear is a Consultant in Clinical Pharmacology at the Royal Infirmary of Edinburgh and Personal Chair of Clinical Pharmacology at the Centre for Cardiovascular Science at the University of Edinburgh.

Dr Marilena Giannoudi is a cardiology registrar based in Leeds. She is Co-Chair of the Trainees and Members & Committee, a Fellow of the Higher Education Academy, and is currently undertaking a PhD.

Recording date: 9 June 2025

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In this episode, Dr Kat Ralston hears about a case that changed the practice of Dr Chris Tiplady. They discuss the importance of recognising when a patient may be entering the last phase of life, what we owe to patients and families in understanding what matters to them, and how we can navigate managing uncertainty and being wrong as clinicians.

Dr Chris Tiplady has been a Consultant Haematologist in Northumbria since 2001 and has held a number of roles in postgraduate and undergraduate medical education over the years. He has been a Director of Medical Education in two trusts and now leads the Master of Medical Education course at Sunderland University. He also has a regular blog published by the Royal College of Pathologists, discussing professionalism in medicine.

Dr Kat Ralston is a geriatric medicine registrar in Edinburgh. She is also the Education Co-Vice Chair and the joint Podcast Lead for the RCPE Trainee & Members' Committee (T&MC).

Recording date: 14 April 2025

-- Useful Links --

NHS England, Last 1000 days - https://www.youtube.com/watch?v=HynytVepxZc

REDMAP toolkit for future care planning conversations - https://www.spict.org.uk/red-map/

The King's Fund, Patients' preferences matter: stop the silent misdiagnosis (May 2012) - https://www.kingsfund.org.uk/insight-and-analysis/reports/patients-preferences-matter

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In this episode of Clinical Conversations, Dr Aoife Duignan chats with Dr Claire Steel and Dr Shelagh O'Riordan about Hospital at Home.

They explore what Hospital at Home is, and the evidence base behind it, thinking through which patients may benefit from it. They also consider how technology can enable patients to receive care in their own homes and what a day in the life might look like. Finally they consider some top tips for becoming involved with Hospital at Home.

Dr Claire Steel is a consultant physician in older people’s medicine in NHS Lanarkshire. She is the President of the UK Hospital at Home Society and clinical lead for Hospital at Home in NHS Lanarkshire. She works closely with Healthcare Improvement Scotland to support the growth and development of H@H in Scotland.

Dr Shelagh O'Riordan is a consultant physician and lead for the Hospital at Home service in East Kent. She is President Elect of the UK Hospital at Home Society and National Clinical Lead for Hospital at Home/Virtual Wards for NHS England.

Dr Aoife Duignan is a geriatric medicine registrar in Edinburgh. She is also the Representation Co-Vice Chair for the RCPE Trainees and Members' Committee (T&MC).

Recording date: 16 April 2025

-- Useful links --

Hospital at Home Society Health Improvement Scotland Toolkit - https://www.ihub.scot/project-toolkits/hospital-at-home-toolkit/hospital-at-home-toolkit/

Hospital at Home RCT - https://pubmed.ncbi.nlm.nih.gov/35129936/

PPL South East Region Virtual Wards Evaluation - https://ppl.org.uk/what-we-do/virtual-wards-consultancy/

Cochrane Review - https://www.cochrane.org/CD007491/EPOC_hospital-home-services-avoid-admission-hospital

UK Hospital at Home Society - https://www.hospitalathome.org.uk/

NHS England Virtual wards operational framework - https://www.england.nhs.uk/long-read/virtual-wards-operational-framework/

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In this episode Dr Emma Spencer discusses decompensated cirrhosis with Dr Michael Williams. This discussion includes the definition of a decompensation event, how to recognise these events on the medical take and the importance of doing so. They also discuss key steps in investigating causes of decompensations of cirrhosis and how to manage these unwell patients.

Dr Michael Williams is a consultant hepatologist, working on the Scottish Liver Transplant Unit in Edinburgh. His clinical interests are liver transplantation and autoimmune liver disease.

Dr Emma Spencer is an IMT3 doctor in the South East of Scotland and a member of the RCPE's Trainees & Members' Committee (T&MC).

Recording date: 13 March 2025

-- Useful Links --

BSG/BASL Decomp Cirrhosis Care Bundle - https://www.bsg.org.uk/clinical-resource/bsg-basl-decompensated-cirrhosis-first-24-hours

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In this episode of clinical conversations, Dr Kat Ralston chats with consultant toxicologist Dr Emma Morrison about poisoning in the older adult.

They explore why we need to think differently about deliberate self-harm in the older adult and talk through common toxicology cases, including decision-making around escalation. Finally, they consider a common sense approach to what we can do differently as clinicians to reduce the risk of self-harm and suicide in this patient group.

Dr Morrison trained in medicine at the University of Glasgow, with an intercalated BSc in Physiology. She also completed a PhD investigating to role of short RNAs as biomarkers and mediators in toxic injury. In 2020, Emma become a Consultant Physician at the Royal Infirmary of Edinburgh.

Emma’s NHS work continues to support her passion of ensuring transparent and equitable decision making in prescribing, supporting the central tenets of value-based medicine. Her roles within medicines governance include Chairing Lothian’s Area Drug and Therapeutics Committee and is a committee member of the SMC.

Dr Kat Ralston is a geriatric medicine registrar in Edinburgh. She is also the Education Co-Vice Chair and the joint Podcast Lead for the RCPE Trainee & Members' Committee (T&MC).

--Useful Link--

TOXBASE - https://www.toxbase.org/

Recording date: 19 December 2024

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In this episode, Dr Kat Ralston chats with Prof Miriam Johnson about palliative care in heart failure. They discuss the evidence supporting specialist palliative care input in this patient group and explore how to develop effective integrated services. They chat about holistic, needs based assessment and share top tips on the approach to the debilitating symptom of breathlessness.

Professor Miriam Johnson is Professor of Palliative Medicine at Hull York Medical School, Associate Director of the Wolfson Palliative Care Research Centre at the University of Hull. She is Adjunct Professor of Palliative Medicine at the University Technology Sydney, Sydney, Australia. For twenty years (2000 to 2020), she also provided consultant palliative physician services to Scarborough General Hospital and Saint Catherine's Hospice, Scarborough where she set up one of the UK’s first integrated palliative care services for people with heart failure.

Dr Kat Ralston is a geriatric medicine registrar in Edinburgh. She is also the Education Co-Vice Chair and the joint Podcast Lead for the RCPE Trainee & Members' Committee (T&MC).

Recording date: 5 December 2024

-- Useful Links --

Abel et al (2024), Hospital admissions in the last year of life of patients with heart failure, https://doi.org/10.1093/ehjqcco/qcad047.

Balata et al (Oct 2024), Early integration of palliative care versus standard cardiac care for patients with heart failure (EPCHF): a multicentre, parallel, two-arm, open-label, randomised controlled trial, https://doi.org/10.1016/j.lanhl.2024.08.006.

Barnes-Harris et al, Barriers and facilitators for cardiopulmonary resuscitation discussions with people with heart failure, https://doi.org/10.1371/journal.pone.0314631.

Campbell et al (2018), Which patients with heart failure should receive specialist palliative care?, https://doi.org/10.1002/ejhf.1240.

Date et al, Modified-release morphine or placebo for chronic breathlessness: the MABEL trial protocol, https://doi.org/10.1183/23120541.00167-2023.

Ekström et al, Effect of regular low-dose extended-release morphine on chronic breathlessness in chronic obstructive pulmonary disease: the BEAMS randomized clinical trial, http://doi.org/10.1001/jama.2022.20206. 

Ferreira et al, The effect of regular, low-dose, sustained-release morphine on routine physical activity in people with persistent breathlessness– a hypothesis-generating study, https://doi.org/10.1183/13993003.01484-2022.

Johnson et al (2024), Benefits of specialist palliative care by identifying active ingredients of service composition, structure, and delivery model: A systematic review with meta-analysis and meta-regression, https://doi.org/10.1371/journal.pmed.1004436.

Jordan et al (2020), Duration of palliative care before death in international routine practice: a systematic review and meta-analysis, https://doi.org/10.1186/s12916-020-01829-x.

King et al (2022), Concurrent Validity and Prognostic Utility of the Needs Assessment Tool: Progressive Disease Heart Failure, https://doi.org/10.1016/j.jpainsymman.2022.01.014.

McConnell et al (2023), Integrating palliative care and heart failure: a systematic realist synthesis (PalliatHeartSynthesis), https://doi.org/10.1136/openhrt-2023-002438.

Roch et al (2020), Utility of the integrated palliative care outcome scale (IPOS): a cross-sectional study in hospitalised patients with heart failure, https://doi.org/10.1177/1474515120919386.

Breathing, Thinking Functioning Model - https://www.btf.phpc.cam.ac.uk/

Caring Together - https://www.mariecurie.org.uk/professionals/working-in-partnership/caring-together

Scottish Palliative Care Guidelines - https://rightdecisions.scot.nhs.uk/scottish-palliative-care-guidelines/

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In this episode, Dr Marilena Giannoudi discusses Type 1 diabetes with Dr Sam Pearson. Topics include diagnosing T1 diabetes, recognising the impact of a new diagnosis of diabetes on patients and possible treatments, including technological interventions.

Dr Sam Pearson is a diabetes consultant at St James hospital in Leeds. They help look after patients with all types of diabetes mellitus but have a particular interest in helping younger adults with type 1 diabetes and how technology may help them.

Dr Marilena Giannoudi is a cardiology registrar based in Leeds. She is Co-Chair of the Trainees and Members’ Committee, a Fellow of the Higher Education Academy, and is currently undertaking a PhD.

Recording date: 14 November 2024

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