Must see photo

Check out Joshua Schwimmer's photo of a foley bag.

Great shot, highly illustrative of vaptans effect on urine osmolality.

Best (only?) nephrology rap: The Kidney Kid

One of my friends from residency sent me this video. It's perfect.

My line favorite is:

There is multiple medical mysteries but I'm a renal super sleuth 

and my one diagnostic tool is the golden window of truth.

Check!

Celebrity interaction: How I "met" Margaret Atwood on Twitter

In September I recommended Oryx and Crake to @DrSnit, a person I follow on Twitter.

Link to tweet

Then to both of our surprise Margaret Atwood retweeted this. 

Link to tweet

This was cool because a famous author had noticed our exchange but in retrospect it seems to be standard social media marketing, track your mentions and regard your fans. But moments later it turned deeper, and dare I say, weirder:

Link to tweet

Now, I agree that Kidney boy does sound like a lame, super-hero side-kick, created by a large dialysis organization for an in-house comic book to give to pediatric patients. But I never imagined that a super-star writer would be creating my costume.

I remember thinking, "What is she talking about? She can't be serious."

Link to tweet

Five days later she was still thinking about this...

Link to tweet

Then a month after the initial exchange, Ms. Atwood delivered:

Link to tweet

And in full size:

Then a couple of days later:

Link to tweet

And finally last night:

Link to tweet

Full size

This has been wonderful and exciting. How cool is it to exchange with an author I love and respect. It demonstrates how small the world can be. Everyone go out and read Margaret Atwood. She does a great job of looking at where the world is going and extrapolating it forward into a unique, detailed and terrifying future. Start with Oryx and Crake, but I liked The Year of the Flood better.

Update

Ms. Atwood took her time but months after this exchange she tweeted the fully colored version:

Update 2. This incident ended up getting world-wide attention. Here is an article in The Guardian. Comics alliance cover it. And the artists from Periscope studios were even inspired to create their own versions of Kidney Boy and Dr. Snit.

Update 3. What happens to your traffic profile when you get a link from the front page of the World section of the Guardian?

Steve Jobs and the revisionist history of Randall Stross

A few weeks ago the Sunday New York Times had an op ed by Randall Stross regarding Steve Jobs. Stross suggested that Jobs' leaving Apple in 1985 was instrumental in him becoming the capable executive that he is today rather than "the worst personnel decision."

In 1993, Stross released a book, Steve Jobs and the Next Big Thing, chronicling the NeXT computer company and its struggles. The book is out of print but I found an old copy and read it a few years ago. The book is well researched and Stross provides ample evidence to to support his conclusion that Jobs was an immature brat, a terrible leader, a liar, and a poor manager. The picture he paints of Steve Jobs is the classic story of the entrepreneur conquring the world, becoming egocentric and then failing miserably when attempts to replicate his initial success. When I read the book, in 2007, I was in possetion of invaluable data not available to Stross in 1993. Jobs masterful turn around of Apple.

So everytime I read a chapter I had to accept the anecdotes Stross recounted while rejecting his thesis and attempt to fit the data to a different conclusion. It was a fun reading experience.

In another recent bit of news on Steve Jobs, take a look at John Scully's interview with Leander Kahney. Its a fascinating view of their relationship and what Steve meant to Apple.

No Dr. Topf, no EKG changes

On Monday night I was called by one of our fellows regarding a patient in the ED with a potassium of 8.5. They had already given insulin, glucose and kayexalate and the follow-up potassium was 8.1. This is not much improvemnt and less than you typically see. The patient was in acute renal failure with a creatinine of 3 and was anuric.

I asked if the patient had any EKG changes and according to the ER doc the patient had just a touch o'QRS widening. What do you think?

Peaked symmetric T's

Link for more on EKG changes in hyperkalemia

That night his CPK was 5,000. The next day it rose to 341,680.

Now dat's a spicy meatball!


- Initially posted using BlogPress from my iPhone

More on acetazolamide

A few weeks ago while on acetazolamide for altitude sickness prophylaxis the whole group noted tingling and paresthesias. What was curious is that the symptoms were most pronounced in the morning. The paresthesias were primarily on the hands and feet with a rare complaint of symptoms on the face.

I suspected that these symptoms are due to hyperventilation induced hypophosphatemia and the high carbohydrate breakfast (oatmeal) caused a bolus of insulin that further lowered the phosphorous. Does anyone know the etiology? Does hyperventilation cause hypophosphatemia if the increase in ventialtion is compensatory for metabolic acidosis?

FYI: the acetazolamide taste alteration makes carbonated beverages inedible.

Journal Club: dialysis time, not the critical factor in graft survival

One of the inherent truths in transplant is that the longer someone is on dialysis the worse the outcome after transplant. Patient with higher dialysis vintage prior to transplant are more likely to lose their graft and die following transplant. This was first shown by Cosio Et al. and subsequently verified by other researchers.

Cosio's primary figure showing dramatically increased mortality with increasing time on dialysis

Though Cosio et al. was the first (?) to find this association the most elegant data comes from Meier-kreiesche, Et al. who looked at graft survival when a paired sets of cadaveric kidneys is donated to recipients with differing duration of dialysis. By looking at paired kidneys they were able to neutralize any confounding factors from the donor. The primary analysis looked at kidneys that were split between one recipient with less than 6-months of dialysis and another with more than 2-years of dialysis. The end-point was graft survival:

They also calculated patient survival and they likewise found a significant splay based on time on dialysis:

Five- and ten-year unadjusted overall patient survival for paired kidneys was 89% and 76%, respectively, in the group on dialysis less than 6 months compared to 76% and 43%, respectively, in the group on dialysis for more than 2 years (P<0.001 each).

The obvious implication was that dialysis was bad for you. The longer you were on dialysis the more baggage you were carrying at the time of transplant and that baggage comes back to haunt the recipient with a shorter life and shorter kidney survival. From the conclusion:

...the longer patients wait on dialysis for a transplant the longer patients are exposed to the chronic effects of end-stage renal failure and dialysis. It is well documented that patients on dialysis have alterations in the concentration of a number of substances (e.g., homocysteine, advanced glycosylation end products, and lipoproteins) that may predispose these patients to both cardiovascular and renal allograft vascular damages. In addition, the poor nutrition, chronic in- flammatory state, altered immunologic function, and inade- quate clearance that often accompanies patients with ESRD on dialysis may predispose these patients to poorer toler- ance to the immunosuppressive agents after transplantation.

On our journal club last week we looked at a study by Schold, et al. that analyzed time on dialysis prior to transplant by dividing it into time prior to wait list and time after being listed. They found that all of the risk from prolonged dialysis comes from the time prior to being placed on the transplant wait list:

The data was more dramatic for graft loss than for mortality. The intersting part of this is trying to explain this discrepancy.  Why would time on dialysis prior to wait listing be any different that time on dialysis after wait listing? There is no biological difference so the authors conclude that the difference must be in a subtle, previously unmeasured difference in co-morbidity or access to care. The authors go on to pre-suppose that efforts to reduce patient exposure to dialysis may not yield the benefits one might expect if these other factors are not also corrected.

Acetazolamide was a smashing success

My camping club, Aggressive Deer Adventures had a great trip to Kings Canyon National Park. The group consisted of 7 men, all 40-something who lived at around 600 feet above sea level. The whole trip took place between eight thousand and twelve thousand feet.

Every one started on low dose acetazolamide (125 mg bid) 36 hours before we left home.

Not one of us developed anything more than a small headache on travel day. Complete success.