Why we needed Kayexalate in the first place

In February I'm giving grand rounds on the Potassium Wars (what, you didn't realize we are in the opening stages of the potassium wars?). I was looking at the original research on Kayexalate from 1961 and came across this ad. Check out the doses of spironolactone they were slinging:

400 mg of spironolactone, daily and this is in a world without loop diuretics!

Purple Urine, now that's not something you see everyday

From the NEJM 2007.

Purple discoloration can occur in alkaline urine as a result of the degradation of indoxyl sulfate (indican), a metabolite of dietary tryptophan, into indigo (which is blue) and indirubin (which is red) by bacteria such as Providencia stuartii, Klebsiella pneumoniae, P. aeruginosa, Escherichia coli, and enterococcus species. The clinical course is benign, and the urine typically clears with resolution of the bacteriuria and acidification of the urine. 

H/T Life in the Fast Lane

The first Nephrology Social Media Internship

A few pioneers at the intersection of social media and nephrology have banded together to create an internship in social media. The founding members of the loosely coordinated Nephrology Social Media Collective (logo pending, but it should be pretty cool) are:

• Myself
• Swapnil Hiremath, co-founder and brain child of NephJC
• Matt Sparks, savior of Renal Fellow Network and co-creator of NephMadness
• Kenar Jhaveri, blogger at NephronPower and editor of AJKDblog
• Paul Phelan, contributor to NephJC, Renal Fellow Network and AJKDblog
• Jordan Weinstein, creator of UKidney
• Edgar Lerma, creator of #NephPearls hashtag and serial author

The idea behind the internship is to give guidance to doctors or students who want to become experts in social media. There are a number of different techniques and strategies in social media and we will provide the intern an opportunity to work with these techniques first hand. Projects that will be open to the interns include:

• NephMadness
• NephJC
• AJKDblog
• Renal Fellow Network
• Research
• UKidney
• DreamRCT

Technologies that the intern will be exposed to include:

• Podcasts
• Google hangouts
• Tweet chats
• Storify for curation
• Mail Chimp newsletters
• Twitter analytics
• Google analytics
• multiple blogging engines including:
• Blogger
• WordPress
• Medium
• SquareSpace

But more important than the technology, is that the interns will have access to our collective wisdom and have access to an instant personal learning network to allow them to pursue their personal social media goals. This is the first time we have done this and we are still working out the exact curricula, but if you are in nephrology, residency or medical school and want to learn how to leverage the power of social media consider applying for the position.

Link

Just another day at the PBFluids world headquarters

Waiting for me in my inbox today:

Hello Dr. Topf, 

My name is Julia XXXXX, and on behalf of Keryx Biopharmaceuticals, I’d like to introduce Keryx as a resource for you as you develop content for your blog, Precious Bodily Fluids, given your commitment to advancing understanding of renal diseases. I’d like to periodically share updates from the company to keep you informed regarding its lead therapeutic product and commitment to patients on dialysis.

In fact, Keryx just announced it has begun shipping AURYXIA™ (ferric citrate) tablets to wholesalers in the U.S. Auryxia is approved for the control of serum phosphorus levels in patients with chronic kidney disease (CKD) on dialysis. Auryxia is the first and only absorbable-iron-based phosphate binder that is clinically proven to effectively control phosphate levels within the KDOQI guidelines range of 3.5 mg/dL to 5.5 mg/dL. The U.S. Food and Drug Administration approved Auryxia in September 2014. In addition, Keryx has created the “Keryx Patient Plus” program to assist with patient accessibility to Auryxia. 

For more information, please visit http://www.auryxia.com/. The full press release is below and includes additional information. 

If you are amendable, we will continue to reach out to share updates from Keryx and AURYXIA in the coming year that we hope will be useful for your readers and followers. 

Please feel free to reach out with any questions. 

Best, 

Julia

My reply

Julia,

Thanks for reaching out. I’m glad there is a new phosphate binder available for dialysis patients. I was wondering if you have any data that shows Auryxia reduces any patient oriented outcomes (e.g. hospitalization, mortality, fractures, morbidity)? And if not, is Karyx planning on doing such a study? And if not, why not?

Joel

Fingers crossed but with a skeptic's scowl

Topf gets taken to Dr. Zen's Design Woodshed

I try to design nice posters and one that I was particularly proud of was 2013's Assessment of the Nephrology Blogosphere that I presented at Kidney Week. 

PDF | Powerpoint

A few months ago I submitted it for a design critique at Dr. Zen's Better Posters. Well this tweet surfaced today:

I blog about a poster about blogging. #meta http://t.co/r7pg4Nxeiu See what works, what doesn't on this poster! pic.twitter.com/kyBYxRvK6A
— Zen Faulkes (@DoctorZen) December 18, 2014

The review isn't pretty:

The colours in the table are not explained anywhere. I am guessing “green”means statistically significant, and “orange” means... a decline in posts over time? Maybe that could be mentioned in the main text at the left. 

The table is big and dense. Again, I wonder if it could be simplified, either graphically (first step: remove the vertical gridline!) or even removed. If I’m reading it right, some of the information in the table is repeated in the graphs to the right of the table. 

The last line of the table - “Totals” - appears to be incorrect. It looks like most of those entries are means, not totals. 

Also, the text mentions 30 blogs, but only 22 are plotted.

I only plotted the 22 with the longest duration of publication. What was the point of graphing KidneyTalk's 6 posts over 2 months? (4 years after the last post, she still owns the URL) 

I also disagree with his critique of the QRcode and bit.ly link. I think QR codes mostly suck and for most people snapping a pic of a URL is quicker and more reliable. I also think every person should have a little home page for their poster where it can be downloaded and supplementary information made available. See the homepage to this year's NephMadness poster.

Overall this was great feedback and I swear my next poster will be better.

Over-indexing on medications

I have a patient with CKD stage four, diabetes and hypertension. In fact, I have a hundred patients with CKD stage four, diabetes and hypertension. However, this patient had uncontrolled blood pressures. Here is the nomogram from her home blood pressures:

She was taking once daily furosemide and we changed it to torsemide, for better pharmacokinetics. She returned a month later and her blood pressure was fixed, systolics equally distributed between the 120s and 130s. So a win for Torsemide, or maybe not...

She was excited because she had been reworking her diet and was no longer drinking pop. She was eating more home-cooked meals and really focusing on eating more vegetables and fruits. She was also being more conscious of her sodium intake.

When I walked into the room I was focused on the medication change, because that was my intervention. But the more I spoke with her, the more I began to lean to the lifestyle interventions. She was adopting spontaneous DASH diet:

• More fruits and vegetables
• Decreased processed and restaurant food
• Decreased fructose intake
• Improved compliance

She denied non-compliance on her previous visit, but her new focus on her health should certainly increase her medication compliance. All of this was in play. 

In the end, medicine is a giant, uncontrolled experiment and correlation does not equal causation. Just because you changed medicine doesn't mean that is was what fixed the blood pressure.

SIADH and lasix

I remember a time when I thought the treatment of chronic SIADH was going to be revolutionized by the vaptans. These small molecular ADH antagonists would interrupt the disease the precise mechanism of disease. I expected a Banting and Best like revolution. (If you have not seen the story of the discovery of insulin take a moment to watch the movie, Glory Enough for All, especially if you thought the greatest thing to come out of Canada was Tim Horton's)


The initial data was promising with convincing studies on conivaptan and tolvaptan, but something happened on the way to SIADH nirvana.

First the EVEREST trial went sideways. In heart failure:

• Angiotensin 2 is elevated and blocking it prolongs life
• The sympathetic nervous system is up-regulated and blocking it prolongs life
• Aldosterone is elevated and blocking it prolongs life
• ADH is elevated and blocking it doesn't do a damn thing

With no hope for a heart failure indication the drug was marketed solely as a treatment for hyponatremia where it was shown to be effective. The pitch was that doctors should not discharge people with hyponatremia and tolvaptan was faster and more effective than the previous standard of care. The drug was priced for short-term inpatient use at $300 a pill tolvaptan was a non-starter for chronic outpatient SIADH.

So generous of Otsuka to make the 30 mg dose the same price as the 15 mg

But I held out hope, I felt that as soon as the FDA licensed tolvaptan for ADPKD, the drug would be re-priced for chronic use and the price would come down. In fact during a TEMPO investigator meeting, an Otsuka executive hinted they would lower the price on approval (personal communication). However, despite being the only known treatment that slows the loss of renal function in autosomal dominant polycystic kidney disease, the FDA told Otsuka and the ADPKD community to pound sand.

Somewhere in there, Otsuka changed the labelling and limited tolvaptan to 30 days or less for hyponatremia, so the dream...is officially dead.

But my patients are still alive and they still have sodiums of 125. Demeclocycline, despite being a generic, is very expensive and not a good option. From the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association guidelines on hyponatremia:

The side effects reported for demeclocycline and lithium were such that we recommend not using them for any degree of hyponatraemia.

Fluid restriction, the cornerstone of therapy, is difficult to maintain and in severe cases is insufficient to correct hyponatremia (I'm thinking of patients with negative free water clearance). Urea has a good track record but I have not heard of it being used in the United States. Salt tablets can help, but often are inadequate to correct the hyponatremia.

On the list of possible treatments are loop diuretics. I have tried loops in hyponatremia on a number of occasions and though the math works, in my hands I have not found them to be effective. In the past, I have used loops in hospitalized patients with hyponatremia. The results have been underwhelming. But I know have a loop diuretic success story in a patient with significant but stable outpatient hyponatremia.

+1 “@medicalaxioms: Nothing aggravates a nephrologist like a kidney that refuses to obey the math.”
— Joel Topf (@kidney_boy) March 31, 2014

I met the patient when he was admitted to the ICU with mental status changes due to a sodium south of 120. This was not his first episode of hyponatremia. We corrected the sodium and restored normal mentation. We did a thorough work-up, looking for the etiology of the SIADH and despite some promising leads that turned into blind alleys, I am quite confident, now, that this is idiopathic SIADH.

During subsequent outpatient follow-up he had persistent hyponatremia with sodiums running in the high 120's. During this time, treatment consisted of salt tablets and fluid restriction. A couple of visits ago I added torsemide, and boom the two sodiums since have been 138 and 134.






Here is the sodium and urine osmolality over time. It plummets after the torsemide is started. This increases the free water clearance.

I also have data on the urine sodium, to get an idea of the electrolyte free water clearance. The change is not nearly as dramatic or convincing.

I have some of the data to calculate electrolyte free water clearance, but I'm missing urine volumes. We can determine the character of the urine from the following formula:

The following percentages represent the fraction of the urine volume which is electrolyte free water. The first three columns are negative, indicating that the urine the patient is producing has less than no free water. Urinating is more like drinking water as urination actually causes the sodium to fall, rather than rise. For a more in-depth explanation of the electrolyte free water calculation, check out this video.

It will be interesting to see if this improvement continues. I now believe that the reason I was underwhelmed when I used loop diuretics in the hospital is that I was working in the compressed time scale of inpatient medicine and only when you stretch the time horizon to months does the drug become effective. I think the reason it takes so long is that loop diuretics need to wash out the concentrated medullary interstitium, thus preventing the ADH from reabsorbing much water. A drug induced partial nephrogenic diabetes insipidus.

Yes, it's a little pocket of insanity but does it have something to teach us?

A few months ago there was a screen shot of a clinic note floating around the internet. It was, in the words of another nephrologist the most passive-aggressive nephrology consult note I have read in a long time:

Patient's sodium dropped further to 120 in the evening. He has had a precipitous drop that I suspect is due to over-diuresis, which does not seem to be a diagnosis within the lexicon of heart failure cardiologists. It is possible that he could have developed SIADH, through a drug side effect. In any case, we have reached the usual place where attempts to fix the heart have blithely interfered with renal physiology, and I am not willing to let his serum sodium decline into the 110s. If we give NS, and he has SIADH, we will worsen his serum sodium. We could use 3% NS, but he is not having mental status changes, yet, and this is bad form for a patient in heart failure. If he is volume depleted, and we use conivaptan, he could develop hypotension which would be difficult to fix. So I seem to have been finagled into ordering tolvaptan, which will hopefully prevent any further decrease tonight. Tolvaptan fixes a number and has not been shown to improve clinical outcomes with chronic use.

Clearly there is a large dose of crazy in the assessment and plan, but it highlights a number of real issues in hyponatremia. Let's dissect the note a bit and tease out the best parts.

The first clam that over-diuresis does not seem to be a diagnosis within the lexicon of heart failure cardiologists seems to be true. A brief survey of google finds a paucity of relevant hits for the phrase and most of those are from nephrologists or family practitioners. Given the frequency that I see patients suffering from this I was a bit shocked at these results.

The next sentence seems a bit preposterous, It is possible that she could have developed SIADH, through a drug side effect. Presuming that a patient with heart failure induced hyponatremia now has a second denovo disease seems a bit of a stretch, but we don't have access to the clinical data and so it is hard to determine if this is true. However the definition of SIADH requires that patients be euvolemic and judging from as much of the story as we know it seems like this patient is clinically hypervolemic. This rules out a clinical diagnosis of ADH, because the release of ADH in heart failure is due to physiological trigger for ADH, a decrease in perfusion. The disease of SIADH is specifically reserved for patients in which there is no physiologic stimuli for ADH release. The presence of heart failure and volume overload, definitionally rule out SIADH.

The next sentence is interesting: In any case, we have reached the usual place where attempts to fix the heart have blithely interfered with renal physiology, and I am not willing to let his serum sodium decline into the 110s. Diuretics increase water and sodium loss, but the cation content of the urine is almost always significantly lower than the plasma cation content, urinary sodium with loop diuretics is typically around 70 mmol/L. So use of loop diuretics cause loss of relatively more water than sodium and result in hypernatremia, except in heart failure. To understand why, one needs to understand electrolyte free water clearance (and an example of using it in the treatment in hypernaatremia is here). The higher the free water clearance, the less prone patients are to hyponatremia. Here are the calculations for electrolyte free water clearance for a patient with hyponatremia due to CHF before and after the addition of loop diuretics:

Before diuretics

In CHF, the patient is actually doing a pretty good job clearing free water. More than half of the urine output is electrolyte free water, the character of the urine is appropriate for correcting the hyponatremia. The problem is not the character of the urine but the amount. The patient just doesn't make enough urine to generate adequate electrolyte free water to account for the water the patient is drinking. Water restriction will be effective for these patients.

So, if the problem is an inadequate amount of urine the logical next step would be to increase the volume of urine with a diuretic:

With diuretics

Unfortunately, though the diuretic increases the volume of urine, it also changes the character of the urine. In this case, it dramatically increases the urine sodium content. This makes the urine almost completely ineffective at removing electrolyte free water and the net result is that the electrolyte free water clearances actually falls with the addition of the diuretic. This is the trap our poor nephrologist is raging against.

The next sentence of the rant: If we give NS, and he has SIADH, we will worsen his serum sodium. We could use 3% NS, but he is not having mental status changes, yet, and this is bad form for a patient in heart failure. I have a problem with this sentence and do not think it is well thought out. The nephrologists clearly believes this patient is over diuresed, we see this situations all the time and they respond briskly to additional fluids. Don't complain that the patient has been overdosed with diuretics and then refuse to provide the antidote for this overdose. I am skeptical of his theory that the patient has SIADH and it is a bit unreasonable to even give a trial of 0.9% saline. In regards to 3% saline, our good doctor might want to take a look at some of the data on the use of 3% saline in heart failure: SMAC-HF (PDF) or Seminars in Nephrology summary. While it is not standard of care the data are certainly intriguing and when the traditional approach is not helping the patient, as apparently is occurring in this patient, it may be worth a look.

The next sentence is regarding conivaptan: If he is volume depleted, and we use conivaptan, he could develop hypotension which would be difficult to fix. Conivaptan is a non-selective vasopressin antagonist, as opposed to tolvaptan which is a selective V2 receptor antagonist. Blocking V1 could cause hypotension as has been reported in multiple case reports. See this open access review.

So I seem to have been finagled into ordering tolvaptan, which will hopefully prevent any further decrease tonight. Tolvaptan fixes a number and has not been shown to improve clinical outcomes with chronic use. This complaint that tolvaptan fixes a number seems a bit obtuse for a nephrologists who was presumably consulted to fix a number. It also implies that tolvaptan is unique in that it has only been shown to fix a number. Well unfortunately, all the therapies of hyponatremia, outside of acute symptomatic hyponatremia have only been shown to fix a number. However given the profound morbidity associated with low sodium, it seems judicious to correct hyponatremia until data proves it is unhelpful. Additionally, to claim in one sentence that you refuse to allow the sodium to fall below 120 and in the next sentence to rail against a therapy that has only has been shown to fix a number seems to belie a profound lack of self awareness.

But keep fighting the good fight against the cardiologists, somebody needs to keep their egos in check. #PracticallySurgeons

Last chance to vote

The longest tradition in the nephrology blogosphere, the Renal Fellow Network's Nephrology Story of the Year! For five years RFN has been posting the top stories of the year and for the last few years they have been off loading the work to the crowd. So do your duty and vote.

Go vote. 

Polls close tomorrow. 

And to the losers stuffing the ballot box for "Perivascular Gli1+ progenitors contribute to myofibroblast pool leading to fibrosis in multiple organs including kidney Cell Stem Cell" I will not stand for that!

I'm pulling for Dendritic cell isoketals activate T cells and promote hypertension as covered in NephJC.

The newest nephrology blog: Nephrology Tweetbook

Run by master tweeter Nikhil Shah, Nephrology Fellow at the University of Alberta, Nephrology Tweetbook is primarily a collection of educational tweets with, as far as I can tell, a single long form post on the use of What's App as an educational tool. Very interesting use of the app.

I'm not sure what he is using to post the tweets to blogger, but he would get better, most useful posts if he used the embed code from twitter.

This is what his posts look like:

No active links.

If he were to use the embed tool in twitter it would look like this:

Nephrology Tweetbook: Text to Treat!! Yes yes yes! @ASNKidney http://t.co/OFVcLAq1TA
— Nikhil Shah (@dr_nikhilshah) December 8, 2014

Nephrology Tweetbook: NAGMA - Review. @kidney_md http://t.co/sLjWb9jPZU
— Nikhil Shah (@dr_nikhilshah) December 8, 2014

Nephrology Tweetbook: Say "PEE" photographing urine! @edgarvlermamd @nejm http://t.co/x8EkFogfjY
— Nikhil Shah (@dr_nikhilshah) December 8, 2014

It's a nice addition to the nephrology social media landscape.

Nephrology is rusting (Updated)

Another year, another horrible match.

Here is the press release: NRMP SMS Nephrology Match for Appointment Year 2015

Some of the highlights:

• 68 of 134 programs did not fill their positions
• There were 0.68 applicants for every fellowship position this is down from 1.5 applicants for every position in 2010

Onecurious aspects to the report: the authors wrote:

In AY2015, nearly every nephrology applicant matched, for a 95.2% Match rate.

But take a look at the table:

254 applicants and 254 positions filled, unless an applicant is doing double duty at a couple of programs, it looks like a 100% match rate.

The other fact that I'd like to know more about is there are 141 US medical schools, 6 of those are too new to have any graduates applying to nephrology, that leaves 135 producing 79 applicants. That means at least 56 did not produce a single nephrology applicant. And I bet at least a couple of schools send multiple grads to satisfying careers in nephrology.

What I want is a list of the schools who are failing nephrology and who is teaching nephrology at those locations. Let's put their heads on a stick.

On the other side of that coin is who is teaching at the schools that produce multiple nephrology applicants and what are they doing right. Lets give those teachers a medal.

Can we get the medical school data from NRMP?

@kidney_boy might be worthwhile looking at schools who train high # of students who want to be kidney docs, see what they do "right?"
— Heather Murray (@HeatherM211) December 4, 2014

A few thoughtful commentaries to balance out my tirade:

• Warren Kupin: A New Nephrologic Syndrome: Acute Fellowship Insufficiency
• Paul Phelan: Nephrology Workforce Crisis: Don’t Forget International Medical Graduates
• Kenar Jhavari: Nephrology at crossroads in 2014-2015

I'm doing grand rounds at the end of January and I'm going to get medieval on kayexalate

So I will be collecting resources on this page.



EMcrit Blog: Is Kayexalate Useless?
Welcome to SOCMOB

Social media session at ASN Kidney Week

At the 2014 Kidney Week the ASN hosted the first session on social media. The session was moderated by Mathew Sparks and Kenar Jhaveri.

The session had four speakers:

1. Bryan S. Vartabedian, MD. led off the session with his talk, The Public Physician: The Emerging Role of the Physician in a Connected, Always-On World. 
2. Margaret S. Chisolm, MD. followed with her talk on Social Media Challenges to Professionalism: Do the Rules Change or Do We Change Social Media?
3. The next speaker was a rarity at Kidney Week, a patient. Sarah E. Kucharski gave a highly personal story: Patients Turning Likes and Retweets into Healing: Social Media and the Age of the Empowered ePatient.
4. I anchored the session with a talk titled, Social Media: How to Get Started, which would have more properly titled, Twitter for Nephrons.

A recreation of my talk is below, and you can also download the Keynote slides here.

Twitter for Nephrons from joel topf on Vimeo.

Dr. Chisolm's persentation is here:

Kidney Talk - Created with Haiku Deck, presentation software that inspires

Matt did a great job of summarizing the Session for AJKDblog.

If you want to see the tweets during the two hour session and the hour afterwards, here is a transcript, (and part 2)with 534 tweets during the session and the one hour after. It is contaminated with other KidneyWk tweets so you have to filter through the list but there are some gems.

Here is a filtered and curated transcript:

Play Kidney Week Bingo

Record all of your misadventures at kidney week with Kidney Week Bingo.

Publicize your exploits as you go, by tweeting them with the hashtag #KidneyWkBingo

There will be a prize for the first person to get claim Bingo.

Download your score sheet here

Kidney Week Approaches

Next week the nephrology world will gather in Philadelphia for the annual ASN Kidney Week. This will be the most social Kidney Week ever. If you are interested in social media and nephrology I'd like to call your attention to a handful of events:

Thursday November 13 ASN Special Session on Social Media. 10:30 in Room 201C. This is the first time social media has been covered a part of the core curriculum at ASN. It should be awesome. ASN has assembled an all-star team to present:

• Dr. Brian Vartabedian (@Doctor_V) author of The Public Physician and blogger at 33 Charts
• The Public Physician: The Emerging Role of the Physician in a Connected, Always-On World.
• Dr Margaret S. Chisolm (@Whole_Patients) contributor to the Johns Hopkins Reflections on Clinical Excellence blog. Author of Social media and physicians' online identity crisis.
• Social Media Challenges to Professionalism: Do the Rules Change or Do We Change Social Media?
• Sarah E. Kucharski (@AfternoonNapper) an ePatient with fibromuscular dysplasia. She is the Coordinator of ePatient Programs for Stanford's MedX and founder of the twitter chat FMDchat.org.
• Patients Turning Likes and Retweets into Healing: Social Media and the Age of the Empowered ePatient.
• Joel M. Topf, MD (@Kidney_boy) blogger at PBFluids.com, contributor of AJKDblog, co-creator of NephMadness, DreamRCT and NephJC.
• Social Media: How to Get Started

Thursday at 12:45 CJASN and the guys from eJC will be running a session on doing A Better Journal Club. I think I will be speaking for 5 or 10 minutes about my experience with NephJC. Room 104 of the Pennsylvania Convention Center.

Thursday night at 8:30 pm, Blogger Night (after the ASN Presidents Reception). If you like the Neph Social Media Crew from Twitter, Renal Fellow Network, AJKDblog or NephJC, join us for drinks at Field House Philly. It is a sports bar. Look for me in the AJKD hat.

Saturday 10-12 Poster Session. SA-PO661 NephMadness Poster session. Sucks that I'll have to miss late breaking trials, what is usually the best session of the week, but oh well. I'll have to keep up via Twitter.

Saturday 12:30-1:20. NephJC Live. NephJC is doing a live ancillary session. We will take the awesome dynamic of the twice monthly twitter chats and see how well it translates to a live session. We have two young investigators presenting data.

The first is Deirdre Sawinski, MD, Assistant Professor from University of Pennsylvania who is going to speaking on her study of kidney transplants in HIV positive patients.

The second is Francis Wilson, MD who will be presenting data from a recently completed RCT on acute kidney injury. In addition to a platinum pated CV he is an experienced singing waiter so hopefully we will get an ad hoc performance.

NephJC Live will also be awarding the first Nephrology Social Media Awards. We will be giving awards for best tweeter, best new tweeter, best blog post about the conference and best curtain of the conference (best Storify related to ASN Kidney Week) I will have a post on the Social Media Awards later this week-end.

The thing about the NephJC Live is that if you want to come you need to register by Sunday, November 9 so we can buy you lunch. Registration closes on Sunday. Register now.

Ever heard of Chinese Restaurant Syndrome? Updated

From a letter in the 1968 NEJM:

Ever heard of Chinese Restaurant Syndrome? http://t.co/VO7pvItjDF Anyone know if he ever got an answer? pic.twitter.com/zdgBIagW72
— Joel Topf (@kidney_boy) October 9, 2014

In a world full of weird coincidences, just days after that tweet, Ira Flatow from Science Friday fame covered Chinese Food Syndrome:

Omg! Science Friday with Ira Flato just referenced Chinese Food Syndrome and that letter from 1968. Weird. http://t.co/oOmvsXnN4Z
— Joel Topf (@kidney_boy) October 10, 2014

Questioning Medicine, sweet podcast.

This morning I received this tweet:

https://t.co/CKcoDOQAE4 @kidney_boy most recent podcast we find a way to make u rich @ 2:45 pic.twitter.com/6eyVJHXmGn
— Andrew Buelt DO (@AndrewBuelt) October 3, 2014

Somehow it reminded me of an email I once received from Nigeria:

REQUEST FOR URGENT BUSINESS RELATIONSHIP 

FIRST, I MUST SOLICIT YOUR STRICTEST CONFIDENCE IN THIS TRANSACTION. THIS IS BY VIRTUE OF ITS NATURE AS BEING UTTERLY CONFIDENTIAL AND 'TOP SECRET'. I AM SURE AND HAVE CONFIDENCE OF YOUR ABILITY AND RELIABILITY TO PROSECUTE A TRANSACTION OF THIS GREAT MAGNITUDE INVOLVING A PENDING TRANSACTION REQUIRING MAXIIMUM CONFIDENCE. 

WE ARE TOP OFFICIAL OF THE FEDERAL GOVERNMENT CONTRACT REVIEW PANEL WHO ARE INTERESTED IN IMPORATION OF GOODS INTO OUR COUNTRY WITH FUNDS WHICH ARE PRESENTLY TRAPPED IN NIGERIA. IN ORDER TO COMMENCE THIS BUSINESS WE SOLICIT YOUR ASSISTANCE TO ENABLE US TRANSFER INTO YOUR ACCOUNT THE SAID TRAPPED FUNDS. 

THE SOURCE OF THIS FUND IS AS FOLLOWS; DURING THE LAST MILITARY REGIME HERE IN NIGERIA, THE GOVERNMENT OFFICIALS SET UP COMPANIES AND AWARDED THEMSELVES CONTRACTS WHICH WERE GROSSLY OVER-INVOICED IN VARIOUS MINISTRIES. THE PRESENT CIVILIAN GOVERNMENT SET UP A CONTRACT REVIEW PANEL AND WE HAVE IDENTIFIED A LOT OF INFLATED CONTRACT FUNDS WHICH ARE PRESENTLY FLOATING IN THE CENTRAL BANK OF NIGERIA READY FOR PAYMENT. 

So I hid my checkbook before I went and checked out the podcast. No worries, they never asked me to send any money to complete the download or authorize my listening. It was just a great medical podcast. The two hosts have excellent chemistry and the discussion was astute and evidence based. I highly recommend it.

You can find Questioning Medicine in iTunes.

Kidney Transplant Report Cards are Out

The Information from the Scientific Registry of Transplant Recipients (SRTR) publish transplant statistics for every transplant center. 7/2/12 – 6/30/13

Here are the results from Michigan. St John's is doing a great job!

Pentoxifylline in renal disease, a tour through the literature

Tomorrow is another exciting edition of #NephJC. We will be discussing pentoxifylline in diabetic nephropathy. There is a summary of the article at NephJC.com.

In support of that article and to aid the discussion, Christos Argyropoulos has stepped up to the blogger plate to provide some color on pentoxifylline.

Joel

+++++++

In wild anticipation of next week’s #NephJC on Pentoxifylline (PTX)  let’s go over some of the known facts about the drug:

• It is a non-selective phosphodiesterase inhibitor.  PDEs are enzymes that inactivate cyclic nucleotides and have been organized in 11 families (Table 1 [1]) based on sequence, structural and pharmacological considerations. Inhibition of PDE4 by PTX (Figure 1) [1] increases cAMP & stimulates PKA activity. 
• Activation of PKA leads to phosphorylation of the cAMP response element binding protein (CREB) which in turn leads to suppression of the TNF-a[2,3] synthesis at the transcriptional level
• Inhibition of cAMP production by these phosphodiesterases has a broad range of immunomodulatory effects (Table 2[1])
• The drug also affects red cell deformability and favorably affects microcirculatory blood flow
• “Mainstream” indications: intermittent claudication, vascular dementia, sickling crises, acute alcoholic hepatitis



Figure 1: Pentoxifylline (white) complexed with PDE4 (ribbons). Also shown are the Mg2+ and Zn2+ cofactors of PDE4 (spheres)

• Pharmacokinetics: bioavailability (10-30%), elimination (mostly renal as 50-80% of the drug is recovered in the urine), half life (24-48 mins)

Is this the best review on treating hypertension in pregnancy? Updated

Note: this is a living post that is growing as I brush up on preeclampsia

From Hypertension:

Update on the Use of Antihypertensive Drugs in Pregnancy

Free PDF FTW!

Another great article:

New aspects of pre-eclampsia: lessons for the nephrologist

Also with a free PDF. Thanks NDT.

+++++++++

Although these renal changes in general are believed to resolve completely after delivery, recent evidence suggests that pre-eclampsia may leave a permanent renal damage.

CKD is a risk factor for pre-eclampsia in advanced CKD 3-5, weak evidence

the risk for pre-eclampsia and other pregnancy complications is sub-stantially increased in women with chronic kidney disease (CKD) stages 3–5 

 CKD 1-3 is not a risk factor unless the woman also has hypertension, higher quality evidence.

but these women were not at increased risk for pre-eclampsia. However, there was a significant biological interaction between eGFR and hypertension making eGFR 60–89 ml/min per 1.73 m2 a risk factor for pre-eclampsia if the women were also hypertensive.

Pre-eclampsia increases the risk for subsequent kidney biopsy and subsequent ESRD:

In the first study, women with pre-eclampsia in their first pregnancy had a considerably increased risk of developing kidney disease that needed investigation with a kidney biopsy [Adverse Perinatal Outcome and Later Kidney Biopsy in the Mother in JASN]. 

women who previously had pre-eclampsia had a four to five times increased risk of later end-stage renal disease, independent of primary renal disease [Preeclampsia and the Risk of End-Stage Renal Disease in NEJM]. Women with recurrent pre-eclamptic preg- nancies and women who gave birth to offspring with low birth weight had an even higher risk. The increased risk remained significant throughout the follow-up period of nearly 40 years. 

 In regards to the natural history of pre-eclampsia:

It should also be kept in mind that although the extensive glomerular changes during pre-eclampsia are believed to completely resolve after pregnancy [The Glomerular Injury of Preeclampsia in JASN], no studies have routinely performed a kidney biopsy months after the pre-eclamptic pregnancy. The fact that as many as 20–40% have microalbuminuria after a pre-eclamptic pregnancy may argue for a permanent glomerular damage in a great proportion of these women [Microalbuminuria after pregnancy complicated by pre-eclampsia in NDT, Blood pressure and renal function seven years after pregnancy complicated by hypertension].

Warning about these conclusions regarding pre-eclampsia causing CKD:

When interpreting the studies of pre-eclampsia and later kidney disease, it should be remembered that pre-eclampsia might unmask asymptomatic or undiagnosed CKD, a disease that might have been present also before pregnancy. A pre-pregnancy eGFR >60 ml/min per 1.73 m2 measured at screening was in a population-based sample associated with future pre-eclampsia risk in hypertensive women [Kidney function and future risk for adverse pregnancy outcomes in NDT]

This article by Eiland, Nzerue, and Faulkner in PubMed Central does a nice job reviewing the pathogenesis of the preeclampsia.

Another good looking article

ACEi talk.

A pharmacist from Blue Cross, Kim Moon, sent me an e-mail and told me she was a fan of the PBFluids and my and twitter. That, of course, instantly made her my newest bestie. She then asked me to do a webinar addressing common issues that prevent primary care doctors from prescribing ACEi/ARB to patients with diabetes. I agreed, anything for a fan of the blog.

A couple of months ago and long before the lecture was written she needed a title, so I threw out, "ACE inhibitors, the good, the bad, and the ugly"

Then I saw this tweet:

'The good, the bad and the ugly' appears in the title of over 450 scientific papers. Just sayin' http://t.co/UvNkyXNLRN
— Dr John Weiner (@AllergyNet) June 9, 2014

How embarrassing. Well, here's the show:

ACE inhibitors: The Good, The Bad and The Ugly. from joel topf on Vimeo.

Link to video (740MB)

PDF (52.4MB) 

Keynote (132MB)

Streaming the video from google drive seems to be broken. Here is a forum describing the problem, and Google's lack of response to the issue. My work around has been to pony up the $60 and join Vimeo plus.

Imagine if the wards were really like the boards

1. You have a new patient with a drug you've never heard of before. Your next step is to:

1. Look it up on your phone.
2. Ask a colleague what the drug is.
3. Take a careful look at the patients medical history and try to figure out the purpose of the drug from the context. Hopefully it won't be relevant to the question you are asked.

2. The patient develops an infection and ID suggests adding clarithromycin. The patient is on a number of cardiac drugs and you are worried about QT prolongation. You should:

1. Look up the possible interactions on your phone.
2. Depend on your memory of potential drug-drug interactions. Because, though you hate to brag, you did pretty good in medical school and have a keen mind.
3. Give the clarithromycin, but also order telemetry for the patient, because you are a careful doctor.

3. A patient presents for confusion and is found to have hyponatremia. She has the following labs:

• Urine Na 80
• Urine K 40
• Serum Na 105
• Urine output 600 mL over the last 18 hours

Calculate the electrolyte free water clearance.

1. Don't worry that you are bad at math, this is probably SIADH so just prescribe tolvaptan.
2. I can't remember the equation, but this just smells like an experimental question. I'm sure I can take care of the patient without this calculation. Let's look at the possible choices and I'll take a logical guess.
3. Fire up MedCalc, put in the values. Out comes the answer.

4. The biopsy comes back for a patient with proteinruia. The Pathologist calls it dense deposit disease. You have never seen a patient with this before but you did do presentation on MPGN type two 11 years ago in fellowship.

1. Perfect, you've got this. This is nephrology, there's no way the standard of care has changed in the last decade.
2. Hit the computer and look it up on UpToDate and do a quick lit search focusing on the top nephrology journals. Consider eculizumab.
3. Review KDIGO GN clinical practice guidelines. Scream out loud when you find that it is not covered. Fall back on answer 2.

New neph blog: UC Kidney Stone Program

Fred Coe and the crew from University of Chicago have started a kidney stone blog. This is the most prominent nephrology scientist to stick his toe in the blogging world. Dr. Coe was one of my teachers when I was at the University of Chicago (I blogged about him here and here). Dr. Coe has been instrumental in establishing the foundations of kidney stone science and continues to move field forward. He was a category in 2014's NephMadness:

(5) Dr. Charlie Pak versus (4) Dr. Fred Coe 

Charlie Pak and Fred Coe are the Bob Knight and Dean Smith of kidney stones. Not only did they dominate the field and do the pioneering work establishing the fundamental discoveries of the field, but they also trained the next generation of stone scientists that are currently leading the field. 

To this day the centers where Pak and Coe worked are world leaders in the field. In a plot twist, that would most likely happen in a comic book origin story, they were classmates at the University of Chicago Medical School, class of ‘61, and then were residents together at U of C. 

Dr. Coe remained at University of Chicago but Pak went elsewhere to established the Clinical Research Center and a new Division in Mineral Metabolism at University of Texas Southwestern Medical Center at Dallas. 

They even jointly won the Belding Scribner Award from the ASN in 2000.  

Intellectually they have staked out differing areas of excellence, Dr. Coe has focused on the the importance of the earliest stones to be anchored to the kidney. The location for these tiny early stones is Randall’s Plaques. The theory is that these tiny crystals form in the interstitium adjacent to the thin limb of the loop of Henle, they grow and eventually erode into the renal papilla. There, they are in contact with  supersaturated urine which can deposit calcium oxalate (or other other types of stones?). The plaques can be seen on cystoscopy and their presence predicts stone formers. Stone formation correlates with the degree of plaque coverage.

The blog is full of scientific and practical advice about kidney stones. His first post about why a blog is particularly insightful. 

A blog post is not a book chapter, a review article, a scientific article, or even a newsletter but something else entirely. It is the exact right size to convey one point and no more. It has no room for ornament or circumlocution, for fuzziness or indirection or even for two different points. You cannot avoid that moment when the main point must ring out clearly.

And this paragraph is just so Coe:

Being a singular, real, and immediate focus of attention, a point is something to work with. We can debate it, dissect it, even dismiss it if evidence permits or its logic is flawed. If a point appears to be sound, people can accept it as true for the moment, as an element that can be put together with like elements to make a picture of reality for this one disease. It is a picture that is true for the moment, arising as it does from science, just as the moment caught up in the pointillist net of Georges Seurat’s exquisite Sunday Afternoon on the Island of La Grande Jatte, being great art, will be true forever.

Welcome to the blogosphere Dr. Coe, we look forward to your posts. Your blog has earned a spot on my list of Notable Nephrology and Medical Blogs.

Lecture on modern strategies to keep up to date in the medical literature. #FOAMed at Work.

I love it when fellows turn the tables on their attendings and school them on how the kids do it today.



Kamran Boka is currently a critical care fellow at Henry Ford Hospital but when he was a wee resident he worked with me at St John Hospital. This is an excellent lecture, make sure you check it out. Boka is fully engaged in the 21st century medical infosphere:

• He runs a medical blog
• He tweets 
• He has created a resident handbook on Apple App Store and Google Play

Check it out. He has important lessons for everyone.

Friday's hyponatremia lecture for St John Hospital and Medical center

Sodium, sodium and less sodium

Keynote | PDF

Urine specific gravity, not that great at estimating osmolality

I have a clinic patient with SIDAH and until the FDA regains some sanity and Otsuka provides a more rational price this will continue to be a frustrating battle. This patient had some pretty typical labs for a patient with SIADH, except for the specific gravity. I don't remember seeing such a discrepancy between the Sp Grav and osmolality before.

I thought a Specific Gravity of 1.010 was essentially isosmotic. But check out this urine Spec Grav 1.012 osm 587. pic.twitter.com/abFhujkdbK
— Joel Topf (@kidney_boy) September 4, 2014

One of the sharpest nephrologists on twitter, Christos Argyropoulos, replied with this reference:

@kidney_boy I got over this myth 4 years ago http://t.co/CBk1EKNYqS
— ChristosArgyropoulos (@ChristosArgyrop) September 4, 2014

The conclusions from the abstract:

RESULTS: This study demonstrated that USG obtained by both reagent strip and refractometry had a correlation of approximately 0.75 with urine osmolality. The variables affecting the correlation included pH, ketones, bilirubin, urobilinogen, glucose, and protein for the reagent strip and ketones, bilirubin, and hemoglobin for the refractometry method. At a pH of 7 and with an USG of 1.010 predicted osmolality is approximately 300  mosm/kg/H(2)O for either method. For an increase in SG of 0.010, predicted osmolality increases by 182  mosm/kg/H(2) O for the reagent strip and 203  mosm/kg/H(2)O for refractometry. Pathological urines had significantly poorer correlation between USG and osmolality than "clean" urines.

Here is a table I made from the conclusions:

Sodium, in the spotlight for next week's #NephJC

In August, the NEJM pushed out three articles examining the role of sodium in human disease. These are the subject of September 9's #NephJC.

The first article is the Association of Urinary Sodium and Potassium Excretion with Blood Pressure. This question used the large epidemiologic study, Prospective Urban Rural Epidemiology (PURE) to answer the question.

PURE enrolled 157,543 adults age 35 to 70 from 18 low-, middle-, and high-income countries on 5 continents.

The study collected 102,216 fasting first morning urines. The authors used the Kawasaki formula to extrapolate 24 hour urine sodium and potassium from the samples. They collected 24-hour samples on 1,000 patients and found that they over estimated sodium intake by about 7%:

The mean sodium excretion was 4.9g and the mean potassium excretion was 2.1 grams.

It was difficult for me to understand the difference between the Observed excretion and Usual excretion but the authors seemed to reference the Usual excretion as the definitive curve.

Sodium excretion was higher in rural areas and in lower income countries. The reverse was true for potassium, higher in cities and higher in higher income countries.

The meat of the paper was the positive association between sodium intake and blood pressure. For every additional gram of sodium excretion the systolic blood pressure went up 1.46 mm Hg and the diastolic rose 0.54 mm Hg (P less than 0.001). Statistical mumbo jumbo increased those numbers to 2.11 systolic and 0.78 mm Hg diastolic. This relationship was non-linear with increased blood pressure effect as the sodium excretion rose over 5 grams.

Potassium had the opposite effect with systolic blood pressure falling 0.75 systolic (1.08 after statistical adjustment) and diastolic dropping 0.06 (0.09 adjusted) mm Hg for every gram increase in potassium excretion. 

Older people showed larger changes in blood pressure with increased sodium excretion.

The sodium effect on blood pressure was a lot larger that the 0.94 mmHg systolic and 0.03 mmHg diastolic found in the landmark INTERSALT study but still seems like a pretty small effect given the difficulty in getting to a low a salt diet. Look at the bell curve showing only 0.2% of samples hitting the WHO goal of less than 2.3 g a day.