Monday, February 9, 2009

NephSAP on the iPhone


Last week on the fellow education day we did the ESRD NephSAP. Dr. Bellovich showed me that the complete text is available through iTunes as a podcast. Sweet. I have started to listen to the NephSAP in the car. Seems like a pretty cool way to get the info.

Sunday, February 8, 2009

Buying and selling of Kidneys for transplant: The biggest ethical question in nephrology.


In India kidneys are widely available for purchse. This allows people with the means to get a kidney. The people with the means include Americans and Europeans as transplant tourists. organ tours.

JAMA published an article in 2002 showed that most of the donors are poor people in debt and a few years later they are still or again in debt and have experienced a decline in health. An essay in Lancet the following years details the global organ traffic and some of its negative consequences.

Despite these horrors they abysmal supply of organs makes the concept of buying and selling organs appealing. I have confidence that a well regulated market place for organs could improve the supply and avoid the horrors which result from the under-the-table, unregulated bazaar that currently exists.

Sally Satel outlines the pro argument in a couple of essays.

Wednesday, February 4, 2009

Kidney stone question


Great question.

I would look at the March 2008 Seminars in Nephrology which is an entire issue devoted to nephrolithiasis.

The issue was guest edited by John Asplin, one of the best teachers I had during my fellowship. We co-authored a chapter on potassium and I tutored medical students for his renal physiology class. He is medical director of Litholink, a independent clinical lab which provides deep clinical information on the metabolic abnormalities found in patients with kidney stones. I use litholink for all of my stone patients and love it.





It also has multiple articles by Fred Coe and Elaine Worcester. Dr. Coe ran a weekly fluid and electrolyte conference that was one of the highlights of my fellowship experience. Every week a fellow would bring a set of electrolytes and Coe would tell you all about the patient simply from the numbers. It was uncanny how good he was.

My favorite quote from Dr. Coe was:
What you do is serious nephrology [he was referring to acute and chronic renal failure]. What I do is just civilian nephrology. [referring to nephrolithiasis]
Elaine and I co-authored a chapter on calcium, magnesium and phosphorous. We had a great collegial relationship during my fellowship and only after I graduated did I realize how large she was in the field of nephrolithiasis.








Craig Langman also wrote one of the articles in this issue of Seminars in Nephrology. He is a pediatric nephrologist and I spent a couple of months with him at Children's Memorial during my second year of fellowship. He's a great teacher. He is now on the lecture circuit for Genzyme. If he comes to town, go. He's one of the great teachers in nephrology.

Update: Dr. Langman sent me a note stating that he is not "on the circuit." But my advice stands, if he comes to town, don't miss him.

Monday, February 2, 2009

Kidney Stone Primer


When a patient needs a metabolic evaluation for kidney stones the twnety-four hour urine should include at minimum:
  • Calcium
  • Oxalate
  • Citrate
  • Uric Acid
  • Volume
  • pH
  • Creatinine
A complete evaluation adds:
  • Sodium
  • Potassium
  • Chloride
  • Urea nitrogen
  • Phosphorous
  • Magnesium
  • Ammonia
  • Sulfate
Hypercalciuria is defined as over 300 mg/day in a man and over 250 mg in a woman. Normal urinary calcium is 150-170 mg per day.

Urine oxalate over 90 mg/day should trigger an evaluation for enteric hyperoxaluria or primary hyperoxaluria.

Hypocitraturia is defined as a citrate below 325mg/day. Hypokalemia can trigger hypocitraturia (along with metabolic acidosis) so be careful when prescribing a thiazide for hypercalciuria, the resulting hypokalemia could surpress citrate and increase rather than lower the risk of developing a kidney stone.

While bowel disease is usually associated with calcium oxalate stones, patients often have decreased urine pH which predisposes them to uric acid stones.
Related Posts Plugin for WordPress, Blogger...