NephMadness: The Final Post

We posted a final wrap of NephMadness at eAJKD. I filled out my brackets on March 21st, right before we revealed the field of 32 but I didn’t post them because of my involvement with the tournament.

Dancing with my brackets.
No I’m not a loser.
Why do you ask?

As promised here are my brackets:

Notes from Glomerulus Region:
  • DOPPS over USRDS: I feel the we have more to learn by looking outside of the US than looking in the mirror
  • Propensity scoring to the Sweet 16: We should demand it in all observational trials of therapy. We need to get better at finding the truth from these observational studies

Notes from the Proximal Tubule region:

  • TREAT is one of the most important trials in nephrology because finally after 25 years someone finally did the placebo controlled trial of ESA that we should of had in the 90’s. It is never too late to do the right thing.
  • ALLHAT is not all that.
  • FGF23 is not important because of how it was effective as a prognostic tool, but because it is a new hormone that regulates phosphorous. How cool is that? It reminds me that no matter how authoritative the text books are when they describe human physiology they are all vulnerable to advances in science.

Notes from the Loop of Henle Region:
  • I think anyone that heard the first hand accounts of using Eculizumab for the 2011 outbreak of atypical HUS in Germany would vote for it. The stories are incredible.
  • UpToDate to the Final Four. What can I say, I have a crush on Bud Rose. He should get the Nobel Prize in Medicine for what he has done for medical education and delivering advances in medicine to doctors treating patients.

My final four was very conventional and of course Transplant for the win.

DCIS = Gleason 6 = CKD 3

Today I read the excellent NYT Magazine story on breast cancer

The entire article is great and I recommend it but one aspect of the story was the rise of ductal carcinoma in situ. Here is how it is described:

Many of those women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.

D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.” Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S.

The point is, our diagnostic technologies have found a “pre-disease” state and we now take credit for curing these people when they may never have developed the lethal form of the disease. A conversation on twitter erupted regarding D.C.I.S. and its equivalence in prostate cancer, another disease mired in controversy regarding diagnostics and the benefit of early diagnosis.

Must read: Mirrors Men & Prostate ca.Gleason 6 = DCIS –> don’t call it cancerOur Feel-Good War on Breast Cancer
— David Y.T. Chen (@dytcmd) April 25, 2013

@kidney_boy @dytcmd I’m not buying the comparison. G6 tumors on biopsy are often upstaged (30%?) whereas I’m not sure DCIS is
— daviesbj (@daviesbj) April 25, 2013

Their is, in fact, a movement to re-name Gleason 6 tumors that avoids the term cancer as a way of emphasizing the low aggressivness of the condition:

Here it is in all its PDF glory

In the absence of definitive markers of the lethal phenotype, a new paradigm is needed to express the risk associated with Gleason score 6 tumors. We propose to adopt at Johns Hopkins an alternative approach based on a modified Gleason scoring system referred to as prognostic grade group. Five prognostic categories will be reported based on prostate biopsy (Table 1). For men undergoing radical prostatectomy from 2004 to 2011, these prognostic grade groups from 1 to 5 have been associated with 5-year biochemical recurrence-free survivals of 94.6%, 82.7%, 65.1%, 63.1%, and 34.5%, respectively (Pierorazio et al, manuscriptin preparation).

This made me think, what is the DCIS or Gleason 6 of nephrology, and I think by far its CKD stage 3. New patients that are referred to me come in to the office with labs results in hand. They frequently have seen information on line or in posters that explain that their eGFR of 52 mL/min is CKD stage three and they see that Stage 5 is dialysis. So they come to two conclusions:

  1. They are going to be on dialysis soon
  2. Why didn’t anyone ever warn them when they CKD stage 1 or 2?
The problem with using numbers to stage a condition is people reasonably expect a stepwise progression from stage 1 through stage 5. The reality is, if they have normal kidneys on U/S and a normal urinalysis, by far the most common situation, they have no kidney disease when their eGFR is greater than or equal to 60 and jumps to stage when their GFR falls below 60. Absurd. Additionally only 1% of stage 3 patient progress to dialysis.
From my GFR handout
I am excited to see how the KDIGO guidelines and their heat map of GFR + Albuminuria perform as prognostic guides, but I would have been happier, if they had renamed CKD 3 as CKD stage 1 and using CKD stage 0 for GFRs greater than 60 ml/min plus evidence of renal disease. 

Update from Twitter (where else?)

Amyloid_Planet: Nice blog post today BTW – bit off a lot with that one.

Kidney_boy: What? You think taking on Komen, the urologists’
 cash cow and K/DOQI is a big post?

Amyloid_Planet: Potentially controversial, yes. I’m surprised you didn’t take a shot at Jesus while you were at it.

Kidney_boy: follow-up post

HIV renal disease

I gave a lecture on HIV renal disease to the ID section yesterday. I give this lecture every couple of years. I swear that lecture changes more from year to year than any subject I talk about.

  • The lecture was about one hour. 
  • The section on APOL1 is rough.
  • I would like a slide describing the transgenic mouse model studies by Klotman that showed that transcription of nef and pol are central to the disease.
  • I need some notes on why I have 2 graphs on slide 16.
  • Add some highlights to table in slide 23.
  • Loved how slide 26 and 27 worked.
  • I think there might be better data on steroids in HIV. Slide 51.
  • Need to flush out IRIS and DILS from slide 67
  • Add comment on adefovir slide mentioning that the hep B dose is a sixth of the anti-HIV dose


Dialyzing the highest potassium

So last week I asked how you would dialyze the patient in the following scenario:

You have been called on a Sunday night for emergent dialysis in a patient with hyperkalemia. The patient is a MWF dialysis patient and had a normal dialysis session on Friday. Her ECG on admission is absolutely terrifying and her potassium is 9.9 (hemolyzed). The blood sugar on admission was 965. When you arrive, with K-machine in tow, the patient has been on an insulin drip for an hour and the potassium is down to 5.2

I have received 54 responces and the results have been pretty stable from the beginning. By far the favorite option was to pack up the dialysis machine and head back home. No dialysis for you

I don’t see any signifigant trends based on background of the provider:
The raw data is available for perusal here. And you can keep voting here.
That is not how I voted. I voted for 2 hours on a 2K bath. My feeling was that the ECG showed dramatic cardiac toxicity and though the emergency seemed to be over, with a repeat potassium of 5.2, I had no guarantee the insulin drip would continue through the night. If it was stopped, intracellular potassium could diffuse back out of the cells. But what really pushed me was the fact that he is scheduled to receive dialysis in just a handful of hours anyways. If I just push that schedule up and dialyze him tonight I provide an extra margin of safety for his potassium and improve my sleep hygiene. No nightmares of lost IV access for the insulin drip.
Because I viewed this emergency dialysis as just pushing forward the scheduled dialysis I went with the standard 2K dialysis bath.
Now for the best part of any blog post, belittling people who don’t agree with me. The above paragraph takes care of no dialysis.
  • Zero K bath. Too great a risk of hypokalemia. We presume that he does not have excess total body potassium, merely maldistribution of intracellular potassium. Zero K baths are dangerous. Who can forget the classic scene in Grey Anatomy where Izzie is fired for ordering a zero K bath, putting a patient in shock, so that the poor dialysis patient misses her transplant. (I love that show, they even let surgical residents write dialysis orders.)
  • One K bath. See above. Though the concern about the toxicity of low potassium baths seems to be overblown.
  • Two K bath. Perfect.
  • Three K bath. Should work just fine.
  • Four K bath. What’s the point, at the current potassium of 5.2, two hours on a 4 K bath will remove a trivial amount of potassium and is functionally identical to no dialysis at all.
Defend your sorry choice in the comments below.

Wondering if my fluids book is worth reading?

The fluids book is certainly priced right (free) but if you need an additional endorsement, Richard Sterns, the Dean of Sodium, uses figures from the book in his talk at the ASN board review class!

Love hearing how Richard Sterns uses my book at @asnkidney board review. Get it for free at……
— Joel Topf (@kidney_boy) August 29, 2012

From Edgar Lerma.

Update: got this e-mail the other day:

Hello from the blogosphere

One of my colleagues pointed me to your website today.  I don’t know that you’re right about me being the “Dean” of anything, but you are correct:  I loved your book.  Hope you don’t mind that I borrowed from it.


Richard H. Sterns, MD
Chief of Medicine
Rochester General Hospital
1425 Portland Avenue

How fun!

There once a dialysis patient from Nantucket…

My son is doing a big project on the kidney. As part of that project he has to write a limerick about the kidney. The family was stumped so of course we decided to crowd source the problem:

My son has to write a kidney poem. What rhymes with dialysis?
— Joel Topf (@kidney_boy) April 18, 2013

The answer was analysis and paralysis (hat tip to @emmadalton and Leon)

But the real fun began as people sharpened there pen knives and carved new limerick’s on to the bathroom walls of twitter.

@kidney_boyThe news is sad.We’ve done a urinalysis.Your kidneys are bad.You will need dialysis.
— Skeptical Scalpel (@Skepticscalpel) April 18, 2013

@skepticscalpel @kidney_boy In retrospect, there must have been a diagnosis we missed…Meh, oh well. Let’s get you on the UNOS list.
— Michael Katz (@MGKatz036) April 18, 2013

@mgkatz036 Stop that NaClits the reason he’s not doing wellIn order to volume resuscitateThe hip new thing is Ringers Lactate
— Joel Topf (@kidney_boy) April 18, 2013

Kidneys, most of us have two.Some have one, shaped like a horse shoe.Can’t live with none,Dialysis or transplant have to be done.
— Vijay(@scanman) April 18, 2013

A man was once stung by a beeHe thought he got off scott freeBut he had rhabdomyolysisAnd now he’s forever on dialysis
— Joel Topf (@kidney_boy) April 18, 2013

Daughter noted spelling error (now instead of know)

@kidney_boy if only his doctors weren’t second rate.they couldn’t afford up-to-date.
— Michael Katz (@MGKatz036) April 18, 2013

Kidneys are shaped like a beanThey keep your blood cleanThey are the coolest organ unseenUnless you open the body and that would be mean
— Joel Topf (@kidney_boy) April 18, 2013

Daughter wrote that one.

When your kidneys failNo need to wailCause in the final analysisYou can always try dialysis
— Joel Topf (@kidney_boy) April 18, 2013

My son is pretty independent and ignored all of the bad poetry advice on Twitter and went with this original creation:

There once was a kidney named Bud
He liked to filter the blood
He got a disease
There’s pus when he pees
And now Bud is simply a dud

Was #NephMadness the biggest MedEd Social Media campaign ever?

I am going to write a wrap-up of NephMadness for eAJKD. As I’m thinking about this the following sentence springs to mind:

NephMadness was the biggest medical education social media campaign, not tied to a conference, ever pulled off.

Am I being an ass or is that right?

Are there even any other MedEd social media campaigns not tied to a conference?

The only one I can think of is #overlyhonestmethods

What other events should it be compared to?

Keep in mind this was a coordinated campaign involving one central blog but generated posts on at least four other blogs, had a single Twitter account but ultimately had 75 people on Twitter using the hashtag.

I really would appreciate any thoughts about this. Please tweet @Kidney_boy or fill in the comments below.

I did this interview for eAJKD. I met Jamie Dwyer once, and though he was charming, well spoken and clearly intelligent the overriding biggest impression was that he was best dressed nephrologist I ever met.