The highest potassium I have ever seen? That would be 15.5 mEq/L.

It’s not real. It was pseudohyperkalemia from leukocytosis. The patient had chronic lymphocytic leukemia with a white count of 300,000. If you are not familiar with this condition, check out these posts on Renal Fellow Network: Westervelt and Nate. Nice full text references here and here (pdf).

The pseudohyperkalemia merit badge

The first time I saw this was when I was senior resident. I was sleeping in the call room my pager buzzed. It was the oncology floor with a potassium of 9. The patient had CML and was in a blast crisis. His leukocyte count around 100,000. I immediately suspected pseudohyperkalemia and ordered a whole blood potassium from the ABG lab. It was normal so I went back to sleep. The next morning I received an angry call from the Hemo-Onc fellow. The patient was coding and he was furious that I only ordered an ABG instead of treating the hyperkalemia.

I don’t know if the patient coded from hyperkalemia, but I wish that I had gotten out of bed and evaluated the patient. I solved the problem the nurses alerted me to, but if I assessed him, maybe I could of averted an arrest.


Area Codes, RTAs, and Amphetamine. This is what Twitter is like.

Dallas is Area Code 214. I wonder if they appreciate that 214 really represents the 3 types of RTA in anatomic order?
— Joel Topf (@kidney_boy) January 7, 2014

This morning I was trying to imagine the mad electrolyte gurus of UT Southwestern in Dallas influencing the naming of the RTAs to match their Area code. Well played Donald Seldin, well played.

Not to be outdone, Dalya Munves joined in the area code and medicine game.

@kidney_boy other Dallas area code is 972, which is imprinted on amphetamine/dextroamphetamine tabs! #ADHDpride
— The Health Scout (@HealthScoutBlog) January 7, 2014

@HealthScoutBlog that’s why on the street they are call Ewings #ImMakingThisUp
— Joel Topf (@kidney_boy) January 7, 2014

Any other area code-medicine mash-ups out there?

Note. The following 5 paragraphs from Douglas Coupland’s Microserfs that I read in 1995 has stayed with me since then. Love this minutia:

“Maybe. But let me digress a bit. Here’s something interesting . . . did you know you can figure out how important your state or province was circa 1961 by adding up the code’s three digits? Zero equals 10.” 


“It’s because zeros used to take forever to go around the little rotary dial-while ones zipped along quickest. The lowest possible code, 212, went to the busiest place, New York City. Los Angeles got 213. Alaska got 907. See my point?” 

Karla always comes up with the best digressions. “Yes.” 

“Imagine Angie Dickinson in Los Angeles (213) telephoning Suzanne Pleshette in Las Vegas (702) sometime before the Kennedy assassination. She dials the final ‘2,’ breaks a fingernail, and cusses a shit under her breath, irritated at Suzanne for being in a location with a loser area code.”

2013 the year in review

2013 was a great year for the blog and for social media in nephrology. After a down year in 2012 for PBFluids, only 57 posts all year, I bounced back by nearly doubling that productivity with 112 posts last year. One of my most productive years. But to me the most remarkable change has been the emergence of a nephrology community in social media. My posts here at PBFluids certainly dripped with social media. Here is the year in review month by month.


Only 2 posts. I think the post on some slipshod research on NSAID toxicity in children stand up pretty well. The post included an embedded tweet from leading nephrology tweeter Pascale Lane.


8 posts. The first post is one of my favorite posts of all time. It is an analysis of the ISDA/AHA clinical practice guidelines on enterococcal infective endocarditis. The post is essentially a recap and summary of Twitter conversations on the subject with some additional research to provide some context. The remainder of the month has some solid work, including a post on dialysis for cast nephropathy bemoaning the lack of Gambro 1100 dialyzer availability in the US and a follow-up on the enterococcal post with a deep dive into additional data. Social poked through in a post on the horrible slides provided by the ASN by Myron Miller. I had a nice email from Paul Segal coming to Dr. Miller’s defense and a tweet from Jim Smith regarding the post.


March was my most productive month of the year. This was because I was researching NephMadness and working on a review of geriatric fluid and electrolyte issues (don’t hold your breath, it was rejected and will not be published). My favorite post of the month is probably this one about the NKF’s effort to get dialysis covered under medicare.


April was a very social month. I posted my first Storify (a web service that allows one to easily capture and publish a collection of tweets) on the link between hyponatremia and hip fractures. I had a few posts on Nephmadness (here, here and here). There was a nice post looking at over diagnosis as it relates to breast cancer, prostate cancer and CKD.  I had a patient show up with a potassium of 9 that led to a couple of posts on hyperkalemia. The image of the EKG is one of my most popular tweets ever. I used a poll on managing the hyperkalemia. Another favorite for the year, was a post about nephrology limericks. Again, this was primarily a summary of a twitter conversation.

@MGKatz036 Stop that NaCl its the reason he’s not doing well In order to volume resuscitate The hip new thing is Ringers Lactate
— Joel Topf (@kidney_boy) April 18, 2013


Another strong month. I tipped my hand about my Kidney Week poster by revealing some of the data on the nephrology blogosphere. My most shared story of the month was on NKFs poorly written story on alcohol and the kidney. PBFluids’ blade is still sharp. I had a couple of posts (here, here) on App.GoSoapBox.Com as I tried to incorporate this audience response system into my lecture. And a post with a screen cast on hyponatremia due to SIADH.


June had a number of social posts. I received a lot of commentary on a post about paying for kidney donors. There was some good discussion about my case of rhabdo with a CPK  over a million. But by far the most commented post was about the fool who drank a quart of soy sauce and developed severe hypernatremia. It resulted in two posts and another google docs poll. I also did a nice post on the Central American CKD epidemic that came after I was tweeted about my thoughts on the issue.


July was a light month, as I began to gear up for the second year medical students. I did publish my electrolyte handbook as an eBook. A project that I hope to spend more time on this year.


The big event in August was not on my blog, but on Twitter where I live tweeted the ASN Board Review Class. Awesome experience. I tweeted using the eAJKD account. Unfortunately eAJKD and I were just getting our live tweeting sea legs under us. We missed the important step of compiling the tweets into a blog post. I find that live Tweeting, focuses me and forces me to rework the information into a tweet. This helps me remember the information better. 



I went to London and live tweeted the Med 2.0 conference for eAJKD. Getting better at this. The blog had two posts where I used single tweets as jumping off sites for more extensive coverage, a model that I think best illustrates the purpose of a blog in a Twitter world. The first was on oliguria and the second was on the practice of giving patients money to help them buy medications, or in this case a treadmill.


Only 6 posts but a lot of impact. The month began beating back the idiots suggesting IV contrast is benign to the kidneys. I took the boards that month and posted my thoughts on the test and the ASN Board Review Class. The longest and one of the most important posts of the year was next. I posted on the CJASN electronic journal club. This has been a failure up to now. I hope that in 2014 this project can be re-invigorated. We will see.


I posted on the FDA’s terrible decision to deny Tolvaptan for ADPKD, following Bill Brazell’s brilliant essay in the Atlantic. We also had some fun guessing the retail price and possible names of the novel potassium binder,  KS-9. I posted on my Kidney Week experience. This was the first time I think Kidney Week really broke through on Twitter with a number of voices. It was a great success. I rounded out the month with an in-depth review of UKidney’s well done library of high-impact nephrology articles.


December was dominated by the Renal Fellow Network’s annual top nephrology stories of 2013 (see here, here, here, here and here). This turned into a collaborative effort as a lot of independent nephrology bloggers and participant in social media began to blog about different stories. I hope 2014 turns into the year when we really see more collaboration in the Nephrology Social Media Space. I think the RFN top stories offers a blue-print for this. The other post that was particularly social was an examination of an abstract linking Pip/Tazo to acute renal failure. A lot of twitter discussion on this.