Videos for patients and by patients

This is my go to video for helping patients make decisions on what modality to choose.

Last night I received the following Tweet:

@kidney_boy God is STILL Alive! https://t.co/1dwZL1DtPu
— Ricardo Riviera (@RivieraRicardo) April 25, 2015

I can’t recommend the video enough. In this age where everything is sanitized and abstracted as much as possible this video is just authentic. It’s as real as it gets. To me it brings to life all of the little things we ask dialysis patients to do, from waking up early, to restricting fluids, to spending 12 hours a week in a recliner hooked up to a machine with only one hand free. 
It is awesome. 
Everyone should watch it.

Canadian Society of Nephrology: Kidney Week’s MiniMe

I was invited to speak at the Canadian Society of Nephrology last fall. Swapnil set up a talk on social media. My first international speaking gig. Very cool.

We have two associates out on Maternity leave and another key partner retired a couple of months ago, so practice is tight. No way I could take half a week like I do for Kidney Week. I left for my 1:30 talk at 8:30 that morning. Direct flight from the D to Montreal. As I’m walking through the airport I’m looking for nephrologist ads. During Kidney Week there will always be a big a pharma company advertising in the airport. I love seeing those ads and trying to imagine wha percentage of the general population have any idea what Samsca™ or Aranesp™ are. Montreal had none of these advertisements. I took a taxi to the Hotel Bonaventure.

Found my way to the conference center and registered for the conference. The conference had about 450 people in total, about one 30th the size of Kidney Week. It is like Kidney Week Mini Me. Same clothes, same attitude but smaller. In this case a lot more than just one eighth the size.

Kidney Week is a major international conferences. I heard more foreign languages in Philadelphia last Novemebr than I heard at CSN which was being held in Montreal. We often associate size with quality but thie would be totally unfair to CSN. The lectures were amazing. They absolutly stand toe to toe with the quality you get at Kidney Week. Of course, there are some Canadian specific lectures that didn’t interest me, but the general nephrology content was excellent. Five lectures in particular were amazing:

1. Patient oriented symptoms of ESRD

emolients weak data but little down side. Baby oil, primrose oil. #csn15
— Joel Topf (@kidney_boy) April 25, 2015

newest evidence for Nalfurafine 5 mcg IV after HD 3x/wk. http://t.co/aHW2Si1mER and http://t.co/OzmBTZjs8C #csn15
— Joel Topf (@kidney_boy) April 25, 2015

Uremic Pruritus: other possible txs SSRI, Ondansetron, granisetron, thalidomide, activated charcoal 6g daily. (Never duplicated) #csn15
— Joel Topf (@kidney_boy) April 25, 2015

2. Conservative care With Dr. Fliss Murtagh

Murtagh is quite prolific. Is planning an RCT to look at onservative care vs dialysis in edge cases. http://t.co/IlP4czPkKq #csn15
— Joel Topf (@kidney_boy) April 25, 2015

#CSN15 murtagh survival data pic.twitter.com/91tBCuLDB1
— Joel Topf (@kidney_boy) April 25, 2015

3. Membranous nephropathy with Daniel Cattran

Some guy named Daniel Cattran to talk about GNs. Wonder if he knows anything. #csn15
— Joel Topf (@kidney_boy) April 25, 2015

@kidney_boy: @kidney_boy Cattran listening to Hladunewich lecture like a sailor. pic.twitter.com/g99hjG02fS#CSN15
— Joel Topf (@kidney_boy) April 25, 2015

4. FSGS with Dr. Hladunewich

Proof. It really happened. #CSN15 #thingsYouDontSeeAtASN pic.twitter.com/i2FrGX8qHa
— Joel Topf (@kidney_boy) April 25, 2015

5. Screening cancer tests in dialysis patients. Dr. Zimmerman gave an excellent and practical talk.

Things you see at #CSN15: speakers wearing hockey sweaters. Oh Canada. pic.twitter.com/1FyhhXHhtq
— Joel Topf (@kidney_boy) April 24, 2015

If your dialysis pt is/has: age >80, CHF, CAD, CVD, PVD, or BMI<19 they get all the risk of the screening and none of the benefit. #csn15
— Joel Topf (@kidney_boy) April 24, 2015

Stop doing screening mammograms in ESRD #Csn15 pic.twitter.com/1oK5CWXW8R
— Joel Topf (@kidney_boy) April 24, 2015

Their were also a few debates. I was disappointed that I had to choose between GN and the hypertension debate. It sounds like it was outstanding:

Next up at #CSN15: Debate on should BP target in proteinuric CKD be 130/80? @NavTangri vs Rob Quinn pic.twitter.com/kYgtFrcojF
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Pro: @navtangri cites AASK fu in @nejm (free) http://t.co/Qlzqi4EUmF of subgroup data to support his position #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

#CSN15: @NavTangri referring to a sub-group analysis on a surrogate outcome in ACCORD. Quinn looking more confident….
— Scott Brimble (@S_brimble) April 25, 2015

Pro: @navtangri attempts a pre-emptive strike against Quinn by trashing REIN-2 http://t.co/99SqdSH9w1 (in @thelancet) #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn: MDRD study primary and secondary outcomes were actually all negative. So was AASK. (proteinuria was only +ve outcome) #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn demolishing AASK: if U ACHIEVE a low BP (regardless of Rx) less progression. But if U TARGET lower BP, there is no diff. #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn uses http://t.co/8A4UcGTgKI from @thelancet to make gr8 point of subgroup analyses interpretation #CSN15 pic.twitter.com/lrkzietZY2
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Swapnil and I did our social media session.

👏 2 @hswapnil 4 a terrific lecture on social media
— Tejas Desai, MD (@nephondemand) April 24, 2015

`

Thanks, Tejas! #CSN15 especially @kidney_boy killed it! And gr8 job by @brownpa79 to @periscopeco it https://t.co/Hk00Wqtwnm
— Swapnil Hiremath, MD (@hswapnil) April 24, 2015

The talk was broadcast live on Periscope. So 21st century.

LIVE on #Periscope: #csn15 @hswapnil and @kidneyboy social media talk https://t.co/T0r0cwwRV1
— Pierre Antoine Brown (@brownpa79) April 24, 2015

The plan was a one-two punch, where Sawpnil presented why you should engage with social medi,a and I followed with a “how to” engage in social media. It went well. I had some trouble using Keynote on the iPhone app to advance the slides. I used Keynote on the iPhone to control Keynote on my computer. It worked perfectly during my (admittedly abbreviated) practice sessions and for about half my presentation before it crapped out. I need a more reliable solution, please tweet recommendations. The AV-guy was pretty good at picking up my signals to advance the slides but it wasn’t natural and threw my rhythm off. I’m Sorry Canada, I could’ve done better. That was another difference from ASN. At CSN they had no trouble wiring in my MacBook Air to their AV set-up. Much slicker than the MUST USE POWERPOINT party line from ASN.

I’ll post the slides when I get a chance, but first I need to add a slide crediting @Doctor_V and Howard Rheingold, who involuntarily donated ideas to my talk. And I want to pump up the Who to Follow section with a description of mining Symplur to find thought leaders. I also need a slide telling people about Twitter4Nephrons.

In the end, I had a great time at CSN and would definitely go again; maybe not next year in Halifax, but why don’t we meet the year after in British Columbia?

The ASN is waking up to social media

The ASN has long had a Twitter account but it was infamous among the nephrologists of Twitter as being a oneway mode of communication. A fact that was lampooned on the ASN Bingo board. Getting a reply from @ASNKidney was a badge of honor.

While complaining about how the leadership at the ASN just doesn’t get it was a great parlor game among the renal bloggers, things began to change. In the Fall of 2013, Sarah Faubel called me to ask if I thought we could do a social media symposium at Kidney Week 2014. This materialized as the Tweets, Likes, and Blogs: How to Use Social Media for Your Patients and Your Benefit session. See recaps here and here.

Even before the session other things were changing. In early November, the ASN sent out it’s first Work Force Task Force Report. In the e-mail that announced it, they asked people to discuss the report on Twitter with the hashtag #NephWorkForce.

It was the first time I had seen a hashtag come from ASN. The community was ready to talk and we had a great discussion about some of the issues, but strangely there was no participation by the ASN leadership. MGKatz said it best:

@kidney_boy @ASNKidney haha it’s like Coffee Talk With Linda Richman… Here’s a topic. Discuss amongst yourselves.
— Michael Katz (@MGKatz036) November 6, 2014

But ASN was not foolish, just cautious. They were testing the waters. When the second Work Force Report was published they had Mark Parker available for a formal tweet chat and he was gracious enough to answer questions from me to knock together a table setting blog post. Again there was spirited discussion, and ASN was actively participating.

In mid February-Dr. Faubel drove one of the NephJC on NephroCheck. She suggested the article, wrote up the introduction and was one of the primary tweeters during the chat. Dr. Faubel is the chair of the ASN AKI Advisory Group. Jay Koyner, another member of that group also joined the chat.

ASN then organized a pre-World Kidney Day chat with leaders from the NKF and ISN. Deidra Crews was the representative from ASN for that chat. This chat was amazing with incredible participation from industry, government and all three major real professional organizations. The ASN no longer looked like a reluctant partner but was driving the conversation:

This year’s WKD theme is of paramount importance given the stark disparities in CKD outcomes #WorldKidneyDay
— Dr. Deidra Crews (@DrDeidraCrews) February 25, 2015

Kidney Health For All. #worldkidneyday #WKD2015 #glassofwater pic.twitter.com/EAadUGhyHx
— Tom M.D. (@tomas_md) February 25, 2015

Hello all. Andy Narva, nephrologist & National Kidney Disease Education Program director. #WorldKidneyDay
— Dr. Andrew Narva (@NarvaNKDEP) February 25, 2015

Happy to join! #worldkidneyday
— IFKF (@IFKF_) February 25, 2015

Hello to the group! Happy to participate in the #worldkidneyday chat tonight.
— DaVita Kidney Care (@DaVita) February 25, 2015

Hi everyone, Allen Nissenson here, CMO for DaVita, nephrologist based in LA #worldkidneyday
— Allen Nissenson, MD (@DrNissenson) February 25, 2015

Ernesto Lopez-Almaraz, Nephrologist, Mexico City. Thank you #worldkidneyday
— Ernesto LopezAlmaraz (@kidney_doctor) February 25, 2015

Leslie Spry representing National Kidney Foundation Thank you #worldkidneyday
— NKF CLINICALS (@NKFCLINICALS) February 25, 2015

Joining in late from up north Great initiative – the tweet chat and #WorldKidneyDay Fantastic discussion
— CSN (@CSNSCN) February 25, 2015

15 minutos más para el chat sobre #WorldKidneyDay. Te invitamos a seguirlo a través de nuestro hashtag. pic.twitter.com/dCVFWB0FkF
— Día Mundial de Riñón (@DiaDelRinon) February 25, 2015

Deidra Crews here. Representing the ASN. I am a nephrologist at Johns Hopkins #WorldKidneyDay
— Dr. Deidra Crews (@DrDeidraCrews) February 25, 2015

Tomorrow the ASN will continue this trend by hosting a chat about the upcoming ASN Hill Day, where ASN goes to the nation’s capitol to talk to our elected leaders about how the government can help kidney patients. The ASN is sending three representatives to chat about the event:

  1. Crystal Gadegbeku @Crystal4Kidneys Section Chief, Temple Health Nephrology, kidney researcher, ASN public policy board member.
  2. Michelle Josephson @Michelle53598125 Transplant Nephrologist and chair of the ASN Transplant Advisory Group
  3. Richard Knight @knightra Transplant patient, vice president of the Association of American Kidney Patients

This should be an interesting chat about something that I have only thin knowledge. Please join the chat at 9PM EDT, hashtag #ACT4Kidneys

We have been calling for ASN to join the social media revolution, now that they’ve awoken we need to do our part to make this partnership meaningful and productive.

Feel free to join us for a Twitter chat to learn about this year’s Kidney Health Advocacy Day on 4/21 @ 9:00 pm EDT #Act4Kidneys
— Am Soc Nephrology (@ASNKidney) April 20, 2015

#NephMadness is back

Last Sunday we launched NephMadness

for the third time. This began as a last minute Hail Mary by the crew at AJKDblog to commemorate World Kidney Day in 2013. The response was so overwhelming that despite initially thinking this would be a one-and-done we decided to come back and improve the idea.

We have steadily improved the execution of NephMadness.

Last year we introduced a system to allow online bracket submissions. We found a company that provides white labelled online tournament brackets. This gave us streamlined registration and allowed for automatic scoring. Participation sky rocketed. Last year we also brought in content experts to act as our selection committee to make sure we had the best field possible.

This year, we have a number of further improvements. The primary complaint last year was seemingly arbitrary way the winners of each match up were determined, basically it was a system we called “Matt and Joel decide.” Not surprisingly people were not enamored with this system and this year we have deputized a blue ribbon panel of nephrology experts to make the decisions.

We are also getting better at producing the brackets themselves and filling out the field. We now have written on 192 concepts since we started NephMadness. We have seen that the best match-ups pit related concepts up against each other and we have really increased the use of that technique in this year’s brackets. In addition we have themed the entire tournament as nephrology’s interaction with other specialties.

Download a PDF of the brackets

We have also changed the schedule. The first two years we tried to track the schedule of March Madness as closely as possible. This meant we opened the brackets on Selection Sunday and closed them a week later. This year we opened the brackets on March 1 and accept submissions for 3 weeks, until March 22. This will, hopefully, increase participation.

Another area of improvement is in the Tourneytopia rollover descriptions. Last year we just copied the scouting reports from AJKDblog and pasted them in to the roll overs. They had a bunch of links and were really long. This resulted in really long descriptions that were difficult to read in the rollovers. This year we have a short 2-3 sentence description for the rollovers written solely for that purpose. Oh and a picture.

Go to Tourneytopia to submit your brackets for NephMadness

Last year we had a confusing collection of three sites, Tourneytopia, NephMadness.com and AJKDblog. This year we jettisoned NephMadness.com and completely redesigned AJKDblog to be a much more effective container for NephMadness. The editorial staff at AJKD really did an outstanding job with the redesign.

This year the journal, AJKD, is really behind the contest. The Feb and March issues of AJKD had pack ins to promote the contest.

A photo posted by @jtopf on

And the journal website has two high profile ads for NephMadness.

The last change is we are partnering with MedScape, a long time partner with the NKF and AJKD to promote NephMadness. Medscape is republishing all the content from the scouting reports and e-mailing their audience.

At St John Hospital and Medical Center we are having all of our fellows and faculty complete their own brackets and then we will have a consensus conference and build a collective entry to see if we can do better as a pit crew or as lone cowboys (and cowgirls).

Twitter Chat Tonight, Tuesday Feb 24 about World Kidney Day

I have been involved in Nephrology social media for years now, and it has been rewarding seeing the global community of nephrologists connect and develop a voice over that time.

While social media in general and Twitter in particular was once thought of as a time waster, it is now recognized as critical communication channel that allows back and forth communication as well as side to side communication.

First order communication: traditional top down

Second order communication: back and forth

Third order communication: back and forth and side to side

The side to side communication is what builds the community and is what twitter excels at. Imagine how boring the NephJC chats wold be if the only communication you saw was from the NephJC host? The whole point of the chat is to leverage the diversity of expertise in the crowd. 

Tonight will be a first in social media. Representatives from the International Society of Nephrology, The American Society of Nephrology and the National Kidney Foundation will be convening to discuss the upcoming World Kidney Day. It should be a great discussion. Please join us in (dare I say?) this historic moment. The discussion starts at 9PM EST and the hashtag is:
#WorldKidneyDay

More information, including who the representatives are, is available on Medium.

Must know facts about albumin! Number seven will blow you away!


Albumin is made in hepatocytes at a rate of 200 mg/kg/day – Created with Haiku Deck, presentation software that inspires

Improving albumin levels among hemodialysis patients

  1. Albumin is made in hepatocytes at a rate of 200 mg/kg/day 
    1. or 14 g in 70 kg person
  2. Total body albumin is 4-5 g/kg
  3. 40-45% of albumin is in the intravascular space
  4. Normal albumin concentration in the interstitial space is 
    1. 0.7 in fat and 
    2. 1.3 in skeletal muscle
  5. Albumin has a half life of 2 to 3 weeks
  6. The drop in albumin with inflammation is due to: 
    1. reduced synthesis and 
    2. increased fractional catabolic rate (FCR)
  7. Intradialytic weight gain of 2.8 liters (4% in a 70 kg man) will dilute the albumin down 0.8 g/dL 
Refs
Improving albumin levels among hemodialysis patients (PubMed)
Measurement of interstitial albumin in human skeletal muscle and adipose tissue by open-flow micro perfusion (PubMed)

Potassium Wars, The Grand Rounds Presentation.

Last week I delivered my grand rounds to both St John Hospital and Providence Hospital. This grand rounds on Kayexalate and the new therapies to increase colonic potassium clearance. Take a look. I hope you enjoy. I have more to say about this talk, and hopefully I will do a directors commentary of the presentation. I have 99 problems but have no for that time now.

Potassium Wars, The Native Keynote file (431 mb) Alternative link.zip (307 mb)
Potassium Wars, The PDF of the Keynote (184 mb)
Potassium Wars, The Movie, It’s almost like being there (1.05 gb)

Or stream it:

K wars, The Movie from joel topf on Vimeo.

ASN Quiz and Questionnaire 2014: Acid-Base and Electrolyte Disorders

CJASN just published two answers to the Electrolyte quiz from ASN Kidney Week, unfortunately they have the answers right next to the questions, so you can’t take the test honestly, Here are the questions, without the answers. Get the article here.


Case 1: Mitchell H. Rosner (Discussant)
A 60 year-old man with a history of a heart transplant and stage 4 CKD was diagnosed with a gout flare 6 days ago and was prescribed prednisone, 30 mg daily; allopuri- nol, 100 mg daily; and colchicine, 0.6 mg three times daily, for the first 2 days and then colchicine, 0.6 mg twice daily thereafter. Before the gout attack, the patient had been feel- ing well and his baseline creatinine was 2.9 mg/dl with an eGFR of 29 ml/min per 1.73 m2. Other medications in- cluded mycophenolate mofetil, cyclosporine, pravastatin, carvedilol, calcitriol, and furosemide.
After 48 hours of taking the allopurinol, colchicine, and prednisone, the patient developed nausea, intermit- tent vomiting, and profuse diarrhea. This continued in- termittently over the next 2 days. However, during the past 2 days, he has developed worsening lethargy; muscle aches; and continued nausea, diarrhea, and abdominal pain. His family brings him to the emergency depart- ment (ED).
In the ED, he was found to be confused, tachycardic, and hypotensive, with a BP of 76/42 mmHg and pulse of 120

beats/min. He then sustained respiratory arrest and was successfully intubated; he was also started on vasopressin, norepinephrine, and intravenous fluids to support his BP. Laboratory results at the time of admission are shown in Table 1.

Question 1a
The acid-base abnormality in this patient is:
     A. Aniongapandnon–aniongapacidosis
     B. Respiratoryacidosisandaniongapacidosis
     C. Respiratoryalkalosisandaniongapacidosis
     D. Respiratory acidosis and anion gap and non–anion gap acidosis
     E. Respiratory alkalosis and anion gap and non–anion gap acidosis 


Question 1b
Which of the following drug interactions were likely responsible for the patients presentation?
     A. Allopurinol,pravastatin,andmycophenolatemofetil 
     B. Allopurinol,pravastatin,andcyclosporine
     C. Colchicine,allopurinol,andmycophenolatemofetil
     D. Colchicine,pravastatin,andcyclosporine 
     E. Colchicine,prednisone,andpravastatin 


Case 2: Mitchell H. Rosner (Discussant)
A 37-year-old woman with a 3-year history of severe sinus disease and headaches is referred to you after several laboratory abnormalities were found. Her medical history is significant for two episodes of nephrolithiasis (no stone analysis was per- formed). On questioning she notes that pain and redness develop in her hands in cold weather. She takes no medications except for occasional antibiotics for her sinus problems. Her BP is 108/50 mmHg and her physical examination is unremarkable except for some fullness over her parotid glands. Her laboratory studies are shown in Table 2. On further questioning, she reports no drug abuse.


Question 2a
Which one of the following laboratory tests would you order next?
     A. Serumandurineproteinelectrophoresis 

     B. Plasmareninandaldosteronelevels
     C. 24-hoururinecortisol
     D. Stool screen for laxative abuse
     E. Anti-SSA,Anti-SSBserologies 

Aggressive intravenous potassium chloride and oral potas- sium citrate supplementation are administered. Laboratory tests repeated 1 week later reveal the following: potassium, 3.5 mEq/L; bicarbonate, 15 mEq/L; and anion gap, 6. The patient is seen by a neurologist for her chronic headaches, and topiramate, 200 mg daily, is started.

Question 2b
Which of the following changes would be expected if lab- oratory work was repeated several weeks after initiation of topiramate?
    A. Potassium,2mEq/L; bicarbonate, 5mEq/L; aniongap,8 
    B. Potassium,4mEq/L; bicarbonate, 20mEq/L; aniongap,8
    C. Potassium, 4 mEq/L; bicarbonate, 5 mEq/L; anion gap, 15 
    D. Potassium, 2 mEq/L; bicarbonate, 5 mEq/L; anion gap, 15
    E. Nochangeinelectrolytesfrompriorvalues