Month: March 2013

I am on the National Kidney Foundation of Michigan’s Scientific Advisory Board. Today, at the board meeting, Celeste Castillo gave a presentation on patient and family centered care. She is a dialysis patient and told a personal story of patient centered communication. She developed end-stage renal failure when she was in college. Every week-end she wanted to do what other college students did and that was drink, so every Tuesday she would show up at dialysis with too much fluid.

Her nephrologist kept wagging his finger at her until one day he sat with her on a Tuesday and started working through the problem with her. The solution: skip the beer and learn to love…tequila. Twelve ounces of beer is roughly equivalent to 1 ounce of tequila, presto, 91% reduction in volume.

Tequila for the win.

In 1971, Congress was debating adding a dialysis benefit to Medicare, and extending that benefit to all Americans. As part of his testimony to the House Ways and Means Committee, Shep Glazer was dialyzed in front of the committee. The process only lasted a few minutes but the event is considered to be the moment where Congress became committed to providing the benefit.

Glazer’s testified the following:

I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a noncompetitive line, was found out, and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?

The part of the story I never knew was that George Schreiner, the Chief of Nephrology and head of the National Kidney Foundation was the primary architect involved in lobbying congress for the dialysis benefit. He provided the dialysis machine but the National Kidney Foundation did not want to lend dignity to what they considered a risky stunt and barred Schreiner from attending.

So Schreiner sent his fellow to attend the procedure.

Can you imagine getting that page from your attending. “Hey, listen Topf, I’ve been barred from the hearing, but here’s what we’re going to do: You are going to take that dialysis machine, in that truck, to Capital Hill and then set it up. Just like I taught you. Yeah, in the hearing room for the House Ways and Means Committee. Yeah, they’ll all be there. Just ignore the national press. And the TV cameras. Then I need you to give dialysis to this guy who’s flying in to testify. After that, come on back and we’ll finish rounds. Okay?”

The fellow was James Carey who had this to say about the event:

Several years later, Carey disclosed to Schreiner that Glazer had gone into ventricular tachycardia during the dialysis session before the committee. Carey had immediately clamped the lines. The “treatment” was very short, perhaps five minutes in all, long enough to open the blood lines but hardly a dialysis session. Nevertheless, the few members of the committee who were present characterized the episode as “excellent testimony.”

That was when being a nephrology fellow was really cool.

As recounted in Biomedical Politics and Christopher Blagg in AJKD.

One of the causes of hypernatremia is water loss from the skin. This is increased in hot weather or if the skin damaged due to a lesion, burn or other wound. But I did not know hypernatremia cold result from cutaneous salt absorption.

Cutaneous Salt Toxicity

Fatal hypernatremia Na = 196

So in parts of the Middle East, Turkey, India, and China it is traditional to salt a newborn. Salt is dissolved in water, and olive oil and rubbed on the skin. There have been multiple reports (PubMed search | case report PDF | Google Search) of systemic cutaneous absorption of salt that causes hypernatremia.

Report from Neonatal Intensive Care Unit in Amman Jordan

1. Three days old boy admitted with severe hypernatremia, serum sodium 194 mmol/L and intracranial hemorrhage who died.
2. Eight days old girl with hypernatremia, serum sodium 164 mmol/L, severe hyperbilirubinemia, serum bilirubin 30 mg/dl, and intracranial bleeding.
3. Fourteen days old boy with generalized healing skin lesions, had normal head circumference at birth but developed severe microcephaly subsequently.
4. Six days old girl admitted with fever, meningitis and UTI, serum sodium 142 mmol/L.
5. Seven days old boy with hyperbilirubinemia, serum bilirubin 21.5 mg/dl, and serum sodium 155 mmol/L.

 A turkish report (unsourced from a website on Turkish Living):

…from a study conducted in Turkey in 2008 about practices in pregnancy and post partum… Eighty percent of the respondents were literate/primary school graduates, 45% had given birth at home. The most potentially harmful practices among women were swaddling (81%), dressing the baby with a sand-filled nappy (‘holluk’) (35%), and bathing the baby in salt water (40%). A relationship between traditional postpartum practices and demographic characteristics of women such as age, educational status, age at marriage and birth place was observed P<0 .05.="">

Sounds like this practice is still common in Turkey. A neonatal team from Jordan did a presentation on this practice at a conference and their slides are online. As part of the research they interviewed 112 women who gave birth at their hospital.

According to Wikipedia this is also a biblical practice. Ezekial 16:4

Newborn babies were rubbed with salt. A reference to this practice is in Ezekiel 16:4: “As for your nativity, on the day you were born your navel cord was not cut, nor were you washed in water to cleanse you; you were not rubbed with salt nor wrapped in swaddling cloths.”The significance of rubbing a newborn with salt is to indicate that the child would be raised to have integrity, to always be truthful.

What do CAM advocates say about this natural and traditional folk practice?

Just bought this last night from Fotolia

Came across this page while researching up the tradition of salting a newborn. We live in a golden era.

Any one ever see this?

Full text available here.

I hope to get back to this at some time but for now here are some comments from twitter:

@kidney_boy Interesting paper. Should we routinely check FeUrea & serum urate in nonedematous hypoNa pts?
— jbdoc (@jbdoc) March 3, 2013

and

@kidney_boy also, bedside u/s has improved vol status determination in my practice
— jbdoc (@jbdoc) March 3, 2013

Precious Bodily Fluids is part of the old guard among nephrology blogs. My first post was May 30th, 2008. Nate Hellman, creator of the Renal Fellow Network was a month earlier on April 23rd, 2008. But we were by no means the first.

The first nephblogger was Joshua Schwimmer. March 7, 2005! I remember reading Josh intermittantly right from the beginning. I even met him for coffee during an ASH meeting in 2006 or so. He was a fan of the Fluids book and encouraged me to blog. When I finally got my ass in gear and started blogging it was his endorsement which turned the microphone on. When he announced PBFluids I had already been working on it for months and suddenly I went from no traffic to a little traffic.

With the caption, K=9. Josh has evloved into the professor emeritus who has establish his role in academics and is now free to investigate what ever touches his fancy.

The current cohort of talented neph bloggers all owe Joshua a debt of gratitude. Next time you see him, kiss the ring.

Spring training is in full swing and my invitation to rejoin my fantasy baseball league has arrived. I was excited to be invited back after my poor showing last year. Yes, I’m looking at you Cliff Lee.

It got me thinking that the game I would really like would be fantasy medical scientist. You would draft a cohort of medical researchers. You would need a complete roster with a cardiologist, oncologist, ID/microbiologist, surgeon (or surgical sub-specialist) a nephrologist, endocrinologist and two other medical scientists to play utility positions.

For the next year you would score points for every paper published by the scientist. The points awarded would be the impact factor of the journal. You would lose triple impact factor for retractions.

Who’s in?

Updates from Twitter:

@kidney_boy Triple Crown for a scientist who publishes as 1st author/ journal with high impt factor/ 3 citations in 3 months
— Edgar V. Lerma (@edgarvlermamd) March 3, 2013