Year: 2013

I want to write more about World Kidney Day, and maybe I’ll get back to this later today but for now, everyone needs to go to the ASN and answer their survey. The ASN is trying to get a handle on AKI burden. Let’s do our part, because after the sequester this maybe the closest thing we get to an NIH sponsored randomized controlled trial in nephrology.

If we are really successful maybe in the future when you misspell nephrology by one letter, Chrome won’t suggest neurology.

If you google image search best comment ever. This  is one of the top hits.

Over the 5 years that I have been blogging, the landscape has noticeably changed. Early on, I would receive rare comments but they were good ones. As I built an audience I received more comments but rarely would I see any significant discussions like the ones you see on KevinMD or other smart medical blogs. About two years ago this trend reversed. My audience continued to rise but comments really began to drop off and I started getting more and more comment spam. I believe this transition was a direct result of the rise of Twitter.

In the last year I have been having repeated high quality discussions about posts, research and projects on Twitter. Online discussion, except in rare exceptions, has moved to Twitter.

Comment spam is robot generated text that tries to get published in order to improve the google ranking of a target website. I never publish them, though a a few may have slipped through. Here are some examples:

Anonymous has left a new comment on your post “Coffee + MacBook Air = No posts for awhile”:

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From Sterns’ article on sodium polysterene sulfonate (Kayexalate) and its ineffectiveness for treating hyperkalemia:

Sodium polystyrene sulfonate (SPS), an ion-exchange resin designed to bind potassium in the colon, was approved in 1958 as a treatment for hyperkalemia by the US Food and Drug Administration, 4 years before drug manufacturers were required to prove the effectiveness and safety of their drugs.

From Watson’s counter editorial on sodium polysterene sulfonate and that its reasonable safety and effectiveness:

When SPS resins were first introduced, dialysis was an in- frequent procedure, and loop diuretics were in development.

You mean loop diuretics had to be developed? There was a time before lasix? Mind blown.

More random potassium trivia. The risk of hyperkalemia in anuric dialysis patients rises twice as high if they are on ACEi or ARB. Colonic and skin potassium excretion?

There were 70 individuals (0.21%) who had more than 20 events [in one year of reporting!, Only one episode per day allowed], and a greater proportion of these patients had CKD, ACE-I and/or ARB use, and diabetes than the general population with hyperkalemia.

Imagine for a moment, a patient with hypertension and galactorrhea. The patient is on risperidone, a notorious cause of galactorrhea. So the patient has hypertension and drug induced galactorrhea. But Occam’s Razor is irritating my brain. There must be a single diagnosis that ties these two symptoms together. Could she have a pituitary tumor causing Cushing’s disease and a prolactinoma? So I turn to my global and highly educated consulting crew, Twitter:

anyone aware of connection between galactorrhea and hypertension?
— Joel Topf (@kidney_boy) March 7, 2013

I received a few great responses:

@kidney_boy Did you know that William of Occam died of multiple causes?
— David Juurlink (@DavidJuurlink) March 7, 2013

and

@kidney_boy @davidjuurlink do you guys know Hickam’s dictum? A patient can have as many diseases as he damn well pleases.
— Irfan Dhalla (@IrfanDhalla) March 7, 2013

Hickam’s Dictum. I’d never heard of it even though Hickam ultimately became Dean of Indiana University, where I did residency.

For a long time I’ve wanted a counter argument to Occam’s Razor and now I have one. Thanks Jimmy Wales!

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