Year: 2021

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Robert Schrier has passed

Robert Schrier was a giant in nephrology. I met him a couple of times at Kidney Week but he was well past his prime and it was hard to make out the lion that he must have been. I didn’t know Dr. Schrier but I do know someone who knew how quite well.

Ever since I left fellowship I have worked at Saint Clair Specialty Physicians. It was originally a multi-specialty practice with internists, surgeons, hematologists and nephrologists. But things change and we are now a couple dozen nephrologist and one vascular surgeon. The practice is one of the oldest nephrology practices in Michigan. It was started by Joe Beals in the 70’s.

Joe was a Hoosier and went to DePauw where he was roommates and fraternity brothers with Robert Schrier. When you think of how small the field of nephrology was in the 60’s, it’s incredible to imagine that college roommates would both independently navigate to the same field. Here is Joe in his own words after I told him that Schrier had passed.

Thanks Joel, no I hadn’t heard. So sad! One of the smartest guys I ever knew. Was a fraternity brother, Sigma Nu, at DePauw University in Greencastle, IN. He was on the DePauw basketball team and baseball team. Worked his way through college working in the kitchen at a sorority house. He sold Fuller Brushes with me one summer in Indianapolis. Has 5 kids, all names starting with “D.” Most if not all also attended DePauw. Wife was a Theta at DePauw. A Fulbright Scholar. Will be missed.

Joseph Beals
Joseph and Mary Beals

Joe is a great doctor and has been a good friend. Strange to realize that I’m the youngest partner at St Clair that worked with the founder.

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Going Viral: Social Media in the Age of COVID

I have been thinking about the role of social media in the pandemic. This is the first medical crisis not the age of the public physician and social media. It has resulted in some some fascinating developments. Some of the changes that came about because of the pandemic will indelibly change medicine and most of them are for the better.

I started thinking about it this past August as part of an invited essay on the topic by Blood Purification. I worked this paper with The Curbsiders’ Paul Williams. We looked at the role of public physicians this time of intense public interest.

We leaned into the definition of public physician created by Bryan Vartabedian. Take a look at the manuscript (PDF link).

I used that paper as a jumping off point for a talk I gave on Social Media and the Pandemic for the Renal Research Institute. I started focused talk on the changes in medical education, looking at how traditional medical education fell apart in the face of social distancing while FOAMed took off.

The RRI is the research arm of Fresenius and they run a top notch nephrology meeting every year. This year, the meeting is in May but they had a few speakers record their talks for release in January. Mine just came out.

I recorded that lecture in mid-late December.

The most recent thinking on this topic was for Innovations in Media and Education Delivery (iMED) Initiative at Beth Israel Deaconess Medical Center first annual conference. I had the honor of presenting the keynote talk. Here I continued my focus on the impact the pandemic had on medical education and the role FOAMed played. A lot of the bones of the talk were there in the RRI talk but the connective tissue is much stronger.

There is no public recording of the talk, but you can take a look at my slides:

Keynote: The Pandemic blows up #FOAMed (526 MB)

PowerPoint: The Pandemic blows up #FOAMed (251 MB) Note: I create, rehearse and deliver the presentation in Keynote. The PowerPoint version is a simple export of the Keynote presentation and often looks like garbage. If you want to see the presentation as it was meant to be, use Keynote.

PDF: The Pandemic blows up #FOAMed (86MB)

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Newest project: Channel Your Enthusiasm

One of my favorite podcasts was Joane Robinsons and David Chen’s Game of Thrones recap podcast, A Cast of Kings. As I listened to it I wondered if the same idea could be used for medical textbook. To have people read the book together and have a monthly podcast that summarized and commented on each chapter.

So we put together Channel your Enthusiasm, the Bud Rose Book Club and Cocktail Hour, a Renal Physiology Podcast.

Here is the team

The website for the podcast is RoseBook.Club.

You can subscribe to the podcast on your choice of services:

The URL for Channel Your Enthusiasm is: http://www.rosebook.club/episodes/?format=rss and you should be able to use that to subscribe to the podcast using any podcast player. I use Overcast. Alternatively you can find it on Apple Podcasts and Spotify.

You can also listen to us on Apple PodCasts
And Spotify Podcasts

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Links to useful podcasts for residents and students rotating on nephrology

Michael Eastman sent me this list of podcasts. He send out an e-mail to residents at the beginning of a nephrology rotation so that residents and students can use their windshield time to brush up their nephrology skills.


Hi all:

I wanted to pass along a compilation of nephrology-related podcasts that I’ve been sharing with the residents.  I find them quite entertaining (and educational!).  Feel free to listen or share with the residents as well, since I usually don’t come on service until halfway through their rotation.  All are quite good.  My favorites are the ones on hyperkalemia and hyponatremia.  The ones on dialysis and transplant are also very good.  Finally, check out all 3 of the links at the bottom from the EMCrit website.

#2: Are You Treating Hypertension Adequately? Discussing the Implications of SPRINT.  

#20: Hypertensive urgency and severe hypertension  

#31: Diuretics, leg cramps, and resistant hypertension with The Salt Whisperer  

or:  Diuretics, leg cramps, and resistant hypertension (Reboot)

#39: Secondary hypertension, hyperaldosteronism, Cushing’s, and pheochromocytoma 

#48: Hyponatremia Deconstructed

Or: REBOOT #48 Hyponatremia Deconstructed

#61: Vasculitis and Giant-Cell Arteritis: ‘Rheum’ for improvement 

#65: Scott Weingart of EMCrit on Emergency versus Internal Medicine: The Devil of the Gaps

#67: Chronic Kidney Disease Pearls with @kidney_boy, Joel Topf

#69: CKD Prescribing Do’s and Don’ts with @kidney_boy, Joel Topf

#77: Hypertension Guidelines Showdown

#87: Toxicology 101: Talking Tox with The Dantastic Mr. Tox & Howard

#88: Acid base, boy bands, and grandfather clocks with Joel Topf MD

#104: Renal tubular acidosis with Kidney Boy, Joel Topf MD

#108: Point-of-care Ultrasound for the Internist

or:  Reboot #108 POCUS: Point-of-care Ultrasound for the Internist

#137 Hyperkalemia Master Class with Joel Topf MD

or:  REBOOT: Hyperkalemia Master Class with Joel Topf MD – #137

#143 NephMadness: Fluid Wars

#144 NephMadness: Inpatient Hypertension

#145 NephMadness: Hepatorenal Syndrome vs AKI 

#146 NephMadness: Pain Meds in Chronic Kidney Disease 

#150 HFpEF Update with Dr Clyde Yancy MD

 #170 Hypernatremia is Easy with Joel Topf MD

#192 Dialysis for the Internist with Joel Topf MD 

#199 NephMadness: Hyperkalemia, Diet, K+ Binders, Exercise

#204 NephMadness 2020: SGLT2 Inhibitors

#210 Kidney Transplant for the Internist

#226 Kidney Boy on Acute Kidney Injury: Myths & Musings

#230 Kittleson Rules Acute Heart Failure

#250 Nephritic/Nephrotic

Other podcast episodes which you may enjoy while on your nephrology rotation:

Hyponatremia w/ Kidney Boy:   https://emcrit.org/emcrit/ed-nephrology/

Right heart failure w/ Sara Crager:  https://emcrit.org/emcrit/right-heart-sara-crager/

Central Line pro tips:  https://www.youtube.com/watch?v=XUjncj6ybak

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Contrast Nephropathy on YouTube

I had the honor of speaking at the Robert Wood Johnson School of Medicine Internal Medicine Grand Rounds in December. They recorded the presentation and posted it to YouTube. So if you are interested you can see the presentation here: https://youtu.be/ShG_p-awl40

You can grab a copy of the slides here…

Keynote: The new Science of Contrast Nephropathy

PowerPoint: The New Science of Contrast Nephropathy (46 MB) Note: I create, rehearse and deliver the presentation in Keynote. The PowerPoint version is a simple export of the Keynote presentation and often looks like garbage. If you want to see the presentation as it was meant to be, use Keynote. 

PDF: The New Science of Contrast Nephropathy (26 MB)

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What is missing from the race and eGFR discussion

The ASN and NKF have a joint task force working toward a response to the race and eGFR problem and they are now inviting people to submit oral and written testimony. I signed up. Hopefully I get an opportunity, but suspect there will be too many people for them to hear even a fraction of the applicants.

I have been thinking about race and eGFR and this is where I am at…

  • Race is a social not a biological construct
  • People identified as black (or self-identified as black) have higher measured GFR for the same serum creatinine as non-blacks
  • These higher eGFR results in black people (self-identified or not), a marginalized group and a population already at increased risk of adverse kidney outcomes, being denied transplant listing and CKD referral.

But what is not ever seem to be questioned in this discussion is the perverse use of estimated GFRs to make critical binary decisions in individual patients. The eGFR equations are amazing how well they predict GFR for groups of patients with minimal bias, but their reliability in an individual is stunningly imprecise. Accuracy in individual patients is measured by P30, the likelihood that the true value will be within 30% of the measured value. The P30 is 84% with CKD-Epi, a bit better compared to the 80% in MDRD. This means that for the critical decision of whether to list a patient for a kidney transplant, a patient with an eGFR of 21 will have an actual measured GFR somewhere between 15 and 27 in 84% of cases. This 30% spread is greater than the 16% adjustment for black race.

Though using race for eGFR should be stopped, and we can do that today by making cystatin-c the coin of the realm, this doesn’t change the problem of over indexing on eGFR for individual patient decisions. Cystatin C is no better than creatinine in providing a precise estimate in eGFR (P30 86%). Decisions like transplant listing and CKD referral should not rely on a measurement with so much uncertainty. We report eGFR on lab reports but give physicians no sense of the imprecision hidden in that number.

I think if eGFR were reported as a range (±30%), we would stop using sharp cut-off limits for critical decisions like transplant and referral.

The use of sharp cutoff for decisions like transplant and CKD referral harms all patients with CKD, not just black people. We should immediately to remove race from eGFR calculations by standardizing cystatin-C as the way to assess eGFR but at the same time we should start the process of unwinding guidelines and individual patient decisions from being wedded to inaccurate estimates of GFR.