Today I read the excellent NYT Magazine story on breast cancer

The entire article is great and I recommend it but one aspect of the story was the rise of ductal carcinoma in situ. Here is how it is described:

Many of those women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.

D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.” Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S.

The point is, our diagnostic technologies have found a “pre-disease” state and we now take credit for curing these people when they may never have developed the lethal form of the disease. A conversation on twitter erupted regarding D.C.I.S. and its equivalence in prostate cancer, another disease mired in controversy regarding diagnostics and the benefit of early diagnosis.

Must read: Mirrors Men & Prostate ca.Gleason 6 = DCIS –> don’t call it cancerOur Feel-Good War on Breast Cancer nyti.ms/ZuCZHh
— David Y.T. Chen (@dytcmd) April 25, 2013

@kidney_boy @dytcmd I’m not buying the comparison. G6 tumors on biopsy are often upstaged (30%?) whereas I’m not sure DCIS is
— daviesbj (@daviesbj) April 25, 2013

Their is, in fact, a movement to re-name Gleason 6 tumors that avoids the term cancer as a way of emphasizing the low aggressivness of the condition:

Here it is in all its PDF glory

In the absence of definitive markers of the lethal phenotype, a new paradigm is needed to express the risk associated with Gleason score 6 tumors. We propose to adopt at Johns Hopkins an alternative approach based on a modified Gleason scoring system referred to as prognostic grade group. Five prognostic categories will be reported based on prostate biopsy (Table 1). For men undergoing radical prostatectomy from 2004 to 2011, these prognostic grade groups from 1 to 5 have been associated with 5-year biochemical recurrence-free survivals of 94.6%, 82.7%, 65.1%, 63.1%, and 34.5%, respectively (Pierorazio et al, manuscriptin preparation).

This made me think, what is the DCIS or Gleason 6 of nephrology, and I think by far its CKD stage 3. New patients that are referred to me come in to the office with labs results in hand. They frequently have seen information on line or in posters that explain that their eGFR of 52 mL/min is CKD stage three and they see that Stage 5 is dialysis. So they come to two conclusions:

1. They are going to be on dialysis soon
2. Why didn’t anyone ever warn them when they CKD stage 1 or 2?

From my GFR handout

Update from Twitter (where else?)

Amyloid_Planet: Nice blog post today BTW – bit off a lot with that one.

Kidney_boy: What? You think taking on Komen, the urologists’
 cash cow and K/DOQI is a big post?

Amyloid_Planet: Potentially controversial, yes. I’m surprised you didn’t take a shot at Jesus while you were at it.

Kidney_boy: follow-up post

So last week I asked how you would dialyze the patient in the following scenario:

You have been called on a Sunday night for emergent dialysis in a patient with hyperkalemia. The patient is a MWF dialysis patient and had a normal dialysis session on Friday. Her ECG on admission is absolutely terrifying and her potassium is 9.9 (hemolyzed). The blood sugar on admission was 965. When you arrive, with K-machine in tow, the patient has been on an insulin drip for an hour and the potassium is down to 5.2

I don’t see any signifigant trends based on background of the provider:

The raw data is available for perusal here. And you can keep voting here.

That is not how I voted. I voted for 2 hours on a 2K bath. My feeling was that the ECG showed dramatic cardiac toxicity and though the emergency seemed to be over, with a repeat potassium of 5.2, I had no guarantee the insulin drip would continue through the night. If it was stopped, intracellular potassium could diffuse back out of the cells. But what really pushed me was the fact that he is scheduled to receive dialysis in just a handful of hours anyways. If I just push that schedule up and dialyze him tonight I provide an extra margin of safety for his potassium and improve my sleep hygiene. No nightmares of lost IV access for the insulin drip.

Because I viewed this emergency dialysis as just pushing forward the scheduled dialysis I went with the standard 2K dialysis bath.

Now for the best part of any blog post, belittling people who don’t agree with me. The above paragraph takes care of no dialysis.

• Zero K bath. Too great a risk of hypokalemia. We presume that he does not have excess total body potassium, merely maldistribution of intracellular potassium. Zero K baths are dangerous. Who can forget the classic scene in Grey Anatomy where Izzie is fired for ordering a zero K bath, putting a patient in shock, so that the poor dialysis patient misses her transplant. (I love that show, they even let surgical residents write dialysis orders.)

• One K bath. See above. Though the concern about the toxicity of low potassium baths seems to be overblown.
  
• Two K bath. Perfect.
• Three K bath. Should work just fine.
• Four K bath. What’s the point, at the current potassium of 5.2, two hours on a 4 K bath will remove a trivial amount of potassium and is functionally identical to no dialysis at all.

Defend your sorry choice in the comments below.

The fluids book is certainly priced right (free) but if you need an additional endorsement, Richard Sterns, the Dean of Sodium, uses figures from the book in his talk at the ASN board review class!

Love hearing how Richard Sterns uses my book at @asnkidney board review. Get it for free at pbfluids.com/p/other.html?m… twitter.com/kidney_boy/sta…
— Joel Topf (@kidney_boy) August 29, 2012

From Edgar Lerma.

Update: got this e-mail the other day:

Hello from the blogosphere

One of my colleagues pointed me to your website today.  I don’t know that you’re right about me being the “Dean” of anything, but you are correct:  I loved your book.  Hope you don’t mind that I borrowed from it.

Rick

Richard H. Sterns, MD
Chief of Medicine
Rochester General Hospital
1425 Portland Avenue

My son is doing a big project on the kidney. As part of that project he has to write a limerick about the kidney. The family was stumped so of course we decided to crowd source the problem:

My son has to write a kidney poem. What rhymes with dialysis?
— Joel Topf (@kidney_boy) April 18, 2013

The answer was analysis and paralysis (hat tip to @emmadalton and Leon)

But the real fun began as people sharpened there pen knives and carved new limerick’s on to the bathroom walls of twitter.

@kidney_boyThe news is sad.We’ve done a urinalysis.Your kidneys are bad.You will need dialysis.
— Skeptical Scalpel (@Skepticscalpel) April 18, 2013

@skepticscalpel @kidney_boy In retrospect, there must have been a diagnosis we missed…Meh, oh well. Let’s get you on the UNOS list.
— Michael Katz (@MGKatz036) April 18, 2013

@mgkatz036 Stop that NaClits the reason he’s not doing wellIn order to volume resuscitateThe hip new thing is Ringers Lactate
— Joel Topf (@kidney_boy) April 18, 2013

Kidneys, most of us have two.Some have one, shaped like a horse shoe.Can’t live with none,Dialysis or transplant have to be done.
— Vijay(@scanman) April 18, 2013

A man was once stung by a beeHe thought he got off scott freeBut he had rhabdomyolysisAnd now he’s forever on dialysis
— Joel Topf (@kidney_boy) April 18, 2013

Daughter noted spelling error (now instead of know)

@kidney_boy if only his doctors weren’t second rate.they couldn’t afford up-to-date.
— Michael Katz (@MGKatz036) April 18, 2013

Kidneys are shaped like a beanThey keep your blood cleanThey are the coolest organ unseenUnless you open the body and that would be mean
— Joel Topf (@kidney_boy) April 18, 2013

Daughter wrote that one.

When your kidneys failNo need to wailCause in the final analysisYou can always try dialysis
— Joel Topf (@kidney_boy) April 18, 2013

My son is pretty independent and ignored all of the bad poetry advice on Twitter and went with this original creation:

There once was a kidney named Bud
He liked to filter the blood
He got a disease
There’s pus when he pees
And now Bud is simply a dud

Beautiful animations and clear explanations. More work like this please.

I am going to write a wrap-up of NephMadness for eAJKD. As I’m thinking about this the following sentence springs to mind:

NephMadness was the biggest medical education social media campaign, not tied to a conference, ever pulled off.

Am I being an ass or is that right?

Are there even any other MedEd social media campaigns not tied to a conference?

The only one I can think of is #overlyhonestmethods

What other events should it be compared to?

Keep in mind this was a coordinated campaign involving one central blog but generated posts on at least four other blogs, had a single Twitter account but ultimately had 75 people on Twitter using the hashtag.

I really would appreciate any thoughts about this. Please tweet @Kidney_boy or fill in the comments below.

I did this interview for eAJKD. I met Jamie Dwyer once, and though he was charming, well spoken and clearly intelligent the overriding biggest impression was that he was best dressed nephrologist I ever met.

The highest potassium I have ever seen is 9.9 mmol/L…

Don’t worry about that potassium of 9.9, the computer says it’s hemolyzed. twitter.com/kidney_boy/sta…
— Joel Topf (@kidney_boy) April 10, 2013

…however, it was a hemolyzed specimen so it is a tarnished victory. The patient is a dialysis patient in DKA and had a blood sugar of 925 at the time of the hyperkalemia.

I love that the only things not circled are a creatinine of 8.9 and BUN of 50.

The patient was started on an insulin drip and one hour later his potassium was 5.2 mmol/L. A drop in the serum potassium of 4.7 mmol/L is profound and atypical. This is due to two factors:

1. The initial serum potassium was not that high, despite the subtle EKG changes the real potassium had to be somewhat lower and falsely elevated due to the hemolysis.
2. In DKA the hyperkalemia seen on presentation is due to a transcellular shift of potassium from the lack of insulin and increased extracellular osmolality (from the hyperglycemia), both of these are quickly reversible with IV insulin.

K⁺= 25.4 – (3.02 x pH) + (0.001 x glucose) + (0.028 x Anion Gap)

Nice picture but this in not an important mechanism in the hyperkalemia of DKA.

The reason that acidemia does not generate hyperkalemia in DKA, is that the anions move into the cells along with the hydrogen ions, so there is no need to excrete potassium to maintain electroneutrality.

A nice review of the hyperkalemia and hyperglycemia in dialysis patients was published a couple of years ago by Tzamaloukas, a widely published investigator on the subject. I love this figure from the review which shows a curvilinear relationship of glucose and potassium in dialysis patients.

Nice graph except for micromoles of potassium per mmol of glucose. Really? Could you make it more obtuse?

One of the interesting conclusions that I learned from the review: one of the most important variables which affects how much the potassium will fall with insulin is the pre-treatments potassium level, the higher the potassium, the greater the response to insulin. The data from that conclusion  comes from this study: Serum potassium and acid-base parameters in severe dialysis-associated hyperglycemia treated with insulin therapy. It is an analysis of 43 episodes of hyperglycemia, half DKA and half non-ketotic hyperglycemia. Here is the money shot showing the relationship to initial potassium to drop in potassium:

What would you do for this patient? 

I will share the results in a week or so.

Addendum: some of the funnier tweets in response to my original tweet:

@kidney_boy probably artifact. Repeat ECG in am
— Lyle Shehane (@lyleshehane) April 10, 2013

@wanna_be_medic @kidney_boy It’s never good if your ECG looks like it was drawn by a five year old.
— Chump (@bungeechump) April 10, 2013

@kidney_boy unfortunately, it’s intravascular hemolysis.
— Michael Katz (@MGKatz036) April 10, 2013

@kidney_boy have patient follow up in Asystole Clinic in 3-5 days.
— GJ (@GregJNYC) April 11, 2013

We loved that comment so much we made it the Hyperkalemia Merit Badge:

William J Stone is Chief of Nephrology at the Tennessee Valley VA and faculty at Vanderbilt Medical School. He discovered beta-2 microglobulin amyloidosis in long term dialysis patients. He describes the discovery here:

I discovered B2M amyloid in 2 hemodialysis patients during the late 1970’s and early 1980’s who sequentially broke both femoral necks. We were doing home hemodialysis on 75 VA patients, who lived an average of 220 miles away. One of them had a cystic knee lesion, which we biopsied. It was Congo red positive. A light bulb went off in my brain. All of the femoral neck tissue from both patients at joint replacement, misread as increased connective tissue, was full of amyloid. Workup for AA and AL was negative. The patient later died of lung cancer. At autopsy we scooped the amyloid out of a large humeral lesion. When sequenced in NYC, its subunit was intact B2M. To my knowledge, this has not been repeated.

In the early days of dialysis he was in Vietnam with Army and used dialysis for battlefield injuries, Stone again:

I was sent to the Third Field Hospital in Saigon from 1968-69, where we dialyzed battle casualties and falciparum malaria cases of AKI. I had completed a basic science nephrology fellowship at Cornell from 1965-67 and had never done dialysis before. We saved a lot of them using the old coil dialyzers.

Dr. Stone has created the Rules of Stone, bits of wisdom that should guide doctors through the uncertainties of diagnosis and treatment.

Rules of Stone

1. Anything can do anything. (WJS clarified: is for people who say things like a stroke alone cannot give you a high fever)
2. Anything can do nothing. (WJS clarified: is for those doubters who say a patient on prednisone will have a tender abdomen if he has perforated an ulcer or a diverticulum)
3. Nothing can do anything. (WJS clarified: refers to self-inflicted illness; e.g. IV injectors of dissolved pain pills can have multisystem disease)
4. Nothing works every time.
5. No lab or diagnostic test is perfect.
6. No disease is always predictable.
7. Just because you can do something doesn’t mean you should do something.
8. A patient known to have x,y, and z doesn’t necessarily have x, y, and z.
9. A person with an illness similar to a previous one probably has it again.
10. No list is complete.
11. The more drugs there are for a disease the less likely they are to benefit it.
12. There are no uninteresting patients (just disinterested physicians).
13. Four drugs are more toxic then two.
14. Always guess 20% if you don’t know the real answer.
15. No drug has been proven useless until it has been tried in scleroderma and ALS.
16. Just because you failed to diagnose the cause of X in the past doesn’t mean you shouldn’t try again.
17. Orneriness is best treated as an outpatient.
18. If an older doctor writes an axiom or a diagram on a piece of paper, ask if you can have it.
19. Common but unrelated diseases co-exist at least 1% of the time.
20. If asked when you last played basketball, be able to answer with a day of the week.
21. Before addressing non-compliance with diet and medicine #1, doctors add medicine #2.
22. In a sick patient without a diagnosis, get invasive early.
23. You cannot learn medicine at home, so the new residency hours rules make no sense. A cadre of doctors with inadequate experience is being created.