The document is worth a download.
You knew that proteinuria is protective against amphotericin induced hypokalemia. Right?
All of you #NephMadness players crying into your coffee about Proteinuria getting beat out by Patient Reported Outcomes need to understand that proteinuria isn’t always bad*.
*I am being sarcastic here, proteinuria is always bad, and the only reason I am writing this post is because of this interesting quirk where it appears to be protective.
Proteinuria protects against amphotericin b induced hypokalemia. In patients on amphotericin, heavy proteinuria, a protein concentration of 3 g/L (3+ on dipstick), is protective against amphotericin b induced hypokalemia.
The study was done on normal formulations (as opposed to liposomal preparations) of amphotericin B.
Amphotericin B is highly protein bound. With standard doses, the normal amphotericin concentration in the urine will be 1-2 micromol/L. With 3+ urine protein, the albuminuria concentration is over 40 micromol/L, and this is apparently enough to bind and neutralize amphotericin’s collecting duct toxicity. Amphotericin’s anti-fungal property comes from its ability to tear open fungi cell membranes. Unfortunately it does a doozy on the membranes of the collecting tubules as well, allowing potassium to flow down its contraction gradient from the cells to the tubular fluid (and out in the urine). Similarly hydrogen flow from the tubular fluid back into the cells causing metabolic acidosis.Β It is an unusual cause of renal potassium loss without increased aldosterone levels.
For you #NephMadness geeks, toad bladder was instrumental to working out the mechanism for amphotericin induced hypokalemia.
Swami is clairvoyant
The Saturated 16 has been announced and 6 of 8 of the Swami’s Regional champ predictions are still alive.
The two misses: Menopause and Shark. Menopause got crushed by the Blue Ribbon Panel and the crowd. I guess we now know why there is so little research on this.
The Swami had Menopause going deep so this is going to hurt.
Shark not making the cut? I have no words.
But with 6 of 8 still alive The Swami looks forward to the coming apologies…
I disagree with every one of Joelβs picks. But hey – maybe Joel knows something I donβt π#NephMadness https://t.co/Gu5uk77x64
— Swapnil Hiremath @hswapnil@bsky.social (@hswapnil) March 28, 2018
https://twitter.com/poyanmehr/status/979121802650759168?s=21
I am The Swami of #NephMadness let me build your brackets and fill your pockets
Student loans…credit card debt…car payments
I can make them all disappear.
In previous years I couldn’t prognosticate on NephMadness because I was contaminated by running the Blue Ribbon Panel. This year I have have no such inside knowledge. I am free and I am going to share the wisdom I have gained by running the previous BRPs to give you can’t-miss-locks.
In previous years there has always been prohibitions from any type of gambling
But in 2018, AJKD forgot to ban gambling. So call your bookie! Mortgage the house! Cash in the kids’ 509 college plan! I’m going to whisper the winners. These darlings are your chance for a better life!
We are going to skip the Satuated Sixteen and go right to the regional champions.
The Effluent 8:
Women’s health
Menopause is the dark horse here. Everyone is going to go with reproductive planning because when a dialysis patient gets pregnant everyone goes crazy. But the issue that affects almost all of our female patients is menopause. This is seriously under-studied and it’s going to cut throught this region like a knife through butter. This is a bracket buster and when it beats reproductive planning on March 31st, #NephTwitter is going to be out for blood. You won’t be crying because your going to pick menopause right now.
Animal House
No bracket busters here. This is going total chalk. Pick Shark like everybody else. Getting cute with camel or toad is just going to make you poor. Shark FTW.
Peritoneal Dialysis
This is going to be a tough call, and I’m worried that the Blue Ribbon Panel could make a mistake here and foolishly go with PD catheter dysfunction but the answer is Volume Issues. Volume Rules.
Trial Outcomes
This one is easy. It is 40% drops in GFR. Nephrologists have been telling people not to perseverate over the creatinine for years. We told them eGFR was a better estimate than any serum creatinine. We have been calculating eGFRs for 20 years. The fact that the FDA is still looking at doubling of creatinine is a travesty. An eGFR based trial outcome is long overdue. 40% loss of eGFR destroys this division to advance to the Elite 8.
Hyponatremia
The US Guidelines are a juggernaut. Ignoring the placebo-controlled trials supporting Vaptans while prescribing your patients urine pills supported by a few observational trials is knocking on homeopathy’s door.
Contrast
NephMadness is innovative but there is no way nine nephrology leaders are going to go on the record and say contrast is not nephrotoxic. This is easy, Contrast is Nephrotoxic cruises to the win here.
Pediatrics
Genes in CAKUT. There are no pediatricians on the BRP. They are going to go full science when faced with this question. Don’t doubt me. This one is a lock.
Transplant
The Untransplantables is going to win this one. Best name. Best science. No contest.
The Filtered Four
Menopause versus Shark
Animal House was fun, but up against Women’s health it will be treated as the gag region that it was meant to be. Menopause walks all over Shark. Sorry.
Volume issues versus 40% drop in eGFR
Redefining the primary outcome of every major CKD study for the next 20 years is going to be unstapable.Β 40% drop in eGFR FTW!
The US Hyponatremia Guidelines vs Contrast is Nephrotoxic
My crystal ball gets a little cloudy here. Guidelines are a little dull and the BRP may not want to advance them to the Filtered Four, but at the same time, I suspect they will be looking at how thin the data on contrast being actually nephrotoxic and will feel a bit guilty. The US Guidelines advance here.
Genes in CAKUT vs The Untransplantables
No contest. The peds topic is dropped like a dirty diaper. The Untransplantables advance
The Filtered Four
Menopause vs 40% drop in eGFR
This is the year World Kidney Day was devoted to women’s health. Menopause takes that momentum and rolls over Drops in eGFR of 40%.
US Guidelines vs The Untransplantables
The US Guidelines have navigated to the final four by finding a weak stream of competitors. They have no reason to be there. They are The Loyola Ramblers and Sister’s Jean’s run is about to run out. The UntransplantablesΒ rips up the guidelines.
The Left and Right Kidney
Menopause versus the The Untransplantables
Everyone loves transplant, and transplant always wins.
Your NephMadness champion will be The Untransplantables.
Now get to Tourneytopia and register to play NephMadness…Time is running out.
giving 3% saline via a peripheral line
At many hospitals 3% is restricted to central lines or ICUs. This is despite data showing that it is safe enough to use peripherally.
From tonight’s NephJC:
My hospitalists and nursing colleagues freak out about 3% saline. Requires central line and step-down unit bed. #NephJC
— KatieOverV (@KatieKwonMD) March 28, 2018
I believe there is evidence that 3% an be given peripherally. have been considering doing a mythbusting blog on this. #NephJC
— ππ€π¨π πππ§π ππ¨ (he/him) π (@PulmCrit) March 28, 2018
we give sodium bicarb peripherally all the time and that has a Na concentration of 1,000 compared to 513 with 3% #NephJC
— Joel M. Topf, MD FACP (@kidney_boy) March 28, 2018
We give it peripherally too #NephJC
— ChristosArgyropoulos MD, PhD FlozinatorInChief (@ChristosArgyrop) March 28, 2018
There: https://t.co/iAuf9d1x84
— Helbert Rondon, MD, MS, FACP, FASN, FNKF (@NephroMD) March 28, 2018
— Helbert Rondon, MD, MS, FACP, FASN, FNKF (@NephroMD) March 28, 2018
And one more
Curbsiders Podcast on rapid interpretation of ABGs
I did another podcast with the Curbsiders. This one was on basic acid-base interpretation. It went pretty well. Great editing.
Introducing #NephMadness BINGO
NephMadness is in full swing and is going strong. The NSMC interns have turned into a publicity machine cranking out the content.
This is the sixth year of NephMadness and I can honestly say it gets more fun every year. I am particularly loving this year because Anna, Tim and Matt are doing the heavy lifting as I spent most of March trekking around the Himalayas.
One of my favorite parts of NephMadness is the meta-conversation that surrounds the conversation. To honor this talk about the talk I present NephMadness BINGO.
Have at it!
Everest Basecamp: The whole enchilada
So I still have one post to write, the flight out and the last 3 three days in Kathmandu. But for now here is the whole trip. I also want to make one more (I’m likely lying and will in fact make further requests) request for a donation to the MMRF.
The MM4MM video. Gives me goose bumps
We had two photographers, John and Ben, with us and they just crushed it. Amazing work!
Day 12 of the #MM4MM Adventure: Escape from Himalayan Mountain
Someone was very concerned about snoring last night. Everytime either Ben or I started to snore we got a sudden, loud, and quite frankly, violent knock on the wall. At this time it seems prudent to remind my dear readers that everything man-made you see in the Himalayas has came up on the back of …
Continue reading “Day 12 of the #MM4MM Adventure: Escape from Himalayan Mountain”
Day 11 of the #MM4MM: The day we actually go to Everest Basecamp
Just like the day before we wake up early to get an early start on a big day but events conspired to push us our start time back. We met in the commons room of the tea house at 6:45, when we were promised breakfast. Cornflakes, porridge and hard boiled eggs weren’t served until 7:20. …
Continue reading “Day 11 of the #MM4MM: The day we actually go to Everest Basecamp”
Day 10 #MM4MM: The day we were supposed to go to Everest Basecamp
The plan was to get a slightly earlier start. Instead of rolling at 8:30 we were going to start hiking at 8:00. This didn’t happen. Renee had a rough night. She had a severe splitting headache. She was nauseated. She was a mess. It was an easy decision to evacuate her by helicopter. Shawn, of …
Continue reading “Day 10 #MM4MM: The day we were supposed to go to Everest Basecamp”
Day 9 of the EBC adventure: Trekking to Lobuche
I woke up at the usual6 AM, but this time to bad news. Kirk had a rough night. Splitting headache, nausea, fatigue, and no sleep from 12:30 to 6 AM. He had acute mountain sickness (AMS). He scored 5 on the Lake Louise AMS scoring system, not including the headache. The move here is immediate …
Continue reading “Day 9 of the EBC adventure: Trekking to Lobuche”
Day 8: The Trip to Dengboche
We started the morning in Tengboche. I slept through the night for the first time since coming to this side of the globe. Only took me a week to flip my biologic clock. We were sleeping at 12,000 feet, the altitude at the top of Breckinridge. Anytime I have been at the peak of Breck, …
Continue reading “Day 8: The Trip to Dengboche”
Day 7 of the #MM4MM EBC Adventure: We meet a real teahouse
After a rest day in Namche it is back to the dusty trail as we hike from Namche Bazar to Tengboche. Up to now our rooms on the trek have had amenities like electric outlets and in-room bathrooms, well we made it to Tengboche and the teahouse had neither of these. There are two wash …
Continue reading “Day 7 of the #MM4MM EBC Adventure: We meet a real teahouse”
Day 6 of the #MM4MM Journey to Everest Basecamp: Vacation Day
Namche Bazar for a day with no hiking. We were spending a rest day before going any higher to help with acclimatization. This is the only non-hiking day we have on the trek. This meant a luxurious 9:00 Am breakfast time. After breakfast Silva, Jeff, John, Paul, and Jim walked about 20 minutes to the …
Continue reading “Day 6 of the #MM4MM Journey to Everest Basecamp: Vacation Day”
Day 5 of the #MM4MM EBC adventure: Trekking
So the plan for the day was to wake up early and hike 3 hours to Phakding, meet the rest of the group, the 6 who slept there and the 7 who will be flying in by helicopter. Then hike 7 hours to Namche Bazar. A long day but one that puts us back on …
Continue reading “Day 5 of the #MM4MM EBC adventure: Trekking”
Day 4: The Hubris of Himalayan Mountain Itineraries, #MM4MM
Today was the day we were going to the mountain. The itinerary was clear: fly from Kathmandu to Lukla and then hike 3 miles downhill to Phakding. It didn’t work out quite that way. We woke up at 4:45 for a 5:00 AM breakfast followed by a group picture and a bus ride to the …
Continue reading “Day 4: The Hubris of Himalayan Mountain Itineraries, #MM4MM”
Day 3 of the #MM4MM Trek to Everest Basecamp, a day in Kathmandu
Today was the last day before we begin trekking. As usual I woke up early, though it is getting later and later as my biological time zone catches up to my geographic time zone. I had a decent breakfast with most of the team. After breakfast I needed to replace the toiletries that I left …
Continue reading “Day 3 of the #MM4MM Trek to Everest Basecamp, a day in Kathmandu”
Day 2 of #MM4MM, the trip to Kathmandu
All day I have been trying to think of a funny joke among the line of “What’s an interventional cardiologist’s favorite city? Kathmandu.” Yeah, yeah, yeah, I know. Keep the day job. I woke up at 1:00 AM Went back to bed until 3:00 AM Got up and started my day. Figured out to use …
Continue reading “Day 2 of #MM4MM, the trip to Kathmandu”
Day 1 on the #MM4MM: The flight of the endless sunset
So the trip to Everest Basecamp began yesterday. Cathy took Jeff, Silva and I to the airport Thursday morning. I dropped my altimeter (gift from Rose and John) going through security. π’ First casualty of the trip. We then met John Raithel at the gate and boarded our A350. About this time it started snowing. …
Continue reading “Day 1 on the #MM4MM: The flight of the endless sunset”
#MM4MMβ¦And so it begins
Cathy (who didn’t want to be in the picture) drive us to the airport. Next stop Seoul and then Kathmandu.
Everest. Myeloma. And the centrality of hope.
John Raithel and his doctor @Amyloid_Planet are part of my team trekking to Everest Base Camp #MM4MM @theMMRF https://t.co/zhKawBE0El — Joel M. Topf, MD FACP (@kidney_boy) February 24, 2018 John Raithel and Jeffrey Zonder are on the Moving Mountains for Multiple Myeloma team going to Everest Base Camp. John’s story is incredible. Check out …
Continue reading “Everest. Myeloma. And the centrality of hope.”
Day 12 of the #MM4MM Adventure: Escape from Himalayan Mountain
Someone was very concerned about snoring last night. Everytime either Ben or I started to snore we got a sudden, loud, and quite frankly, violent knock on the wall. At this time it seems prudent to remind my dear readers that everything man-made you see in the Himalayas has came up on the back of a man or beast. This includes all of the building materials for the tea houses. So the walls are thin. When this person pounded on the walls I legitimately feared his fist would go through the wall. At one point I got up to use the bathroom and Ben heard me moving around the room and thought the pounder had come to the room to rumble. The following day, no one fessed up to the violent knocking.
The snow storm had knocked out their solar power so their was no electric lights in the teahouse. It was strictly a headlamp affair.
Breakfast was gruel, toast, and hard boiled eggs. I had brought a foil pouch of tuna fish. I had not found an opportunity to eat it or share it before now and since this was our last day of hiking I had a tuna fish sandwich for breakfast.
The hike was a long one. We were starting at Duglha and were going to hike all the way to Namche Bazaar. Karma estimated we had 12 hours of hiking, Bishnu thought we could do it in 10. For the morning the ground was talus covered with snow. The hike was quick. We quickly hiked off the moraine and then cruised through the meadow we hiked through after leaving Dengboche. Pheriche where we picked up American Paul, who had stayed behind at Dingboche three days earlier. After we crossed the Dudh Cosi (again) the snow melted and we had a fast level walk into a tea break and then into lunch.
There was a lot of porter, yak and mule traffic on the trail. And if you looked at the loads they were all addressed to Everest Basecamp. During climbing season there will be 1,500 to 2,000 people living on the edge of that glacier and we were seeing there beginnings of the tent city slowly make its way up the mountain.
After lunch we climbed the ridge to Tengboche. This was a long continuous hike up but only a warm up to the main event. After cruising into Tengboche we had a 2,500 foot descent to the river. It was steep and long. Dropping half a mile, even when steep takes a long time. My knees were barking by the time we reached river level. At the river we came to the bakery that 4 days earlier had no donuts. Well, today they had donuts. They had the oldest, dustiest, stalest donuts. This did not stop me from eating one. And it was good.
After the world’s worst bakery we had one last climb of the trip. I think it was about 2,000 feet vertical. It started steep and then eased into a steady gradual climb for an hour or so.
I finished the hike with Ben, Jen, and Ellen. We finished with headlights. Eleven hours. A rolling hike with a total descent from 15,000 to 11,000 feet with two significant climbs. A fine end to a fine trek through the Himalayas.
Day 11 of the #MM4MM: The day we actually go to Everest Basecamp
Just like the day before we wake up early to get an early start on a big day but events conspired to push us our start time back. We met in the commons room of the tea house at 6:45, when we were promised breakfast. Cornflakes, porridge and hard boiled eggs weren’t served until 7:20. So we started at our usual hiking time at 8 AM.
Though the night had been brutally cold, the weather that morning was another cloudless blue skies. It was cold, but not bitter. I had somehow come to the idea that the hike to EBC was an easy stroll and we could bang it out in a couple of hours.
It was not easy.
It was up.
It was down.
It was rough terrain over boulders, loose talus and dusty scree.
And there was no atmosphere.
It really was just like the hardest section of the hike to Gorek Shep. But the altitude here was punishing. I thought that this hike was the most difficult segment of the entire trek, though, most of the people I talked with disagreed. We scrambled for close to three hours before we stood on the verge of Basecamp.
During the hike we got to see Everest peak over a ridge of mountains that normally obscures it. Like I said, perfect weather. As we hiked up the left side of the lateral moraine of the Kumbu glacier, it became apparent we were hiking into blind canyon. I knew that Everest climbs started by climbing through the Kumbu ice fall, but it was unclear where that went. Eventually it became apparent that the glacier took a turn to the right and there was a hidden gap in the wall that led up the mountain to camp one. Once that geography became clear my eyes knew where to look for Basecamp and could pick up the prayer flags.
That black pyramid like mountain in the background is Everest. 
Saad had trouble in the day before and this day also started pretty rocky. Initially he had really cold hands and I lent him my down gloves. This did not help and it became apparent that he had more than cold hands. He complained of dulled thinking and some confusion. He was having acute mountain sickness. He descended with Jim back to Gorek Shep.
The remainder of the group stumbled, bumbled, and fumbled toward the end zone. We stopped a few 100 yards short of basecamp to gather the group so we could all arrive together.
It was sublime.
I’m not entirely sure, but I think the wedding dress is from this wedding that happened last year.
AJKD represents at Everest Basecamp
Love your kidneys
CJASN and Everest Basecamp
Silva and Jeff had a touching moment where they dedicated the climb to the loved ones they lost and then drank some home-made Raki and poured some out. Before long, English Paul and Bishnu were calling for us to wrap it up and hike back to Gorek Shep.
The hike back? Just as hard.
When we got to Gorek Shep we quickly ate lunch and started hiking down to Duglha, the place we ate lunch two days ago (on the hike from Dengboche to Lobuche). As we walked out of the teahouse it was already snowing. We hiked through the snow and hightailed it off the mountain. We descended from 17,500 at Basecamp to around 15,000 at Duglha. Everyone was grateful to be out of the high altitude. The snow made for an epic Himalayan day.
We had veggie mo mos for dinner. Ben ate 13 mo mos. I wasn’t sure if I should impressed or repulsed.
