Author: Joel Topf

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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.

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Another interesting case, another animated explainer

I recently wrote a chapter on DKA and really fell in love with the topic all over again. It reminded me of an interesting patient with a unique variant of DKA. First off, it was the patient’s initial presentation of diabetes. A rare, but not unheard of, presentation of DKA in adults.

But what was really remarkable was that the patient presented with a blood sugar of over 1500 mg/dL (>83.3 mmol/L). The lab kept refusing to result out the BMP due to the crazy sodium and the poor ER docs were going crazy. They suspected the diagnosis but they were holding back on the insulin drip until they could see the BMP. I wonder if the clinical scenario had not been so dire, would the lab have actually resulted out a specific glucose? How many dilutions does it take to calculate a blood glucose when you are operating at over 1500 mg/dL?

The sodium on arrival was 145 with the high glucose that converts to 167 using Katz’s conversion. But god knows if that equation even works way up there with a serum osmolality of 452!

Using a serum glucose of 1500 mg/dl gives an osmolar gap of 54, that sounds awfully big. A glucose of 2000 gives a more reasonable osmolar gap of 26.

Watch the video and you will see that the sodium creeps up bit by bit during the resuscitation. This is largely due to ongoing fluid losses (osmotic diuresis) and unmasking the hypernatremia with the correction of the hyperglycemia. We calculated a free water deficit when the sodium hit 170 and it was over 7 liters.

Here is the tweet

The video

The keynote slides: Hyperglycemia DKA Hypernatremia

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How I made that short video about interpreting ABGs

Here are the tweets (I’m using WordPress’ ability to post a tweetstream, pretty cool)

We need to know if it is alkalosis or acidosis, so we ordered an ABG.

Thought I’d try my hand at a @HannahRAbrams style explanatory animation for the above ABG. Need to get it down under 2:20 to fit in a tweet.

And the last bit

Originally tweeted by Joel M. Topf, MD FACP (@kidney_boy) on October 7, 2020.

I made the video with Keynote, it is a single slide with a lot of animation. Here is the slide (all 750 kilobytes):

Creating the animation just takes patience. This slide has 44 steps to the animation. It is a mixture of build ins, actions, and build outs.

Once I had the animation perfect I used “Record Slideshow…” to record the animations and my narration, then exported the movie using “Export To Movie…”

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Ascension St John Nephrology Fellowship closing argument

If you are a resident looking for a nephrology fellowship take a moment to consider St John. We are a small nephrology fellowship that values hand-crafted nephrology education. Ascension St John hospital is a 714 bed hospital that is literally on the border of Detroit and Grosse Pointe. Yes, that Grosse Pointe.

This provides us a steady stream of patients with diverse backgrounds. St John operates a busy ER with a healthy mix of trauma. We get people from the upper socioeconomic classes and their unique presentations and diseases. Importantly, especially for a community program, St John is big enough to offer all the services:

  • ECMO
  • CRRT
  • Plasma exchange
  • Red and white cell pheresis
  • Acute PD
  • Kidney transplant

We still do our own biopsies. We have our own interventional nephrology suite, where we place tunneled venous catheter, provide fistulagrams, and do access angioplasty for our hemodialysis patients.

But the most important part of our fellowship is that we are not a rough and tough, traditional, malignant program. We take a gentler, kinder approach to medical education. Over the last few years we have decoupled our reliance on fellows to do the work of nephrology. It wasn’t trivial and it required buy in from the entire staff but we realize that treating fellows as worker mules was not good for their education. This uncoupling means fellows will be busy, experience requires being busy, but we don’t let our fellows get overwhelmed by the work. Our program takes fellows by the hand and guide them through a bespoke education track to provide them with a top notch nephrology education. Regardless of how unsteady or unsure you are about your kidney knowledge, we will turn you into a first rate nephrologist. That’s our promise.

So if you have finished your interviews but still haven’t found the program that feels like home, check us out.

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DDAVP Clamp

Bibliography:

Perianayagam, A. et al. (2008) ‘DDAVP is effective in preventing and reversing inadvertent overcorrection of hyponatremia’, Clinical journal of the American Society of Nephrology: CJASN, 3(2), pp. 331–336. https://cjasn.asnjournals.org/content/3/2/331

Gharaibeh, K. A. et al. (2015) ‘Risk factors, complication and measures to prevent or reverse catastrophic sodium overcorrection in chronic hyponatremia’, The American journal of the medical sciences, 349(2), pp. 170–175.

The initial infusion rate (mL/hr) of 3% saline can also be simply calculated as a product of patients’ weight (kg) and desired correction rate (mEq/L/hr)

Sood, L. et al. (2013) ‘Hypertonic saline and desmopressin: a simple strategy for safe correction of severe hyponatremia’, American journal of kidney diseases: the official journal of the National Kidney Foundation, 61(4), pp. 571–578. https://www.ajkd.org/article/S0272-6386(12)01471-0/fulltext

Rafat, C. et al. (2014) ‘Use of desmopressin acetate in severe hyponatremia in the intensive care unit’, Clinical journal of the American Society of Nephrology: CJASN, 9(2), pp. 229–237. https://cjasn.asnjournals.org/content/9/2/229

Adrogué, H. J. and Madias, N. E. (2000) ‘Hyponatremia’, The New England journal of medicine, 342(21), pp. 1581–1589. https://www.nejm.org/doi/pdf/10.1056/NEJM200005253422107

Mohmand, H. K. et al. (2007) ‘Hypertonic saline for hyponatremia: risk of inadvertent overcorrection’, Clinical journal of the American Society of Nephrology: CJASN, 2(6), pp. 1110–1117. https://cjasn.asnjournals.org/content/2/6/1110

Morris, J. H. et al. (2018) ‘Rapidity of Correction of Hyponatremia Due to Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Tolvaptan’, American journal of kidney diseases: the official journal of the National Kidney Foundation, 71(6), pp. 772–782. https://www.ajkd.org/article/S0272-6386(18)30004-0/fulltext

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Covid Diaries 5: “Hello, my name is Joel Topf and I’m going to be your doctor here…”

One of the most distressing things I am seeing is conspiracy-minded conservatives in the US doubting the mortality numbers from the COVID pandemic. I really get upset as these people try to gas light the nation and convince people that COVID wasn’t that bad. And that people are just inflating the numbers for political gain.

I round at a number of dialysis units. At one unit, I cover the first shift. First shifts are popular. Lots of people want to do their dialysis first thing in the morning and have the rest of their day to themselves. I have 20 odd patients on that shift and every couple of months I’ll get a new patient when a chair opens up. This happens when a patient moves, transfers to another unit, gets transplanted, or unfortunately, passes away. Openings on the first shift are rare and they don’t stay open for long.

I distinctly remember going to round at this unit in late May and almost immediately seeing a new face. So I started my routine, new dialysis patient, spiel, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And then a few chairs down, I saw another new face, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And then a bit later, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And once again, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

I met as many new patients on that one day as I typically get on that shift in a whole year. Each of those new faces represented a patient lost to COVID.

We are not lying about the disease.

We are not exaggerating the dead for political gain.

We are counting them and we can barely keep up.

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COVID Diaries 4: when we got sick

I lost momentum on the COVID diaries, but today as some people are gas lighting the severity of the COVID-19 pandemic I want to finally publish a couple of posts that I started but never published.

As COVID-19 was raging through Italy one of the storylines that made it back to our shores was the number of docs that were getting sick. The number of doctors who were dying. A scary thought entered my head, in the form of a Twitter poll (it is strange how many of my thoughts are arraigned as tweets)

How many doctors at your hospital will die before you start thinking about heading for the hills?

A. Zero. I’m thinking about bugging out now

B. 4

C. 18

D. Infinity. I ain’t no coward.

I asked the question in a group chat but never on open twitter as it felt too inflammatory. My feeling was that it was less the number and more who got sick. The closer you were to the poor doc on the vent in the ICU the more terrifying it would be. Thankfully Ascension St John didn’t lose any doctors, nurses, or employees. But we did have people get sick. A lot of them.

Early in the epidemic we had an outbreak in the cardiology department. At least 8 of the cardiologists got sick and two of them were hospitalized. I don’t know how the ‘Rona spread through their department, but that gave a sense of how fast the disease could spread without precautions.

The housestaff (residents and interns) were also hit hard. Fully twenty-five percent of the internal medicine residents missed work because of COVID-19.

One in four

Thankfully none of them had to be hospitalized.

Probably another dozen doctors in the department of medicine got sick. A number of them were hospitalized, but no one died. Not because we were good, but because we were lucky.

My father is an oral surgeon and the program director of the oral surgery residency at St John and Beaumont Hospitals. His chief resident got COVID-19 and perished. I was on-call in a hospital full of Covid-19 patients when my dad called to tell me. It was startling and focused the mind. After that I found my self calling old friends just to say “hi.” Kind of getting my personal affairs in order, you know, just in case.

Looking back at the docs that got infected, it is noteworthy that the vast majority of infections were early in the epidemic. They were all in late March and early April. The time when we didn’t know what we were doing. I remember seeing videos on how to take off and safely store your mask between COVID patients.

Those halcion days when we thought we could label patients as COVID and NOT COVID. As soon as that lunacy went away and we just started wearing our mask all the time the infections among the staff melted away. It was a stark before and after experiment, but to my eyes masks worked.