Journal Club: Albuminuria

Today’s journal club was on Aliskiren (Tekturna)combined with Losartan versus Losartan alone from the NEJM and Benazepril + Amlodipine (Lotrel) versus ACEi + HCTZ (Lotensin HCT) from KI. Both studies use change in albuminuria for the primary endpoint.

The Aliskiren study had an expected outcome. The shocker would have been if it had gone the other way. The surprising thing was how close they came to showing an actual decrease in progression (p=0.07) in only 6 months and with only 600 patients. Looks like aliskiren + ARB is a lock to slow the progression to doubling of creatinine and prevention of dialysis.

The Guard study was a surprise because the old generic lowered albuminuria more than the new hotness Lotrel. A lot of spin in the discussion on why that may have occurred.

Teaching on Two Ell: Acute Renal Failure and GFR

Yesterday we discussed the problem with the curvilinear relationship between gfr and creatinine and how the MDRD equation dispenses with this problem. Today we will go over a handout introducing GFR, MDRD and how to manage them, including referral to a nephrologist.

Additionally I want to do my canned acute renal failure lecture. This lecture has been made obsolete by the recent ATN data and data from Vanderbilt so it will need to be revised.

ARF No ATN Data

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Hyponatremia and Marathons

I love it when some of the arcane nephrology knowledge makes headlines. When I heard NPR covering hyponatremia I almost cried. I am training for a half marathon in October and so I have been thinking about this topic.

Almond, Et al’s study published in the NEJM looked at 488 blood samples from 766 runners recruited from the 2002 Boston Marathon. They found post-race:

  • Average sodium 140±5 mmol/L
  • 13% had a sodium <>
    • 22% of woman
    • 8% of men
  • 3 runners had Na <>

When they looked at predictors of hyponatremia, univariate predictors included:

  • Female gender (p<0.001)
  • Lower BMI
  • Fewer prior marathons (p=0.008)
  • Slower training pace (p<0.001)
  • Longer race duration (p<0.001)
  • Hydration frequency (p<0.001)
  • Hydration volume (p=0.01)
  • Urination during the race (with more frequent voiding having a higher risk of hyponatremia) (p=0.047)
  • Weight gain during the race (p<0.001)

Of note use of sport drinks compared to pure water made no difference. In the multivariate analysis, hyponatremia was associated with:

  • weight gain
  • longer racing time
  • body-mass index of less than 20

Of note the female gender falls out in the multivariate analysis as it likely was accounted for both by the longer running time and lower BMI.

In the discussion the authors mention that most sport drinks have only 18 mmol/L of Na.

Teaching on 2 Ell, the second week

On Monday one of our interns gave a lecture on the range of renal pathology possible found with lupus nephritis.

Lupus Nephritis

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This was a follow up on her lecture on the renal manifestations of lupus nephritis by WHO criteria. After her lecture we went down to bowels of the hospital to look at the kidney biopsy we had done on Friday on one of our patients with lupus.

On Thursday we began interpretation of Acid-Base disorders.
Also on Thursday I lectured the house staff on Nephrogenic Fibrosing Dermopathy, Acute Phosphate Nephropathy and Contrast Nephropathy. Renal adventures in imaging.

On Friday the 13th we completed Acid-Base disorders. As part of acid-base we talked about the anion gap. This article in CJASN on the anion gap was wonderful.

Rhabdomyolysis

Just got my second rhabdomyolysis patient in the last 2 months. Both had anuric acute renal failure and both had CPKs over 100,000.

In fellowship, the dogma was that sodium bicarbonate was ineffective and could do harm. The reasoning was that alkalinizing urine made calcium-phosphate less soluble, increasing the likelihood of calcification in the tubule extending the renal damage.

Recently, I found a paper from the Journal of Trauma 2004 by Brown and Rhee (Alternative) which showed compelling trends for improved outcomes with mannitol and bicarbonate. What was so impressive to me was that as the disease got more severe (higher CPK) the experimental group appeared to do relatively better. The authors were prevented from reaching a significant p value primarily by having too few patients with severe rhabdo.

I will use the handout from a prior morning report on the subject for the teaching session on Monday.

Rhabdo for Morning Report

Two Ell

This month I’m attending on the renal ward at Saint John Hospital and Medical Center. I have a huge team: one fellow, one second year resident, three interns (2 categorical and one ER resident) and two medical students. I have been having a blast teaching them.

I am going to track all of the teaching I do this month here.

So far this is the formal (as opposed to bedside) teaching we have done:

Monday June 2: Introduction to Two-Ell
Tuesday June 3: Nephrotic Syndrome
Wednesday June 4: Dialysis basics and Anti-hypertensive agents saves lives
Thursday June 5: Renal Adventures in Imaging (the nephrologic implications of Gadolinium and NFD, phosphate nephropathy as a complication of colonoscopy prep, and contrast nephropathy)

Adventures in Renal Imaging

More to come.

I’m gonna write a book.

Actually I’m going to rewrite an old book. The Fluid, Electrolyte and Acid-Base Companion was published in 2000 but went to the printer in 1999. This book on the physiology underlying common clinical electrolyte problems was written by two residents, one in internal medicine, one in Med-Peds.

Since 1999 I have:

  • Done a year of pediatric critical care as part of Riley Children’s Hospital’s Newborn transport team
  • Completed a 2 year fellowship in Nephrology at the U of Chicago
  • Written a textbook chapter in Intensive Care in Nephrology on calcium, phosphorous and magnesium
  • Written a chapter in Principles of Critical Care, Third Edition on electrolyte issues in critical care
  • Written a review article on magnesium
  • Worked as part of the faculty for St John Hospital’s Nephrology Fellowship Program since 2003
  • So in the last nine years my knowledge and teaching sophistication on electrolytes has exploded. All this time I have been thinking about rewriting this book:

  • Fixing it
  • Adding an evidence based medicine perspective
  • Removing some of the esoteric chapters which add to the length without helping the student
  • Add resources to make it a better resource for teaching on rounds
  • Make it relevant in web based world (Think optimized for iPhone)
  • Complete revamp of Sodium with electrolyte free water
  • Finish the job we started by adding calcium, magnesium and phosphorous
  • So I’m going to write a book.
    So it begins.

    Lecture Schedule

    March 21 Providence MS3: Acid-Base

    February 28 Providence MS3: Sodium

    January 24 Providence MS3: Body Water
    January 3 St John Hospital Residency: Potassium

    2014

    December 12 St John Nephrology Fellowship: ASN Kidney Week: reviewed.
    December 11 Mclaren Macomb: potassium and alkalosis
    December 6 St John Hospital Residency: AKI
    December 5 St John Nephrology Fellowship: NephSAP

    November 26 Providence Hospital Internal Medicine: Potassium
    November 22 Providence MS3: Acid-Base
    November 13 Mclaren Macomb: Potassium
    November 8 ASN Kidney Week, NephMadness
    November 7 ASN Kidney Week, Introduce KDIGO Mobile App

    October 24th St. John Hospital MS3: Acute renal failure
    October 22nd: Providence Hospital Internal Medicine residency: Acute Kidney Injury
    October 17th St John Nephrology Fellowship: Fellow level hyponatremia part 2
    October 10th St John Nephrology Fellowship: Fellow level hyponatremia part 1
    October 9th Mclaren Macomb: Acute Kidney Injury
    October 3 St John Nephrology Fellowship: NephSAP Fluids and Electrolytes

    September 27 ACP of Michigan: Uric Acic, Hypertension and Gout
    September 17 Beaumont Hospital and Medical Center: Acid Base
    September 11 Mclaren Macomb: Fluids and Electrolytes
    September 12 Providence Hospital MS3: Acid-Base
    September 6 St John Hospital Residency: Sodium

    August 29 St John Nephrology Fellowship: Anemia
    August 27 Oakland University Beaumont School of Medicine 2nd years: Potassium, alkalosis and secondary hypertension
    August 27 Providence Hospital Internal Medicine residency: Acid-Base
    August 19: Oakland University Beaumont School of Medicine 2nd years. Acid Base
    August 15 Oakland University Beaumont School of Medicine 2nd years. Na and water TBL
    August 3 Providence Hospital MS3: Sodium
    August 2 St John Hospital Residency Acid Base

    July St John Hospital Residency
    July Providence Hospital

    June 14 Providence Hospital MS3: Potassium
    June 11 St. John Hospital MS3: Acid-Base

    May 16 St. John Hospital MS3: Fluids and Electrolytes
    May 13 William M. Davidson Medical Education Week: NephMadness recap
    May 10 Providence Hospital MS3: IVF and sodium
    May 8 Mclaren Macomb: NAGMA
    May 3 St John Hospital internal medicine residents: Board review
    May 2 Providence Hospital Grand Rounds: Social Media in Health Care

    April 23 St John Hospital ID Fellowship: HIV and the Kidney
    April 12 Providence Hospital MS3: Acid-Base
    April 10 Mclaren Macomb: Acid-Base part 2
    April 9 St John Hospital MS3: Acute Renal Failure
    April 5 St John Hospital internal medicine residents: Metabolic alkalosis

    March 22 Gift of Life Minority Organ and Tissue Transplant Education Program: Social Media in Transplant
    March 15 Providence Hospital MS3: Potassium
    March 14 St John Hospital internal medicine residents: How to give a Lecture Lecture
    March 21 St. John Hospital MS3: Acid-Base
    March 13 Mclaren Macomb: Acid-Base
    March 1 St John Hospital internal medicine residents

    February 15 18 Providence Hospital MS3: Fluids and Electrolytes
    February 14 St. John Hospital MS3: Fluids and Electrolytes
    February 13 Mclaren Macomb: Hyponatremia

    January 18 Providence Hospital MS3: Acid-Base
    January 17 St John Hospital MS3: Acute Renal Failure
    January 9 Mclaren Macomb: IV Fluids
    January 3 St John Hospital Nephrology Fellowship: NephSAP divalent ions part 2

    2013

    December 13 St John Hospital Nephrology Fellowship: NephSAP divalent ions part 1

    December 11 St. John Hospital  MS3: Acid-Base
    December 7 Providence Hospital MS3: Sodium and Water
    December 6 St John Hospital Nephrology Fellowship: Renal Week Recap

    November 27 St John Hospital and Medical Center Grand Rounds: Medicine and Social Media
    November 13 St. John Hospital  MS3: Fluids and Electrolytes
    November 9 Providence Hospital MS3: Potassium
    November 9 St John Hospital internal medicine residents: Diabetic Nephropathy, A New Hope

    October 24-28 Michigan State Medical Society: Diabetic Nephropathy, A New Hope
    October 24 Providence Hospital MS3: Acid-Base
    October 26 Providence Hospital MS3: Sodium and Water
    October 9 St John Hospital MS3: Acute Renal Failure

    September 11 St. John Hospital third year medical Students: Fluids and Electrolytes
    September 7 St John Hospital internal medicine residents: Non-Anion Gap Metabolic Acidosis

    August 31 Oakland University Beaumont School of Medicine 2nd years. PBL: Glomerular Disease
    August 24 Oakland University Beaumont School of Medicine 2nd years. PBL: Acute and Chronic Kidney Disease
    August 21 Oakland University Beaumont School of Medicine 2nd years, Acid-Base
    August 20 Oakland University Beaumont School of Medicine 2nd years, Potassium Balance Disorders
    August 17 Oakland University Beaumont School of Medicine 2nd years. PBL: Sodium and water

    August 16 Providence Hospital 3rd year medical students: Potassium
    August 3 St John Hospital internal medicine residents: Acute Kidney Injury
    August 2 St John Hospital Nephrology Fellowship: Anemia and lack of placebo controlled trials
    August 1 Providence Hospital internal medicine residents: Acute Kidney Injury

    July 25 St Mary Hospital Grand Rounds: Acute Renal Failure, an update
    July 24 St John Hospital internal medicine residents: Acid-Base
    July 19 Providence Hospital 3rd year medical students: Sodium
    July 17 Providence Hospital internal medicine residents: Water, IV Fluids, Sodium, Diuretics

    July 13 Providence Hospital 3rd year medical students: Acid-Base

    July 10 St John Hospital third year medical Students: Acute Renal Failure
    July 3 St John Hospital internal medicine residents: Water, IV Fluids, Sodium, Diuretics

    June 12 St John Hospital third year medical Students: Acute Renal Failure
    June 8 Providence Hospital 3rd year medical students: Potassium

    May 24 Providence Hospital 3rd year medical students: Sodium
    May 15 St. John Hospital third year medical Students: Fluids and Electrolytes
    May 4 St John Hospital internal medicine residents: Renal Anemia

    April 19 Providence Hospital 3rd year medical students: Acid-Base
    April 18 Providence Hospital Resident Reasearch Day: Judge
    April 10 St John Hospital third year medical Students: Acute Renal Failure
    April 6 St John Hospital internal medicine residents: HIV associated nephropathy

    March 20 St. John Hospital third year medical Students: Fluids and Electrolytes
    March 13 St. John Hospital third year medical Students: Acid-Base
    March 2 St John Hospital internal medicine residents: board review

    February 24 UIC/Advocate Christ Medical Center Residents: Non-Anion Gap Metabolic Acidosis
    February 10 Providence Hospital 3rd year medical students: Potassium
    February 9 Providence Hospital 3rd year medical students: Sodium and Water
    February 3 St John Hospital internal medicine residents: Tolvaptan is effective in which patient and metabolic alkalosis
    February 2 St John Hospital Nephrology Fellowship: Board Review NephSAP CKD and Progression part 2

    January 19 St John Hospital Nephrology Fellowship Initiation of Dialysis
    January 17 St John Hospital third year medical Students: Acute Renal Failure
    January 12 Providence Hospital 3rd year medical students: Acid-Base
    January 5 St John Hospital Nephrology Fellowship: Board Review NephSAP CKD and Progression part 1

    2012

    December 13 St. John Hospital third year medical Students: Acid-Base
    December 8 St. Mary’s Hospital in Saginaw: Fructose, CKD and Hypertension
    December 2 St John Hospital internal medicine residents: Severe lactic acidosis and electrolyte disorders of the drunk.

    November 29 Providence Hospital 3rd year medical students: Potassium
    November 17 Providence Hospital 3rd year medical students: Acid-Base
    November 15 St John Hospital third year medical Students: Fluid and Electrolytes
    November 15 St John Hospital and Medical Center Grand Rounds: Diabetic Nephropathy, an Update
    November 11 U of C Alumni Reception. Marriott. 6:45pm
    November 11 Blogger get together McGillins Olde Ale House. 8pm
    November 11 AJKD Editorial Board Meeting Franklin 4 Room Marriott. 12:45-1:45
    November 4 St John Hospital internal medicine residents: Non-anion gap

    October 28 Providence Hospital 3rd year medical students: Sodium and Water

    October 27 Providence Hospital Grand Rounds: Anemia and lack of placebo controlled trials

    October 26 Michigan State Medical Society: Fructose, CKD and Hypertension
    October 25 Providence Hospital Residency Program: What’s New in Potassium
    October 22 Lupus Alliance of America: Panel discussion
    October 20 Providence Hospital 3rd year medical students: Acid-Base

    October 12 St. Mary Mercy Hospital: Fructose, CKD and Hypertension

    October 11 St John Hospital third year medical Students: Acute Renal Failure
    October 6 St John Hospital Nephrology Fellowship: Dialysis Kinetics

    September 30 Providence Hospital 3rd year medical students: Acid-Base
    September 22 St John Hospital Nephrology Fellowship: Physiology of Sodium and Water Handling
    September 20 Royal Oak Beaumont Internal medicine residency: Acid-Base Disorders
    September 13 St John Hospital third year medical Students: Acute Renal Failure
    September 2 St John Hospital internal medicine residents: Potassium

    August 30th Providence Hospital Residency Program: Potassium
    August 26th Providence Hospital 3rd year medical students: Acid-Base

    August 9th St John Hospital third year medical Students: Fluid and Electrolytes
    August 5 St John Hospital internal medicine residents: Acid Base

    July 26th St John Hospital third year medical Students: Acid-Base
    July 22nd Providence Hospital 3rd year medical students: Fluids and Electrolytes
    July 22nd St John Hospital internal medicine residents: Acute renal failure
    July 21st Beaumont Family Practice Residency: Acute renal failure
    July 21st St John Hospital Nephrology Fellowship: Anemia and lack of placebo controlled trials
    July 19th Providence Hospital Residency Program: Body water, IV fluids and diuretics
    July 1st St John Hospital internal medicine residents: Body water, IV fluids, diuretics and dysnatremia

    June 14th St John Hospital third year medical Students: Acid-Base
    June 9th: Abbott pharmaceuticals secondary Hyperparathyroidism: FGF-23
    June 8th: St John Hospital and Medical Center: Update in CKD: Anemia
    June 3rd: St John Hospital internal medicine residents: a case of Milk-Alkali syndrome and Fructose, Hypertension and Uric Acid
    June 2nd: St John Hospital Nephrology Fellowship Program: NephSAP Fluids and Electrolytes
    June 1st: Grand Rounds Beaumont Hospital: Fructose, Hypertension and Uric Acid

    May 26th St John Hospital Nephrology Fellowship Program: Hyponatremia
    May 17th St John Hospital third year medical Students: IVF and Hyponatremia
    May 6th St John Hospital internal medicine residents: Nephrology board review
    May 2nd: Michigan CRN meeting: Fructose, Hypertension and Uric Acid

    April 29th: Providence Hospital third year medical students: Sodium in the morning, potassium at 11
    April 20th: Providence Hospital third year medical students: Acid-Base
    April 18th: St John Hospital cardiology fellows: Cardiorenal Syndrome
    April 14th: Beaumont Gross Point family practice residents: IVF and Sodium Part 1
    April 12th: St John Hospital third year medical Students: Acute Renal Failure
    April 8th: St John Hospital internal medicine residents: How to give a lecture: Keynote Tutorial

    March 29th: Providence Hospital internal medicine residents: hypernatremia and hypercalcemia
    March 17th: St John Hospital third year medical Students: Acid-Base
    March 4th: St John Hospital internal medicine residents: Cardiorenal Syndrome

    Feburary 18th: Providence Hospital third year medical students: Potassium
    Feburary 16th: Providence Hospital third year medical students: IVF and Na

    Feburary 11th: Providence Hospital third year medical students: Acid Base
    Feburary 8th: Providence Hospital internal medicine residents: Hyponatremia, hypokalemia

    January 18th: St John Hospital Grand Rounds: Dialysis for the internist, an update

    2011