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Hypercalcemia from 1,25 vitamin D toxicity

I received an outpatient consult for acute kidney injury. One of the things that makes Saint Clair Nephrology a remarkable nephrology group is our ability to get patients in quickly. While competing practices in the area have a 3-month wait list to see new patients we get patients in within a week. This patient was seen two days after his doctor called.

The patient was frightened. He had previously been healthy and his doctor told him his kidneys were failing and that he needed to see a nephrologist. He arrived with a creatinine in the high 2s from a base line of 1.2 mg/dL. Along with the AKI his blood pressure was touching 180 systolic, out of character for him. Of note on the initial labs his calcium was 13.6 mg/dL.

The initial work-up showed suppressed PTH. SPEP and UPEP were normal.

On the next visit I checked the 1,25 vitamin D and it was 117 IU. I suspected lymphoma or sarcoidosis but the chest x-ray was unremarkable and the patient did not have any palpable lymph nodes or abnormalities on the CBC. No weight loss, night sweats, or fevers. ACE levels were unremarkable.

On further questioning on his third visit, the patient mentioned he was taking a generic knock off of Mega Red Fish Oil. Fish oils can have significant amounts of vitamin D and the supplement is famously lax with quality control. He stopped the fish oil, we started him on oral prednisone and the 1,25 vitamin D level quickly responded within a couple of weeks. The patient had a full recovery from the hypercalcemia, hypertension, and acute kidney injury.

 

 

Update

Some great comments from Twitter

 

 

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#NephMadness Editorial in AJKD

Matt and I wrote an editorial on NephMadness. Last year was the fifth year of NephMadness and Matt and I felt it was time to pass the reigns to some new blood. Tim Yau came on board last year and got a lot of experience. Anna Burgner was added to the executive team this year. They are doing a cracking job.

As Matt and I move to lesser roles, Feldman, Dember, and Sterns invited us to review our experience with the first five years of NephMadness. It was very kind of them. The editorial is out now. Take a look.

My favorite part of this is that when you type NephMadness into PubMed, you will get two hits. (As of writing this, the new article is not indexed. Awkward.)

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Cardiorenal conference in New York: #NephCards2018

You probably know Kenar Jhaveri. He is the founder of NephronPower and the first editor of AJKDblog. He is a professor of Medicine at Hofstra Northwell School of Medicine on Long Island. Kenar is a good friend and one of the great nephrology educators.

He is sponsoring a cardiorenal symposium in March. I’d love to go but I’ll be most of the way to Everest Basecamp at that time. If you have some spare conference time, you should check out The Heart-Kidney Connection.

There will be mad tweeting so in mid-March tune your Twitter machine to #nephcards2018

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The Everest Itinerary

I am so excited to go to the Top of the World with MM4MM to help raise money and awareness for the multiple Myeloma Research Foundation. If you haven’t already, please take a look at my fundraising page.

The trip is being guided by Embark. They seem quite professional.

Here is the itinerary. From what I understand this is just provisional as all plans in the mountains must be.

 

Day 1. We meet in Kathmandu (4, 593 feet).

Day 2. We fly from Kathmandu to the world’s most dangerous airport in Lukla (9,383 feet).

Day 2. After landing in Lukla we hike to Phakding (8,563 feet).

Day 3. From Phakding we trek to Namche bazaar at 11,290 feet. Namche is in a bowl in the hill side, it is a commerce center. Will arrive in the afternoon and may need to climb up to our hotel.

Day 4. We have a rest day in Namche to help with acclimitization. We won’t go any higher to sleep but we will do day hikes. We should have the opportunity to go to Kumchong to see a Hillary School.

Day 5. The next day we will go to Tenboche (12,687 feet). This hike starts by going down and then up. We will be going to the Tanboche monastery, one of the largest in the area. Namche the crowd thins out and the villages are farther apart.

Day 6. The next day is at the Pheriche (14,340). We should get a view of Everest from here.

Day 7. Above Pheriche we encounter the glacier and go to Lobuche, 16,700 feet. We will be walking on the terminal moraine of the glacier.

Day 8. Biggest day is from Lobuche to Gorakshep. We will dump our gear and then climb up to the Everests Basecamp (17,598 feet). We will head back to Gorakshep to sleep (16,942 feet).

Day 9. The next morning we will get up early and head to the summit of Kalapathhar, the highest point of the trip (18,514 feet) and what should have a spectacular view of the glacier and Everest.

Day 10. We then go all the way to Pheriche (14,340 feet)  that night. Long day.

Day 11. The next day we go from from Pheriche to Namche where we will catch a helicopter to take us to Kathmandu.

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I want to do some physiology testing on my climb to Everest Basecamp

This March, I am going to climb to Mt Everest Basecamp (EBC), altitude 17,900 feet. Actually I will be going a bit higher to Kalapathhar at 18,500 feet but no one knows what Kalapathhar is, so EBC it is. This is an 8-day trek and I want to do some physiology testing along the way. I am going to bring a pulse oximeter, a sphygmomanometer and some urine dipsticks to do serial urinalysis. I have a pretty strict weight limit. So careful choices need to be made with regard to equipment choices.

In terms of physiology testing I have multiple subjects willing to be part of my science fair.

My questions to the readers of PBF, is what questions can I answer?

I believe that everyone is going to be on acetazolamide.

I am interested in water intake, cramps and exercise fatigue. I could probably get that data with a daily survey and then I could correlate it with pulse oximetry and urine specific gravity at the end of the day’s hike.

I am also interested in peak specific gravity as we go up the mountain. Does it fall with increasing hypoxia? But this may be hopelessly obscured by the acetazolamide.

I would like to do some cognitive testing as we go up the mountain.

What other questions should I try to answer. What other medical instruments should I take? Bioelectrical impedance?

Also remember to donate to multiple myeloma research and my trip to EBC.

 

 

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Resident lecture on NAGMA

One hour lecture on NAGMA. Just some small changes edits from the last time I gave it. It is one of the few lectures that is still in PowerPoint. It is due for a complete overhaul. It also needs a slide on the treatment of RTA that covers the amount of bicarbonate in a 650 mg tablet (8 mmol) and the fact that distal (type 1) RTA requires a limited amount of bicarbonate (at most 1 mmol/kg). This is appropriate for residents and medical students.

If you are interested in ward teaching and RTA, take a look at this post by Robert Centor.

Also this is a nice article on the issue of saline having a pH of 5.5, covering both the reason (its the PVC bag) and the implications (none).

NAGMA (PPT)

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My SGLT2 inhibitor grand-rounds lecture

This past autumn I was invited to give a lecture at the Michigan ACP. I love that meeting. I decided to talk about the mortality data on SGLT2 inhibitors and how we got that data and how curious that data is. Then, last week I had the opportunity to give the lecture again for grand rounds at St John Hospital and Medical Center. Here it is in 4 chapters:

Chapter 1: The History and top line CV outcomes

Chapter 2: What’s driving the improvement in outcomes?

Chapter 3: Renal outcomes

Chapter 4: Side effects and conclusions

Here is the Keynote presentation for your editing pleasure: Keynote (278 mb)

In response to chapter 2, Matt Sparks had this interesting tweet:

This brings up an important point. One of the most intriguing slides is the one below that looks at how long it takes for the Kaplan-Meier to separate.

With glycemic control and blood pressure interventions, their is notable lag, but with the SGLT2i drugs the lines diverge from the very first dose. We also see that pattern with ACEi in heart failure and aldosterone antagonists in heart failure. This may be a clue of where to look for the cause of the survival advantage.

RALES (3 months)

CONSENSUS (first dose)

I will be adding this slide to the next version of the talk.

 

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List of therapies that reduce cardiovascular mortality in diabetes

I’m giving grand rounds on Tuesday on SGLT2 inhibitors and I’m trying to come up with a list of therapies that lower CV death in diabetes.

Here is my list:

  • Blood pressure control
    • UKPDS
    • ADVANCE All-cause mortality was reduced with a near miss on CV mortality (P=0.041)
  • Empagliflozen
  • Canagliflozin
    • CANVAS Only partial credit here. CV death was part of the composite outcome, but CVD was not significant on its own
  • Semaglutide
    • SUSTAIN-6 Weak. Hit the primary outcome but CV death was explicitly identical between groups
  • Liraglutide

Drugs that have run the FDA CV disease gauntlet and that are non-inferior to standard of care:

  • Exanatide
  • Rosiglitazone
  • Pioglitazone
  • Alogliptin
    • EXAMINE (This is a secondary prevention trial. As far as I can tell it is the only FDA mandated outcome trial that is specifically designed as a secondary prevention. Not sure why.)
  • Saxagliptin
  • Degludec

 

I’m sure I’m missing some. There must be a statin trial of diabetics. Right?

 

Swapnil was first with the statin answer:

And Edgar came up with a great visual from a review paper:

And Szymon came up with the Steno trial. I can’t believe I forgot about that one.