musings of a salt whisperer
Sometimes I post just so I can find the information in the future. PBFluids is my personal nephrology EverNote.
Chemotherapy Nephrotoxicity Review by @kdjhaveri #Nephpearls pic.twitter.com/kyG1BYg6zs
— Edgar V. Lerma (@edgarvlermamd) July 26, 2013
For those who are unaware, Dr. Jhaveri is the author of the best in class NephronPower and editor in chief at eAJKD.
I wrote a short editorial on hyponatremia and it’s effect on mortality for eAJKD. I like the comparison of tolvaptan to Epo. Hopefully we will not have to wait two decades for a properly done RCT with patient oriented outcomes. We know the drug raises the sodium, now let’s see if it reduces fractures, falls and mortality.
Home blood pressure nomogram in my EMR. Tufte would be proud. pic.twitter.com/6bw47ihWXl
— Joel Topf (@kidney_boy) July 10, 2013
Edgar Lerma then asked for an app-based solution
@ChristosArgyrop @kidney_boy Can you recommend a Free APP that does useful Home BP Tracking/ Plotting? I realize not everyone can do it
— Edgar V. Lerma (@edgarvlermamd) July 12, 2013
I linked to an old post on PBFluids that highlighted iBP but in the last few weeks patients have shown me two new free options:
BP Companion on iOS and BPwatch on Android. I do not have a full review, but both seemed like well designed apps and the patients really liked them.
I re-worked my sodium and water handout to better track my IV fluid and diuretic lecture that I do for residents in July. The old hand-out focused on IV fluids and dysnatremia. The new one goes deeper into IV fluids including new data on the advantages of LR over NS, and the problem of iatrogenic fluid overload. I then stripped a bunch out on the principles of total body sodium and put an abridged section on hyponatremia with more contemporary view on vaptans and their role the treatment of hyponatremia. I removed the hypernatremia section.
The next step is to remove the dysnatremia section completely and make that a stand alone book.
Work in progress.
I am making a significant commitment to the The Electrolyte Handbook. I plan on making continuous tweaks, corrections, and additions. A quick list of ideas include:
The fact that this is going to be a living book leads to some problems. A website always shows the most up-to-date version, but since the PDF and e-book don’t auto-update I have a problem on how to get the most up-dated version in to the hands of users. I have not worried about this issue with my existing hand-outs because the content is entirely conceptual so mistakes did not have clinical implications.
This handbook, however is intended to guide therapy so I need a way to notify users of fixes. So I am going to build an e-mail list. I will only send e-mails when updated versions of the handbook come out. I have no plans to spam. This e-mail is designed to help you, by making sure you are using the most up to date version of the Electrolyte Handbook.
Change log:
This is a quick guide to correcting electrolytes designed for new interns. It works in Apple iBooks. PDF format and e-Pub format are forthcoming. I also plan adding: IV fluids, sodium, acid-base and acute renal failure to be a quick, on-call guide for interns.
Giants pitcher, Chad Gaudin, was arrested Jan. 27 and charged, July 3 with open and gross lewdness.
“Chad Gaudin was examined in the emergency room of a local hospital while experiencing symptoms believed to be related to acute renal failure due to a condition known as rhabdomyolysis. The symptoms included confusion, dehydration and loss of orientation and/or consciousness. Although he has been accused of improperly touching another hospital patient while on the premises that night, there are differing and exonerating versions of what occurred that have been reported by eye witnesses.”
Another month of consult service and another flight of merit badges:
The first is for the case of rhabdo described in this post.
The second was for a particularly vexing acid-base conundrum that left us all scratching our heads.
And the last was for a diagnosis of Goodpastures Syndrome we made by history and U/A. We found a RBC cast that along with the description of hemoptysis a month prior to admission directed us to the diagnosis. Unfortunately we were too late and unable to salvage any kidney function and the patient now is on dialysis looking for a transplant. When I asked what to do for the badge, my fellow suggested a frowny face.
The badges can be downloaded as a PDF or Pages document and print beautifully on Avery 5163
Shipping Labels
.@pbjpaulito Did you know about this? http://t.co/ttcnT21GCzcc @kidney_boy
— Meenakshi Budhraja (@gastromom) June 29, 2013
The link goes to this article at the Huffington Post Journal of Medicine and this article from 2012:
The story is about a mystery epidemic causing widespread chronic kidney disease and end-stage renal disease in the farmers of Central America. Here is a less sensational view of the epidemic. The best part of the article is the five paragraphs that quote three independent experts that all agree that the most likely etiology is repeated episodes of dehydration:
“I think that everything points away from pesticides,” said Dr. Catharina Wesseling, an occupational and environmental epidemiologist who also is regional director of the Program on Work, Health and Environment in Central America. “It is too multinational; it is too spread out.
“I would place my bet on repeated dehydration, acute attacks everyday. That is my bet, my guess, but nothing is proved.”
Dr. Richard J. Johnson*, a kidney specialist at the University of Colorado, Denver, is working with other researchers investigating the cause of the disease. They too suspect chronic dehydration. “This is a new concept, but there’s some evidence supporting it,” Johnson said. “There are other ways to damage the kidney. Heavy metals, chemicals, toxins have all been considered, but to date there have been no leading candidates to explain what’s going on in Nicaragua… As these possibilities get exhausted, recurrent dehydration is moving up on the list.”
This reasoned diatribe is followed by this:
…scientists have no doubt they are facing something deadly and previously unknown to medicine.
Did the authors even read their own article? Dehydration would hardly be something unknown to medicine. After that, the article really goes off the rails with statements like:
In nations with more developed health systems, the disease that impairs the kidney’s ability to cleanse the blood is diagnosed relatively early and treated with dialysis in medical clinics. In Central America, many of the victims treat themselves at home with a cheaper but less efficient form of dialysis, or go without any dialysis at all.
Newsflash: peritoneal dialysis (the cheaper dialysis that you do at home), is not less efficient than hemodialysis.
The article tips an article that was to be published soon:
Some 30 percent of coastal dwellers had elevated levels of creatinine, strongly suggesting environment rather than agrochemicals was to blame, Brooks, the epidemiologist, said. The study is expected to be published in a peer-reviewed journal in coming weeks.
That article is now available. Here is the primary figure of the article:
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| masl is meters above sea level |
It is an interesting story and I am going to keep my ear perked for more information.
Some facts about this CKD epidemic:
