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Good luck Steve and thanks for your dent in the Universe

We’re here to make a dent in the universe. Otherwise, why even be here? We’re creating a completely new consciousness, like an artist or a poet. That’s how you have to think of this. We’re rewriting the history of human thought with what we’re doing. –Steve Jobs

I was sad to hear the news of Job’s resignation from Apple. My wife and I watched Pirates of Silicon Valley as a toast to the man who I view as a modern Leonardo De Vinci. A genius who revolutionized our world.

I said hi to Steve once. On the day the Fifth Avenue Store opened in New York I was walking around the plaza and saw Steve walking up to the store with another person. I was about ten feet away and I said, “Steve!”
He turned to me and I said, “You changed my life.”
He smiled, said thank-you and then kept walking.
I felt like such a dork. “you changed my life.” Ughh. I wish I had said something better.
It was 2006 and all I had with me was a Palm Treo

Later that night, my wife and I saw a show (I think it was Avenue Q) and then went to check out the scene at the Cube. We waited in line and went down into the store on opening night. It’s the only Apple event I’ve witnessed.

Still smiling after saying hi to Steve hours
earlier, and my extremely understanding wife
The resignation letter states that he will continue to have a role at Apple, and it’s likely we will see little different from Apple but as I wrote when he took his most recent leave of absence, “I want to live in a world where the man who launched the PC revolution is still leading it.” As of today, that’s no longer the case.

So long Steve, and thanks for your dent in the universe.

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Crazy idea or genius? Nephrology Merit Badges

I want to create a series of buttons to give to residents and students to mark achievements in nephrology.

My birthday is coming up, looking at the 1 inch beginner button system

One of the common resident complaints regarding nephrology is that it’s too hard. The nephrologist response to this complaint  is usually to deny the difficulty, because its not hard for the nephrologist. Perhaps that denial is counterproductive, first it’s hard to disrupt a widely held belief that is continually reinforced by the community of medicine, secondly when you deny the difficulty you insult the intelligence of the student struggling with new concepts. Its essentially saying, “Hard? differentiating among the pulmonary renal syndromes is easy, what are you stupid?”

Instead of denying the difficulty we should re-frame the meme. Yes, nephrology is hard and look how cool it is that you mastered these concepts.

Merit badges, or pieces of flare as my fellow interjected, would add levity and encourage residents to tackle deeper concepts.


Potential nephrology merit badges:
  • It’s the heart, no it’s the kidney, no it’s the heart, no it’s the kidney…: diagnose and successfully treat a case of cardiorenal syndrome
  • ABG guru: interpret ABGs showing all four primary acid-base disturbances
  • Quinton: insert a temporary dialysis access to provide emergency dialysis access
  • Tissue is the Issue: perform a renal biopsy
  • Look Closely: correctly interpret a urine microscopy specimen
  • K/DOQI Genius  : use the K/DOQI guidelines to craft a plan of care for a CKD patient
  • RIFLEry: use the rifle criteria to correctly stage a case of AKI
  • RTA (pronounced like Fonzie would RTAAAAAA!): use urinary anion gap and other clues to correctly diagnose and classify an RTA
  • Bud Rose: use free water clearance to draw meaningful conclusions about hypo- or hypernatremia
  • Put on your Helmut (Rennke): be a star in the pathology room
  • Gerry Appel: exceptional management of nephrotic syndrome
  • Ron Falk: diagnose and manage a patient with ANCA-associated vasculitis
  • The Town Schrier: Use FENa, FEUrea and BUN:Cr ratio in a meaningful way to diagnose a subtle case of pre-renal azotemia
  • Mark Halperin: Master of the Cortical Collecting Duct: use the TTKG equation intelligently to help in the management of a patient
  • Wisdom of Solomon: prevent a case of contrast nephropathy
  • Cry me a river: for expertise in the use of high dose diuretics
  • EPA Super Fund Site: use dialysis to correct uremia in AKI
Suggested merit badges from other creative nephrologists:
  • Way to Go KDIGO: use the KDIGO guidelines to do what ever you want to your dialysis patient 
  • Golden Pocket: Forgetting to tighten the cap on the urine that you are bringing back to the lab to spin
Thanks to Steve Rankin and Edgar Lerma
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Calling all nephrologists! If you care about anemia, you have until August 30th

The Centers for Medicare and Medicaid Services has proposed changes in the Quality Incentive Program (QIP) for 2013. The changes specifically involve anemia. The QIP was created to assure that even though the costs of providing dialysis care are born exclusively by the dialysis provider, there are specific quality goals that if not met result in financial penalties. The quality goals currently place are:

  • Percentage of Medicare patients with an average Hemoglobin < 10.0g/dL (Hemoglobin Less Than 10g/dL Measure)
  • Percentage of Medicare patients with an average Hemoglobin > 12.0g/dL (Hemoglobin Greater Than 12g/dL Measure)
  • Percentage of Medicare patients with an average Urea Reduction Ratio (URR) ≥ 65 percent (URR Hemodialysis Adequacy Measure).

Dialysis units that fail to hit the goals perscribed by the quality score receive a reduction in the Medicare payment by 0.5-2%. It should be apparent that the required hemoglobin targets ares problematic, especially given the recent action by the FDA (see my recent post Between a rock and a hard place). CMS is proposing the elimination of the floor on hemoglobin targets:

…Therefore, for the PY 2013 ESRD QIP, we propose to continue to use the following two measures previously adopted for the PY 2012 ESRD QIP:

  • Hemoglobin Greater Than 12g/dL Measure.
  • URR Hemodialysis Adequacy Measure.

This feels wrong to me. Creating an economic incentive that puts the cost of treating anemia on the provider but doesn’t provide any minimal goals may result in a race to the lowest hemoglobin. What’s to stop a rogue dialysis unit from removing ESAs from their formulary. We can all freely admit that ESAs have some previously under appreciated risks and that our enthusiasm for treating anemia was not entirely evidence-based, but our response to should not be to turn back the calendar to 1988.

After the release of Epo, the transfusion rate plummets. It falls by two thirds in a year and continues to fall so that the current rate of 0.3% per quarter represents a 98% reduction in transfusions. Revolutionary. And this doesn’t even begin to address the quality of life brought to dialysis patients by higher hemoglobins.

CMS states that they cannot add another unique quality indicator for 2013 and are looking toward 2014 to do this. In the absence of new quality guidelines they should keep the goal to maintain a hemoglobin over 10 g/dl but lower the target to 9 g/dL for 2013.

Patients deserve an incentive that keeps providers conscious of anemia. In study after study, low hemoglobins walk hand in hand with poor outcomes. The concern regarding anemia has been driven by attempts to normalize hemoglobin. It is clear that normalization is hazardous and without scientific support; however a failure of the experimental group does not mean we should abandon the therapy given to the control group. In every study the control group received ESA to maintain hemoglobins at least 9 g/dL.  Removing the hemoglobin floor from the quality measures would be giving a de facto license to withhold an important medication from dialysis patients.

The TREAT trial is the best study every done on outcomes in CKD with an ESA.
These dosing groups resulted in an effective separation in hgb with little profound anemia

I have copied this post to Regulations.gov as my comment on the latest guidelines.

The deadline for comments is August 30th.

A science liaison at Amgen told me that Amgen was advocating for a hemoglobin floor of 10 g/dl. The Renal Physician Association is also supporting a hemoglobin of 10 g/dL. [This paragraph was updated 8/22/11, after a complaint that I mis-interpreted Amgen’s position. My apologies.]

I have heard that CMS has received few comments from physicians. Embarrassing. Anemia is important and nephrologists should care how the governments crafts incentives that will change how our patients are treated. Go now and comment. Tell CMS what you think.

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Great article on the Nesiritide debacle

There has been some great articles regarding the expensive, waste of a decade induced by nesiritide.

I like this article the most because it’s written by someone who is not in medicine. It tackles many of the same issues I looked at in my post, The problems with numbers, namely when drugs are approved based on intermediate end-points bad things can happen.

The best thing we can say about niseritide is that when the definitive trial was finally done, the previous concerns about renal failure, were shown to be merely illusions created by the smoke and mirrors of meta-analysis.

Acute renal failure was an early concern regarding Nesiritide…

…but when the right placebo controlled trial was done, no renal failure.
So go and read Carolyn Thomas’ view of nesiritide and see how we have failed the people we are entrusted to care for.