Posts

Posted on

New tweet, Old presentation

We tweet and think the tweet evaporates after a day or two (actually, that’s particularly optimistic, most disappear after an hour or two) but occasionally a reply can come from the distant past like a message from a deep space probe.

Today, someone replied to a tweet I wrote in May of 2019.

I’m not sure if The Drug Policy Organization ever posted the webinar, but I now realize that I never posted the slides to my website. So here they are:

Keynote | PDF | Powerpoint

I also made a movie of the demo part of the presentation. I tried to show the logic and process of building a visual abstract.

And here is a screencast of the entire presentation:

Thanks for the nudge Salina!

Posted on

Contrast Associated or Contrast Induced Nephropathy? Who the hell knows. St John Ascension Grand Rounds

Everyone talks about the importance of mentors in career development, but there is another type of Fairy God Mother that doesn’t get as much press but can be just as important, this is the Sponsor. A sponsor doesn’t give advice and guide you like a mentor does, but when opportunities come up they think of you and put your name forward.

The most important sponsor in my career has been Chief of Medicine at Ascension St John, Lou Saravolatz. As a fellow, Dr. Saravolatz discovered a bug now known as Methicillin Resistant Staph Aureus (remind me, what world changing research are you doing in your fellowship?). But as Chief of Medicine he has been my (and a host of other docs) sponsor. Dr Saravolatz invited me to give my first grand rounds presentation in 2003. A talk on contrast nephropathy.

Today, I gave another talk on contrast nephropathy. Here are the files. I will try to get a video with my narration up in the next few days.

Keynote

Powerpoint (I just export the Keynote presentation to Powerpoint so I suspect many of the animations are crap. It is here just to preempt the chorus of Twitter requests for it)

PDF

Here is a video of this presentation Rutgers Robert Wood Johnson Department of Medicine grand rounds.

I also am posting the talk bit-by-bit as #Tweetorials.

The first:

The second

The third

The fourth

Posted on

We need to do it differently

Michael Heung of the University of Michigan tweeted this yesterday

Here is the image again in case Twitter breaks.

This is not an uncommon finding at medical schools around the country. I have been to lectures by Dr. Heung at Kidney Week and he is a gifted teacher. There is nothing wrong with him. The knee-jerk response is to do what Oakland University William Beaumont School of Medicine did and make lectures mandatory. I get a full auditorium for every one of my lectures. It strokes my (already formidible) ego, but I don’t think it is the right response.

The empty lecture hall is because medical students are finding ways to learn that are better for them than sitting in a class room six hours a day. It’s more efficient to stream the lecture at 2x-speed with tabs open to other resources. If this is how they learn best, schools shouldn’t enforce inefficiency by making them attend lectures. Medical school deans should recognize how the material is going to be consumed and then develop curriculum around that consumption.

Every medical student, after paying tens of thousands of dollars for tuition, spends additional thousands of dollars on materials, tutorials, and videos to get ready for the big bad board exam at the end. What is the core competency of medical schools if it is not getting students ready to excel at licensing exams? Every one of those subscriptions is an indictment of the product that medical schools are providing their students.

Here is a list of vendors from the 2018 American Medical Student Association Convention. Check marks indicate vendors that provide services that medical students should be getting from their (wildly expensive) schools.

If we were to start from the position that students are going to consume every lecture on their own time on their own laptop, would we record the same slide show with the same talking head every year? No, that’s an absurd waste of the professor’s time to produce content that is not compelling or a good use of the medium. This is like the first movies, where directors would just film stage productions, ignoring the nature of the novel medium. Instead of seeing the empty lecture halls as a problem it should be viewed as the huge opportunity it is. The students have already moved to the new medium, it is time for medical schools to catch up.

It is time to turn those lecture halls into production studios. It is time to hire professional animators, artists, and video producers, and go from slide shows that need to be performed live every year to tightly produced educational shows that can be created once and shown many times. Let’s teach for the contemporary reality, rather than fight it with rules that serve to waste student’s and teacher’s time.

Posted on

Kidney Week 2019

Kidney Week is my favorite week of the year. It’s Kidney Christmas. Kidney Week is the one week when all of the connections I make over direct message, e-mail, and text via the black rectangle in my hand transform into living, breathing people. If you are going to Kidney week, I’d love to meet you in real life.

Here is a rough itinerary

Pre-Conference

Tuesday and Wednesday

Fundamentals of Renal Pathology – Anthony Chang, MD, FASN, Lynn D. Cornell, MD, Mark Haas, MD, PhD

Conference

Thursday:

1:00 to 1:30 pm I’ll be at the ASN Community Booth discussing Leveraging Social Media for Your Career in Nephrology.

6:30-7:30 pm Nephrology Secrets Book Signing at the Elsevier booth (1119) during the ASN Welcome Reception

Friday

10:30 am Join Cathy Quinlan and I on the NephJC Poster Tour. Meet at the Arkana booth (2515)

9:00 pm NephJC Tweet-up

Posted on

Pseudohyperkalemia: the tweetorial

Last week I posted a tweetorial on pseudohyperkalemia due to CLL and a high white blood cell count.

This case peaked with a potassium of 9.5. Pretty frightening, but that was nothing compared to the potassium of 15.5 I saw in 2014. Details here.

I had another case of pseudohyperkalemia in 2011. That one was due to thrombocytosis.

In response to my Tweetorial, Yash Chivate shared a case of pseudohyperkalemia of his own.

Posted on

Free Onconephrology text book

Awesome, current resource on onconephrology from the ASN. Nineteen chapters with everything you need to be a superior consultant nephrologist

Chapters

  1. Onco-Nephrology: Growth of the Kidney-Cancer Connection
    Mark Perazella, MD, and Mitchell Rosner, MD
  2. Why Do We Need an Onco-Nephrology Curriculum?
    Mark Perazella, MD, and Mitchell Rosner, MD
  3. AKI Associated with Malignancies
    Amit Lahoti, MD, and Benjamin Humphreys, MD, PhD
  4. Tumor Lysis Syndrome
    Amaka Edeani, MD, and Anushree Shirali, MD
  5. Electrolyte and Acid-Base Disorders and Cancer
    Anushree Shirali, MD
  6. Glomerular Disease and Cancer
    Divya Monga, and Kenar Jhaveri
  7. Hematologic Diseases and Kidney Disease
    Ala Abudayyeh, MD, and Kevin Finkel, MD, FACP, FASN, FCCM
  8. Clinical tests for Monoclonal Proteins
    Nelson Leung, MD
  9. Hematopoietic Stem Cell Transplant-Related Kidney Disease
    Sangeeta Hingorani, MD, and Joseph Angelo, MD, MPH
  10. Radiation Nephropathy
    Amaka Edeani, MBBS, and Eric Cohen, MD
  11. Chemotherapy and Kidney injury
    Ilya Glezerman, MD, and Edgar Jaimes, MD
  12. Pharmacokinetics of Chemotherapeutic Agents in Kidney Disease
    Sheron Latcha, MD, FASN
  13. CKD as a Complication of Cancer
    Laura Cosmai, MD, Camillo Porta, MD, and Maurizio Gallieni, MD, FASN
  14. Hereditary Renal Cancer Syndromes
    Katherine Nathanson, MD
  15. Work-up and Management of Small Renal Masses
    Susie Hu, MD Anthony Chang, MD
  16. Cancer in Solid Organ Transplantation
    Mona Doshi, MD
  17. Cancer Screening in ESRD
    Jean Holley, MD
  18. Ethics of RRT, Initiation and Withdrawal, in Cancer Patients
    Michael Germain, MD
  19. Palliative Care in Patients with Kidney Disease and Cancer
    Alvin H. Moss, MD, FACP, FAAHPM

The more you learn the cheaper that ASN membership looks.

Posted on

What books or resources should I use to learn nephrology?

I received this DM today (my DMs are open. I was nervous about opening DMs but a year later I would rate the experiment as a delightful success. It has opened up Twitter to many new discussions that otherwise would not have occurred).

Hi Dr. Topf, I’m a final year medical student from the UK. I’ve been following you for a while due to my interest in renal medicine. Are there any books/online resources that you would recommend to learn renal physiology? I feel that I lack fundamental principles and concepts which I’d like to improve. Thanks!

Arnav

This is actually a relatively common question and I am going to attempt to write this post so I can link to it in the future.

The answer depends on the goals of the student

Preclinical medical student.

Vander’s Renal Physiology

Slim, readable. Good choice.

The Acid-Base Haggadah

This is designed to be part of a workshop but it can be read on its own.

Medical student or resident on a clinical rotation

This list is for the learner who is looking to know what to do.

Nephrology Secrets

Of course I’m one of the authors and I edited every single word in this book but a year later I still am amazed at how well this review book walks the tightrope of being concise without over simplifying complex topics. I may be biased, but I think this is an excellent book.

NKF Nephrology Primer

Before Secrets this was my go to recommendation, but this book is getting long. I’m beginning to think this may be too long for a student resident on a one month nephrology rotation. That said you can’t find better renal educators that editors than Gilbert and Weiner.

The learner really wants (or needs) to have a mechanistic understanding of why we do what we do then…

Fluid, Electrolyte and Acid Base Companion

It is strange that one of the things I am most proud of in my entire career is a book I wrote as a resident but it is no exaggeration to say this book for transformative for my life. I poured five years of work into this project and i think it stands up. However you should skip the tremendously outdated and overly complex section on the treatment hyponatremia and instead read the European Clinical Practice Guidelines.

Burton Rose’s Clinical Physiology of Acid Base and Electrolyte Disorders.

People look at the copyright on Rose’s electrolyte book and conclude the book is out of date.
It is.
It doesn’t matter.
Rose excels at providing the reader a cohesive mental model of how the kidneys work so that things make sense. Then if you need to learn more and get a more up to date and nuanced view of how the kidney works it is pretty simple to plug those updates into your mental model of the kidney.

The nephrology fellow

Use the following:

  • Nephrology Secrets
  • Burton Rose’s electrolyte book
  • Daugirdas’ Handbook of Dialysis
  • All of the KDIGO clinical practice guidelines
  • A subscription to UpToDate
  • A subscription to Nature Reviews Nephrology
  • Attend every NephJC

Read the first three cover-to-cover and then cover-to-cover again. The KDIGO Guidelines will give you the state-of-the-art for many of the important issues in Nephrology and the full guidelines provide a solid scientific rational for why the guideline are the way they are. You should have more than a superficial familiarity with the guidelines. Use UpToDate and Nature Reviews to go deep on every weird, rare, or interesting patient. Use the last one to stay up to date with clinical research. That’ll do. That’ll do quite nicely.

What did I miss? What are your favorites. Hit me up on #MedTwitter or slide into my DMs.

Some good updates from Twitter

And Mir Tariq Ali reminded me of major omission to my list. I forgot Daugirdas’ Handbook of Dialysis. This is the third book that every nephrology fellow should read cover to cover and then read again.

Posted on

Medical management of hyperkalemia

My team was consulted for acute kidney injury (AKI) and hyperkalemia. Before we saw the patient they had already been given the standard, calcium, bicarb, and insulin/glucose cocktail. This had no effect. Potassium went from 6.4 to 6.4.

The patient was still making urine. The AKI was due to emergency surgery with an impressive estimated blood loss (translation: blood loss measured in liters). We gave a liter of NS, 80mg of IV furosemide and 0.2 mg of oral fludrocortisone. Potassium went from 6.4 to 3.4 despite a further increase in the serum creatinine.

Remember to use the kidney for treating hyperkalemia. Even in AKI you can get impressive results.

Renal clearance of potassium is entirely dependent on the cortical collecting duct, specifically the principal cells. It is a multi-step process:

  1. reabsorption sodium down its chemical gradient through eNaC
  2. The chemical gradient to allow sodium resorption is generated and maintained by the Na-K-ATPase
  3. Movement of sodium without an anion(or a cation going in the opposite direction creates a negative charge in the tubular fluid which pulls potassium down an electrical and chemical gradient from the cells into the tubule. This occurs through ROMK and BIGK.

That is how potassium is excreted but, how is potassium regulated? There are two primary components to regulation:

  1. Aldosterone stimulates the transcription of all three transporters (ENaC, Na-K-ATPase, and ROMK) as well as transcribing versions of the proteins which are more active.
  2. Tubular flow. Increased distal sodium delivery provides plenty of sodium to be reabsorbed into the principal cell providing the negative charge, as well as washes away any secreted potassium to maintain the chemical gradient favoring potassium excretion.

The medical management we provided takes care of both aspects of potassium regulation, the furosemide and saline makes sure there is a robust supply of sodium delivered distally and the fludrocortisone makes sure there is ample aldosterone activity to assist with potassium clearance.