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Most insulting/funny sentence ever from a consulting doc

I have a new patient that I inherited from a former colleague. She came to me with a letter from her ophthalmologist addressed to the patient that she was suppposed to give to her primary care doctor and nephrologist.

Here is the money quote:

I am going to give you a copy of Harrison’s textbook to look for secondary causes of hypertension.

When the patient came in she didn’t have the book so I have no idea how to re-run her work-up of secondary hypertension (which had been done multiple times in the past).

Hey asshole, next time you have a bad outcome on one of your patients I’ll make sure I send you a copy of Clinical Ophthalmology: A Systematic Approach. What a dick.
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I just gave the world’s greatest lecture on diabetic nephroapthy

It was incredible. The residents, who usually sleep through the second half of noon conference, were completely charged up and by the end of the lecture were holding up lighters and chanting my name. I dove from the stage and was passed around like a Rock God.
Here is the lecture in powerpoint format to download. You can also see the Slideshare but they mangle the animations so if you want to really feel the educational frenzy download the .ppt.
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Calculating the urinary microalbumin to creatinine ratio

One of my high volume referring doctors uses a lab which does not calculate the microalbumin to cr ratio. It always stops me in my tracks when I see the values.

  1. To convert microalbum and urine creatinine to the useful ratio first make sure both values are expressed as mg/L or mg/ml
  2. Divide the microalbumin concentration by the creatinine concentration
  3. Multiply the resulting ratio by 1,000 to get mg albumin over grams creatinine
For example a patient had the following labs:

Microalbumn urine 5.6 mg/dL

Creatinine urine 91.2 mg/dL

Dividing the albumin by cr gives: 0.061

Multiply that by 1,000 to get 61 mg albumin/g creatinine

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Hemoglobin A1c of 18.6

18.6!
That corresponds to an average blood sugar of 486!
Six months and 1,500 mg of metformin later it is down to 8.4% corresponding to an average of 194. That 18.6 has got to be an error. Right? Right?
Unfortunately for her GFR is 30 mL/min.
No metformin for you.
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iPhone, Android: Fight

Different data from the iPhone, Blackberry: Fight! from a few months ago but the same conclusion.
This battle is over! And the iPhone has won.
From Larvalabs:

Our two best selling games have been ranked and are currently ranked pretty highly on that hard to find list of paid apps. RetroDefense was #1 for a while and is currently around #12 with a perfect 5 star rating. Battle for Mars is currently #5 overall with a 4.5 star rating. Both of these games are selling for $4.99, which is on the upper end of the price range. Finally, both of these games have been featured by Google in the market app and on the Android website. So with all this in mind, here’s our daily Android sales for this August (these numbers include sales from our other two apps, but they barely register):

That’s a $62.39 daily average. Very difficult to buy the summer home at this rate.

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So how much do we spend on routine daily labs?


Apparently a crap load:

Several studies have identified the overuse of daily lab testing and how certain interventions can effectively reduce tests ordered. A study by Miyakis et al. examined the effects of disclosing lab test costs on the frequency at which healthcare providers ordered these tests. 24,482 laboratory tests were ordered before the intervention (mean 2.96 tests/patient/day). Among those, roughly 70% were not considered to have contributed towards management of patients (mean avoidable 2.01 tests/patient/day). After costs of tests were disclosed, the avoidable tests/patient/day were significantly decreased (mean 1.58, p = 0.002), but containment of unnecessary ordering of tests gradually waned during the semester after the intervention. (1) A study by Kumwilaisak et al. examined how the implementation of formal guidelines effected how laboratory tests were ordered. 1,117 patients were enrolled. After the institution of the guidelines, the number of laboratory tests decreased by 37% (from 64,305 to 40,877). Furthermore, this result was still present at 1 year. (3)

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Adrian Izhack Katz August 3rd, 1932 to August 17th, 2009


Dr. Katz was my mentor in the nephrology clinic my first year of fellowship. It was his last year of clinical work at the University of Chicago. He was also the supervising attending during some of my dialysis rotations. That rotation was liking being a traffic cop for inpatient dialysis. It is also where I got my twitter handle, @Kidney_boy. It was my beeper salutation.
He was a master of clinical medicine but we came at it from opposite directions. He was finishing and I was starting. He wanted to impart fatherly, philosophic reflections. I was hungry for raw data. I was racing to fill my head with facts. I wish I had an opportunity to spend time with him after I had matured.
Some memorable moments with Adrian:
  • We had just finished clinic in the DCAM and were walking back to the nephrology section. We often would go to his office to discuss something but this time he invited me into a lab. He turned on a Bunsen burner and made two shots of Turkish Coffee. Spending those moments drinking fresh coffee in the lab was the single coolest teacher-student moment of my life.
  • My wife and I had twins while we were in Hyde Park. Only two professors came over for the Bris on my birthday, Adrian Katz and Pat Murray.
  • Adrian and Miriam invited my wife and I over to his house for Passover. We brought our 6 month old twins. I remember being terrified of what they would break. The Katz’s were wonderful hosts and it was like going to the Wizard of Oz for dinner.
  • I remember his office. It was a beautiful large office with great built in bookcases lining one wall. The cases were full and every second or third book had a small yellow sticker. For months I had been meeting him in there. I had noticed the dots but assumed it was just a personal filing system. One day he asked me if I knew what those dots meant. I shrugged. He explained that a dot represented a book or chapter he had written. It was a mind boggling accomplishment, you were literally faced with a wall of academic achievment. I have written textbook chapters. For me it is about as easy as coughing up a lung. Amazing.
  • We were talking about intradialytic hypotension. How could we dialyze this patient without resorting to CVVH and a transfer to the ICU. I mentioned cold dialysate and he said that it is effective but patients don’t like it. My eyes widened like saucers and I said:

“I didn’t know that patients could feel the cooler temperature.”
Adrian replied, “You could fill an ark with what you don’t know.” And then started laughing uproariously. When he finally regained composure, he had tears in his eyes. He explained that he had once had a mentor who had used that same joke on one of Adrian’s peers. It was such a happy memory for him that he couldn’t contain it.

University of Chicago has a nice obituary.

He was a respected teacher.
The world is a shade paler without him.
Found a photo deep in the hard drive from that Seder:

Update from 2014, found another great photo

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Another one bites the dust: TREAT is negative

Darbepoeitin meets a similar fate as epoetin alpha in CKD patients. Here is the press release from the trial onset, a more opportunistic time:

Amgen Inc. (Nasdaq:AMGN), the world’s largest biotechnology company, today announced that the company has initiated a landmark trial to evaluate the impact of treating anemia on cardiovascular outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes. TREAT (Trial to Reduce cardiovascular Events with Aranesp(R) (darbepoetin alfa) Therapy) is one of the largest clinical trials in the company’s 25-year history. The TREAT study design as well as additional Sensipar(R) data was presented at the American Society of Nephrology (ASN) annual meeting in St. Louis.

“Current research suggests that anemia is an augmenter of cardiovascular risk in individuals with CKD and type 2 diabetes,” said TREAT lead investigator Marc Pfeffer, M.D., Ph.D., chief of medicine at Brigham and Women’s Hospital and a professor at Harvard Medical School. “TREAT will be the definitive study to determine if treating anemia with Aranesp does, in fact, lower the risk of death and non-fatal cardiovascular events in individuals with CKD and type 2 diabetes.”

TREAT is an international 4,000 patient, multicenter, randomized, double-blind, placebo-controlled trial. The primary endpoint of TREAT is a composite index of time to mortality or non-fatal cardiovascular event, including myocardial infarction, myocardial ischemia, stroke and heart failure.

The rational for TREAT was published in the American Heart Journal. From the abstract:

BACKGROUND: Patients with chronic kidney disease (CKD) have a high burden of mortality and cardiovascular morbidity. Additional strategies to modulate cardiovascular risk in this population are needed. Data suggest that anemia is a potent and potentially modifiable risk factor for cardiovascular disease in patients with CKD, but these data remain unsubstantiated by any randomized controlled trial (RCT). Furthermore, the clinical practice guidelines for anemia management in patients with CKD are based on limited data. The need for new RCTs to address critical knowledge deficits, particularly with regard to the impact of anemia therapy on cardiovascular disease and survival, is recognized within the guidelines and independent comprehensive reviews of the existing published trial data.

STUDY DESIGN: The Trial to Reduce Cardiovascular Events with Aranesp (darbepoetin alfa) Therapy (TREAT) is a 4000-patient, multicenter, double-blind RCT, designed to determine the impact of anemia therapy with darbepoetin alfa on mortality and nonfatal cardiovascular events in patients with CKD and type 2 diabetes mellitus. Subjects will be randomized in a 1:1 manner to either darbepoetin alfa therapy to a target hemoglobin (Hb) of 13 g/dL or control, consisting of placebo for Hb > or =9 g/dL or darbepoetin alfa for Hb <9> or =9 g/dL. TREAT is event-driven and has a composite primary end point comprising time to mortality and nonfatal cardiovascular events, including myocardial infarction, myocardial ischemia, stroke, and heart failure. TREAT will provide data that are critical to evolution of the management of cardiovascular risk in this high-risk population.

This was the last nail in the coffin for use of ESAs to normalize hemoglobin in pre-dialysis CKD. In the years since CHOIR and CREATE one of my partners kept holding out hope for TREAT. He mentioned that TREAT made it through its interim safety monitoring without being stopped so it was unlikely to show the same detrimental findings found in CHOIR.
This data is just preliminary as it was published to satisfy financial requirements. The official results will likely be presented at Renal Week.