Late post from June.
Near the end of the month our fellow the amazing Dr Jabri gave a lecture on anemia. Good talk.
Here are his lecture notes.
Teaching on Two Ell: Acute Renal Failure and GFR
Yesterday we discussed the problem with the curvilinear relationship between gfr and creatinine and how the MDRD equation dispenses with this problem. Today we will go over a handout introducing GFR, MDRD and how to manage them, including referral to a nephrologist.
Additionally I want to do my canned acute renal failure lecture. This lecture has been made obsolete by the recent ATN data and data from Vanderbilt so it will need to be revised.
Teaching on 2 Ell, the second week
On Monday one of our interns gave a lecture on the range of renal pathology possible found with lupus nephritis.
This was a follow up on her lecture on the renal manifestations of lupus nephritis by WHO criteria. After her lecture we went down to bowels of the hospital to look at the kidney biopsy we had done on Friday on one of our patients with lupus.
On Thursday we began interpretation of Acid-Base disorders.
Also on Thursday I lectured the house staff on Nephrogenic Fibrosing Dermopathy, Acute Phosphate Nephropathy and Contrast Nephropathy. Renal adventures in imaging.
On Friday the 13th we completed Acid-Base disorders. As part of acid-base we talked about the anion gap. This article in CJASN on the anion gap was wonderful.
Rhabdomyolysis
Just got my second rhabdomyolysis patient in the last 2 months. Both had anuric acute renal failure and both had CPKs over 100,000.
In fellowship, the dogma was that sodium bicarbonate was ineffective and could do harm. The reasoning was that alkalinizing urine made calcium-phosphate less soluble, increasing the likelihood of calcification in the tubule extending the renal damage.
Recently, I found a paper from the Journal of Trauma 2004 by Brown and Rhee (Alternative) which showed compelling trends for improved outcomes with mannitol and bicarbonate. What was so impressive to me was that as the disease got more severe (higher CPK) the experimental group appeared to do relatively better. The authors were prevented from reaching a significant p value primarily by having too few patients with severe rhabdo.
I will use the handout from a prior morning report on the subject for the teaching session on Monday.
Two Ell
This month I’m attending on the renal ward at Saint John Hospital and Medical Center. I have a huge team: one fellow, one second year resident, three interns (2 categorical and one ER resident) and two medical students. I have been having a blast teaching them.
I am going to track all of the teaching I do this month here.
So far this is the formal (as opposed to bedside) teaching we have done:
Monday June 2: Introduction to Two-Ell
Tuesday June 3: Nephrotic Syndrome
Wednesday June 4: Dialysis basics and Anti-hypertensive agents saves lives
Thursday June 5: Renal Adventures in Imaging (the nephrologic implications of Gadolinium and NFD, phosphate nephropathy as a complication of colonoscopy prep, and contrast nephropathy)
More to come.