Wednesday, October 7, 2015

Consult Rounds: Cancer Drug induced Thrombotic microangiopathies

Cancer Drug induced TMA come in 2 variants

1.       Type 1 TMA:- onset is delayed, usually 6-12 months after starting therapy
Cumulative dose related
Clinically, could be permanent and irreversible renal damage
Would avoid rechallenge
High incidence of acute mortality and may require dialysis even after stopping agent
Thrombi in both arteriole and glomerular capillary
Examples: Mitomycin C and gemcitabine induced

2.       Type 2 TMA:- onset is more acute and only at time of initiation of agent.
Not dose related
High likelihood of recovery
Some evidence of safe rechallenge
Thrombi in glomerular capillary mainly
Patient and kidney survival excellent
Examples:  anti VEGF and TKI agents induced

Friday, October 2, 2015

Topic Discussion: CLL and the kidney

Classically, it's well know that infiltrative disease is seen with CLL and the kidney leading to AKI.
What other diseases can you see with CLL and the kidney?

A recent paper by The Leung group at Mayo discusses the Mayo clinic experience of CLL and monocloncal B cell lymphocytosis patients that had a kidney biopsy.

Most common findings:
20% had MPGN
12% had infiltration of CLL
12% had TMA from chemotherapy -- classically related to pentostatin
10% had Minimal change disease

Other less commonly observed findings were AIN, AL lamda amyloidosis, light chain cast nephropathy, membranous GN and mesangial proliferative GN.

Other unrelated biopsy findings were diabetic nephropathy, obesity related FSGS, and HTN nephropathy.

Thursday, October 1, 2015

Topic Discussion: Non Dilated Obstructive Uropathy

Anuric renal failure has very few causes. The top three are usually: hydronephrosis, hydronephrosis and hydronephrosis! But sometimes, it’s the sonogram and imaging that sways you away from the diagnosis. The sonogram reads- no hydronephrosis and or dilatation.  But clinically, the only thing that makes sense to you is obstruction? What do you do then?

Non dilated obstruction is not uncommon especially in patients with cancer that effects the retroperitoneal regions. There is so much cancer mass that there is no ROOM for the kidney to expand. But doesn’t mean that hydronephrosis is not present. The syndrome of non-dilated obstructive uropathy (NDOU) and AKI is well reported. However, the literature suggests that this syndrome is rare, accounting for less than 5% of cases of urinary obstruction.

One of the earlier studies had looked at a series of patients at a single center and found that most common cause of these type of situations were cancers ( likely RP related)- so prostate, colon, bladder, lymphomas and other series have found cervical cancer as well.  Antegrade urography had found the obstruction in all of the cases in that one series. 

The first ever case of this was described by Ormand in 1948 with someone with retroperitoneal fibrosis.

A more recent study from Mayo Clinic has a case series of 3 cases. Despite the absence of dilatation on renal imaging, strong suspicion for NDOU led to decompression procedures with prompt recovery of kidney function in all three patients - two required percutaneous nephrostomy tube placements and/or ureteric stents and one responded to simple Foley catheter drainage. Here is another case series summarizing the data.

Treatment is usually diagnostic.  Given the pathology and the cause of the obstruction being present after the ureteral stents are placed, they usually only temporize the treatment. Percutaneous nephrostomy is usually the best procedure in such situations. 

When one encounters such cases, Urology and IR help is critical in getting the right diagnosis and prompt treatment.  

Thursday, September 24, 2015


The NYHA heart failure patients have a new device that is useful in predicting their volume status. A Lancet article in 2013 showed that this device called the CARDIOMEMS ( implantable hemodynamic monitoring).  This big study showed that it reduced hospitalizations of heart failure patients.  This device measures the pulmonary artery pressures (PAP) via remote monitoring.  The device is placed via interventional means and the remote box predicts the PAP. Based on that the physician can assess volume status and increase or decrease diuretics or give fluids preventing inpatient visits. 
The holy grail of ESRD patients has been the dry weight and how do we know they are more volume overloaded or need more UF.   MEMS or microelectromechanical systems can perhaps play a major role in renal care.  MEMS offers a potential to predict volume status in ESRD patients.  The current use of drt weight comes with fluctuations, errors and not much reliability.  This device could be planted in HD patients and perhaps we could remotely monitor their fluid status and call for extra UF sessions, or remove less fluid and so forth and perhaps even prevent hospitalizations.  
What an amazing achievement by the cardiologists.

Monday, September 14, 2015

Onconephrology CME: Sept 26th one day symposium: First of it's kind

One last push for a plug in for the first ever one day CME on onconephrology.  It's ASN, ISN, NKF and C-KIN endorsed event.  

We are conducting a one day symposium on OncoNephrology: Cancer, chemotherapy and the Kidney at Hofstra NSLIJ School of Medicine on Sept 26th, 2015 from 7:30AM to 4PM
The conference will highlight and review the latest happenings in OncoNephrology

WHY to attend:

1. First of it's kind in USA to focus on this topic
2. We shall be using innovative technology to allow for a fun and interactive conference( polleverywhere, joinme and so forth)
3. A chance to win few nephrology textbooks as a raffle during the day
4. FREE to attend for any trainee ( student, fellows or residents)
5. Live tweeting of conference will be available via AJKDblog

Talks and Speakers highlighted;

AKI in Cancer Patients;  Joseph Bonventre, Harvard Medical School
Chemotherapy Toxicities:  Mark Perazella, Yale University
Targeted Therapy and the Kidney: Kenar Jhaveri, Hofstra University
Hypercalcemia of Malignancy: Naveed Masani, Winthrop University
Anemia, CKD, ESKD and cancer: Steven Fishbane, Hofstra University
Renal Cancer, an update: Thomas Bradley, Hofstra University, NSLIJ Cancer Institute
Paraneoplastic GN; Hitesh H Shah, Hofstra University
TMA:  Bradley Dixon, Cincinnati Children Hospital
Post Kidney Transplant Cancers: Vinay Nair, Mt Sinai Medical Center
Paraproteinemias, an update: Gerald Appel, Columbia University Medical Center
Cases with the Onconephropathologist: Glen Markowitz, Columbia Medical Center

Course directors:  Kenar Jhaveri, Steven Fishbane and Thomas Bradley( Division of Nephrology and Hematology/Oncology at Hofstra NSLIJ School of Medicine)
Planning committee: Kenar Jhaveri, Steven Fishbane and Thomas Bradley, Hitesh H Shah, Pravin Singhal, Jyotsana Thakkar and Rimda Wanchoo( all from Division of Nephrology, Hofstra NSLIJ School of Medicine)

To Register: go here

Sunday, September 13, 2015

TOPIC DISCUSSION: Mnemonic for toxins that are removed by hemodialysis

Toxins that are removed by hemodialysis

Here is a mnemonic I found online


I = Isopropanol
S= Salicylates
T = Theophyline
U = Uremia
M= Methanol
B= Barbituates, beta blockers (water soluble ones such as atenolol)
L= Lithium
E= Ethylene glycol


Monday, August 31, 2015

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