Tuesday, November 18, 2014

Pause to think about POISE

One of the largest AKI trials was presented at ASN Kidney week 2014 and just published in JAMA as well- POISE 2.  It was a trial to look at a preventive strategy for AKI in non cardiac surgery setting.   An international trial, with 88 centers, 22 countries, from 2011-2013 of over 6000 patients was done to see if ASA or clonidine given prior to surgery prevented AKI post surgery.  Not to my surprise, a mong patients undergoing major noncardiac surgery, neither aspirin nor clonidine administered perioperatively reduced the risk of acute kidney injury. In addition, the ASA group had more risk of bleeding and the clonidine arm had more risk of hypotension. 

The logic behind using this strategy doesn’t make sense to me.  There are few trials in the surgical literature that might have prompted this trial.

The funding was provided by the CIHR, Spanish ministry of health and few other funding pharm agencies.  A multi international trial of AKI that might be one of the largest to date is an amazing ordeal but the concept seemed less likely to have worked.  A drug that causes bleeding and another one that causes hypotension is more likely to cause harm then benefit.  Ischemic re conditioning or sonogram might have been an interesting approach.  

Sunday, November 9, 2014

ASN Nephrology Fellow's Events 2014

Welcome reception: Nov 12th: 6-7PM
Marriott Downtown, Grand Ballroom, Salon H

Fellows In Training Bowl( Mystery Case Debate): Nov 14th 2-3PM
Convention Center, Room  119A

Fellows In Training Bowl( Jeopardy game Nephrology Challenge): Nov 14th 3-4PM
Convention Center, Room  119A

Meet the Experts Session Nov 15th  9:30AM - 10:30AM( Meeting the ASN Award Winners)
Convention Center, Hall D

Fellows Forum Nov 15th 10:30-11:30AM
Convention Center, Room 203

Fellows Poster Discussion Section Nov 15th 2-3PM
Convention Center, Room 112

Sunday, November 2, 2014

ASN 2014 Abstracts

ASN abstracts 2014 are now online and available for review.
Posters on demand will also have online posters for viewing soon as well.

For those interested in Social media and education in nephrology, few special sessions being held this year

1. Tweets, likes and Blogs: How to use social media for your patients and your benefit.Nov 13, 1030-12:30PM

2.Boost your teaching skills to become a contemporary nephrology educator. Nov 14, 2-4PM
3. Case Based Debates ( Fellows in training bowl)- Mystery case competition Nov 14, 2-3PM
4. Nephrology fellows jeopardy- Nov 14, 3-4PM

Saturday, November 1, 2014

IS CKD-MBD a syndrome?


Is it a syndrome? An article in NDT addresses this entity as a possible syndrome in CKD
When one looks at nephrotic syndrome or metabolic syndrome, those entities usually fulfill the criteria for calling it a “syndrome” as most patients would fit that criteria and prognosis and treatment would be resulted.  In CKD-MBD, this article argues against it being a potential syndrome in CKD but perhaps might be.  CKD-MBD represents a synopsis of three closely related disease conditions: laboratory abnormalities indicative of disturbed bone and mineral metabolism; renal osteodystrophy summarizing the variety of bone lesion subtypes occurring in CKD; cardiovascular disease representing accelerated arteriosclerosis, left ventricular hypertrophy and a variety of additional pathologies in the vasculature and the heart in patients with CKD.
But do all patients with CKD have all the bone parameters abnormal; and if they do, what is the CVD risk and prognosis?  But it’s worth some thought of this potentially being a syndrome.

Have a look at the full paper.

A workshop is being held in Europe to further define this

Sunday, October 19, 2014

C-KIN( Cancer and Kidney International Network)

C-KIN | Cancer and the Kidney International Network

The first ever international society specifically for onconephrology has been created.
It's called the C-KIN( Caner and Kidney International Network).
Check out the their twitter feed at https://twitter.com/CKINnews and their annual conference schedule and abstract details as well. C-KIN aims at improving patient care through better knowledge, education and awareness on cancer and the kidney related issues and research.

Thursday, October 16, 2014

Clinical Case 85: Answers and Summary ( iron use in ESRD)

ESRD patient with anemia, Fe sats of 12%, Ferritin 450 needs IV iron. Patient has bacteremia.
A. Proceed to give IV iron as anemia and low Fe sats demands it.  (2%)
B. Given active infection, do not give IV iron till 2 weeks after infection resolved (73%)
C. Given active infection, do not give IV iron till 4 weeks after infection resolves. (24%)

There have been no clinical trials of adequate sample size and duration to provide us sufficient understanding of the safety of intravenous iron. Is bolus iron better or continuous form? Is iron infusion pose an infection risk?

Brookhart et al. retrospectively studied patients on dialysis treated at Davita Inc. dialysis facilities and found that patients receiving 200mg intravenous iron per month had an increased risk for hospitalization or death because of infection. They also found that bolus dosing was more associated with infection. More recently, A CJASN study by Miskulin et al. found a increased risk for infection-related mortality when cumulative iron dose exceeded 1050 mg over 3 months or 2100 mg over 6 months( not statistical but a trend). In an accompanying editorial to the Miskulin study, Fishbane et al (must read) discuss what the USRDS data suggests. As the mean serum ferritin of United States patients on dialysis approximately doubled from 1993 to 2001, the rate of bacteremia/sepsis increased approximately by 40%. From 2001 to 2010, serum ferritin stabilized, and soon enough the bacteremia/sepsis rate also stabilized. In light of these above findings, it is advisable to hold iron infusions in setting of active bacteremia.  

What about other active infections such as cellulitis or pneumonias? No data exists for those at this point. How long do we wait is a good question. Most likely choice is 2 weeks but data for that is not clear. Some of you chose 4 weeks: might also be a reasonable choice.  Another concern might be catheter use.  Infection risk as stated by the Brookhart study that risks are largest among patients with a catheter and the ones with a recent infection. 

Tuesday, October 14, 2014

Topic Discussion: Ebola and the Kidney

Ebola is a RNA virus that has a high rate of transmission.  As we have now noted the world’s largest outbreak of this virus to date, the cure for this entity remains a mystery.  Ebola hemorrhagic fever is a severe infection. It can have a mortality rate of up to 70-90%. The infection can occur in humans and animals. The virus family is Filoviridae and genus Ebolavirus. It was first discovered in 1970s near Ebola river in Congo.  Since then most of the outbreaks have been in Africa.  While the natural reservoir host of Ebola remains unknown, some believe it might be bats.

How does the kidney get involved? Severe volume depletion from this hemorrhagic disease leads to acute kidney injury.  Electrolyte abnormalities such as hyponatremia, hypokalemia and so forth can be noted as well.  Renal failure was described in this entity in early 1980s. DIC ensues and a shock state leads to AKI. Prior animal studies have shown that there is some necrosis and calcification in tubules and glomerular tufts of kidney. The first victim in the US in Texas was on dialysis as well.

While some treatments and preventions are being considered, there is only supportive therapy that can be offered at this time. However, survival is improved by early supportive care with rehydration and symptomatic treatment. Early intensive care therapy might be necessary.
What might be of interest to us as nephrologists is the use of dialysis modalities to help clear the virus. Hemopurifier, a device from  Aethlon Medical (San Diego, CA) that’s capable of filtering blood of impurities like viruses is available. Apparently it is being used currently ( per their report) for filtering the blood of an infected doctor with the virus in Germany. The device can be used with standard dialysis and continuous renal replacement therapy (CRRT) machines and doesn’t require any special hardware upgrades.

More information regarding this can be found at the website

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