Friday, April 17, 2015

SiteGPR: A website for renal dosing of medications

Dosing of drugs in renal disease is a common topic of discussion. A nice website tool that helps manage that better is here.

SiteGPR presents evidence-based recommendations on drugs dosage adjustments in patients with renal insufficiency.

In addition, it has a long list of medications that are linked with renal toxicity.
A great tool to be used.

Friday, April 10, 2015

Nephtangles: The nephrology interface with ABIM MOC

As we are all aware of the increased requirements from ABIM in the last few years for board certification.  What are we to do? Sit tight and wait for a final decision? Is MOC here to stay or to go? What is our role as a practicing physician.

I urge all to read Nephtangles blog

The blog has multiple posts highlight some important developments in the last few months on this very important topic.

Thursday, April 9, 2015

Blood Transfusions and AKI following CABG: Does age of PRBCs matter?

Blood transfusions have been linked with risk of AKI following cardiac surgery. Anemia and number of PRBCs transfusion are independent risk factors for development of AKI post CABG, Catalytic iron can produce oxidative stress, surrogate for hypotension and a “sick patient” and age of PRBCs maybe the culprit? In addition, PRBCs have been linked with non renal adverse outcomes such as 16% increase risk of mortality post CABG, risk of sepsis and pneumonia and risk of increased length of intubation.
A recent study called RECESS trial just published in NEJM looked at the age of PRBCS and risk of outcomes following CABG. RECESS was a randomized trial at multiple sites from 2010 to 2014 looking at patients 12 years of age or older who had complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions.
The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge.Overall results showed that the duration of PRBCS storage was not associated with MODS events. In addition, adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group.
What about renal outcomes? In the supplementary sections, the renal outcomes are mentioned and there was no difference in both arms. Serious renal adverse events in both arms were also similar. So AKI risk might still exist due to PRBCs transfusion risk but it’s not due to the age of the PRBCS. 

Tuesday, April 7, 2015

Saturday, March 28, 2015

Clinical Case 87: Answers and Summary

34 y old Indian Male with IgA nephropathy, crt is 2.4mg/dl and 2.5gm of proteinuria: treatment?

RAAS blockade only
  6 (12%)
RAAS blockade and Fish oil
  9 (19%)
Steroids with RAAS blockade
  19 (40%)
Treatment depends on Biopsy Oxford Classification of IgA Nephropathy
  13 (27%)

The KDIGO recommends no specific guidance for treatment with steroids in IgA nephropathy patients when they present with GFR between 30-50cc/min. A recent study published in JASN in 2015 looked at steroid use in IgA Nephropathy patients. It is called the VALIGA study.  A retrospective study that studied over 140 patients with IgA nephropathy from European registry and classified based on Oxford classification MEST score.   46% received immunosuppresive agents and of them 985 were steroids.  The ones who were treated had all the features of clinical progression( rising crt, or proteinuria).  All also received RAAS blockade.  The patients who got steroids had a significant reduction in proteinuria, a slower rate of renal function decline and greater chance of not being on dialysis.  While, initially we had thought that the benefit of such treatment was only in patients with mild- moderate AKI, this study found benefit even in the GFR<50cc/min cohort with levels of proteinuria.  

So in the above patient, the best answer would be Steroids with RAAS blockade. If the biopsy did show crescentic GN, the treatment ofcourse would be with cytotoxic agents in addition. 

Sunday, March 15, 2015

ASN- KSAP First installment

Nephrology Self-Assessment Program (NephSAP) has served for twelve years as a strategy for nephrologists to keep knowledge up-to-date and earn both CME credits.

ASN has recognized a need for material that covers basic principles of clinical nephrology that would be appropriate for individuals who are studying for the In-Training/In-Service examination or preparing for the American Board of Internal Medicine (ABIM) examination in the subspecialty of Nephrology. To this end, the concept of the Kidney Self-Assessment Program (KSAP) was developed.

KSAP is similar to having a Q bank for board preparation and re certification exams.
Please visit and see what you all think

This was must needed and well intended

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