Friday, June 24, 2016

UKidney Toxicology Series

Check out the Nephrology Social Media interns discuss an up to date information on Toxico-Nephrology.

Wednesday, June 1, 2016

Topic Discussion: Novel ways to combat Intradialytic hypotension

Intradialytic hypotension(IDH) during hemodialysis(HD) is a challenging clinical concern and often hard to treat.  After one has ruled out cardiac disorder ( especially diastolic dysfunction), common medications and ideas attempted are: midodrine pre dialysis, low temperature during dialysis, daily short dialysis sessions, florinef use, steroids in the right clinical setting, and sodium and or calcium profiling.  Switching to peritoneal dialysis can be an option as well.  The KDOQI guidelines recommends most of these above mentioned changes.
What are some other novel mechanisms that can be used?

1.Carnitine:  Carnitine deficiency has been associated with IDH and trial of L-carnitine at 20mg/kg with dialysis might help reduce IDH

2.Sertraline: This anti- depressant has shown improvement in orthostatic hypotension. Both retrospective and prospective studies in small number of patients demonstrated that treatment with sertraline hydrochloride was associated with an improvement in the hemodynamic parameters in patients with IDH. A recent randomized control trial from Iran also showed good benefit with this agent in IDH. The dose one can usually start is 50mg once a day and then max at 100mg daily per most trials when used for IDH.

Some good references:

Rho et al nicely demonstrated in a CJASN paper in 2008 that IDH patients experienced greater decreases in both systolic and diastolic blood pressure during the dialysis session despite equivalent ultrafiltration in both groups. AVP concentration did not increase in the IDH patients compared with controls despite hypotensive episodes. As a result, many have tried to use DDAVP as a treatment option for IDH.
As early as 1990s, vasopressin was tried in 6 patients to help IDH in one single center study with success.  The largest study(17 patients) using this was from Iran. In that study, the treatment arm received intranasal DDAVP (two puffs) 30 minutes before all HD.  Hypotensive episode occurred 18 times (8.82%) in vasopressin group compared with 125 times (61.27%) in placebo group and there was a significant association between them (p=0.0001). In addition mean arterial blood pressure in vasopressin group was 80.77 and in placebo group was 73.92 and also there was a significant association (p=0.0001). The mean Kt/v in group 1 and 2 were 1.29 and 1.28 without any differences between them (p=0.896). This might be another interesting option to consider in IDH.  Risk of  thrombotic events might be something to think about.


This agent has been approved by FDA for autonomic neuropathy.. The trade name is Northera. Droxidopa is a synthetic amino acid precursor which acts as a prodrug to the neurotransmitter norepinephrine. Unlike norepinephrine, droxidopa is capable of crossing the protective blood–brain barrier. Why in IDH? Well recently published trial that was a placebo controlled, phase 2 study looked at efficacy and safety of this agent in IDH.  The investigators looked at placebo vs 400mg vs 600mg dose.  Increase in droxidopa intra-HD MAP were not significantly different from placebo, although droxidopa groups showed significant improvements in mean SBP after HD of +4.8 ± 11.6 mm Hg (600-mg) and +3.4 ± 13.1 (400-mg) compared with -4.4 ± 17.9 mm Hg in placebo, and the drop seen in mean nadir SBP pre- to intra-HD was also reduced. HD terminations decreased 5-fold in the 600-mg group and 2-fold in the 400-mg group, whereas the number of discontinuations stayed unchanged in the placebo group. Treatment of both dosages were well tolerated. This might be an interesting option as well. The most common side effects noted were GI related. 

Sunday, May 29, 2016

Journal of Onconephrology

Journal cover

Announcing the first of it's kind
Journal of Onconephrology, the official journal of C-KIN
We are hoping this journal will become THE place for the articles related to cancer and the kidney be published,

Wednesday, May 25, 2016

First article from 1966 that inaugurated the ASN

The field of Nephrology is not that old. ASN is going to be celebrating the 50th year of creation of the American Society of Nephrology this Fall 2016. I wanted to share the first article ever published in 1966 introducing ASN to the world. It was recently linked in ASN Kidney News.  Worth a read.
Even back then in 1966, a plea was made for early referrals for CKD, and not wait too long...

Check it out here...

Thursday, May 19, 2016

IN THE NEWS: Cardiac output out and renal congestion in? what is the real cause of renal failure in CHF?

A dynamic study published in JACC might throw a curve on our thinking on heart failure and renal dysfunction. Chronic CHF( not cardiogenic shock) related renal dysfunction has been attributed by many to hypoperfusion due to impairment of cardiac output. Hanberg et al disprove this concept via an elegantly done analysis of cardiac index and renal dysfunction a registry database of CHF patients. There was no relationship that was significantly noted with cardiac index and renal dysfunction.  In this study , the patients were hospitalized for CHF, cardiac index was NOT the primary driver of renal dysfunction.
What is the major player then in the negative renal function?
Systolic Blood pressure might being low
High abdominal pressures – abdominal compartment syndrome
Renal vein congestion
Neurohormonal activation

An editorial in the same issue proposes alternate mechanism? But yet again physiology has not helped us. What was taught in textbooks and prior reviews was intuitive and perhaps it’s not that simple.  Improving forward flow might not be as important as providing “decongestion” from a kidney’s perspective.

Worth a read for the cardio-renal folks out there

Sunday, May 15, 2016

In the News: Will the smart phone change Nephrology Care?

While smartphone apps have flourished in the general world we live in, Nephrology hasn’t seen direct patient care related smartphone apps. There are some great educational apps and a list of them are provided in a prior post on AJKD Blog. A survey done that was mentioned in that post focused mainly on educations of nephrology related apps.
The most recent CJASN issue presents perhaps one of the first( there might be more but not published) nephrology app that can be used in clinical practice. While this is not a randomized control trial, nor there was sustained long term follow up of these patients, this is a good start for a proof of concept for perhaps work in this area.
This smartphone app targeted four behavioral elements in patients with CKD stage 4 or 5, it targeted BP, medication management, symptom assessment, and tracking laboratory results. The mean reductions in home BP readings between baseline and exit were statistically significant  and  27% with normal clinic BP readings had newly identified masked hypertension. In addition, medication errors were also identified.  An accompanying editorial also sheds some interesting thoughts on this concept. The editorial rightly addresses the downloadability of such apps. 
How many of your CKD patients own a smart phone?
If they do, how many are “techy” enough to download the app?
Mass use of such apps might be tough given the socio-economic barriers some of our patients might face.  Regardless, we need such apps and available for free for patients. Perhaps, we can teach them to download them and use them effectively to prevent re-hospitalization, medication errors, and offer and provide better patient care. 

Wednesday, April 13, 2016

Perspective: Broken Medicine

Here is a question for you:

A 55 y old male with HTN is here for follow up.  He has no other medical problems.  Medications include losartan, metoprolol, amlodipine, and HCTZ.  Blood pressure is 160/100 mm HG.  What is the next best step for his blood pressure control?

A.      Dietary history
B.      Check Renin/Aldosterone levels
C.      Check secondary workup
D.      Make sure the patient is taking all medications properly
E.       Obtain a 24 hour ABPM
Any of the above or all of the above would be good choices and one can start with either one. Here are the real world choices…
A.      Obtain Renal consult
B.      Obtain Endocrine consult
C.      Obtain Cardiology consult

Here is where the fragmentation begins. Why does this happen?
Here are the top reasons in my opinion
Not enough time to think
Inertia to think
Patient satisfaction( I want a HTN specialist)
Training not adequate
Trainers were not master clinicians and hence they believed in panconsultemia as well

Once consults are obtained: - more confusion as cardiology and nephrology don’t agree on drug choices. Endocrine wants more tests. Now more accidental findings…. And it continues. 

Welcome to medicine in 22st century.
Let’s please stop this madness!!

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