Sunday, July 5, 2015

Tuesday, June 30, 2015

Topic Discussion: What is the incidence of MGRS?


There is a new entity that is now being defined as MGRS ( when MGUS affects the kidney). The incidence of MGUS rises with age and there is lifetime 1% risk of transforming to myeloma or other cancers such as amyloidosis.

What is the incidence of MGRS? So what percentage of MGUS patients develop renal disease? Turns out, no published work has this answer.  An abstract presented at American society of Hematology (ASH) in 2013 might have the closest answer.


The study looked at a large database of lab values and 15 year follow up analyzed.   425 confirmed MGUS patients with no progression to Myeloma were evaluated.  297 patients had MGUS and normal renal function at baseline.  Over median of 852 days , 21/297 developed renal Impairment.  15/21 had monoclonal free light chain production.  Time to renal impairment was shorter with the higher free light chain ratio at baseline. Patients with involved Free light chain >100mg/dl were at the highest risk of renal failure.   So based on this one study, there is about 7% risk of MGRS from MGUS.  Seems high but we really need to wait published data on this topic. If it is truly 7%, screening with UA and protein/crt ratio with a complete metabolic panel might be indicated in patients with rising FLC ratios. 

Saturday, June 27, 2015

ASN and NBPAS

Recent changes to MOC and criticism of ABIM, where does nephrology stand.  Bold move by ASN to interview with founder of the new organization National Board of Physicians and Surgeons(NBPAS).

I think starting this discussion now is so critical. Hats off to Tod Ibrahim and ASN to take this initiative as we need to redefine that is reasonably priced and truly looks at clinical work that we do.

http://asn-online.org/media/podcast.aspx?p=kidneynews&e=2015_06_25_Teirstein.mp3


Tuesday, June 23, 2015

IN the NEWS: GN Types and ESRD

How do different GN types do on ESRD? A recent USRDS analysis looked at this very question.

1.      Over 84,000 patients were found to have GN that were on ESRD In the time period reviewed
2.      Interestingly IgA nephropathy had the fewest other comorbidities and the lowest use of hemodialysis
3.      Crude mortality was also lowest in IgA nephropathy patients
4.      Highest mortality was in Lupus nephritis and diabetic nephropathy patients when compared to IgAN
5.      Patients with ADPKD had a relatively favorable comorbidity and laboratory profile, comparable with that in IgAN.
6.      Overall, LN patients did the worst of all GNs.
7.      Cardiovascular disease accounted for the highest proportion of deaths within all GN subtypes, ranging from 34.2% in vasculitis to 44.6% in FSGS.
8.      The highest proportion of infection-related deaths was observed in LN
9.      There were marked survival discrepancies that persisted even after adjustment for socio demographic and clinical factors.
10.  Some GN subtypes (e.g., IgAN) conferred a particularly favorable prognosis, superior to that in ADPKD as stated above but, LN displayed shortened survival, similar to in patients with ESRD caused by diabetes.



These are some very important findings of the study. Categorizing GNs as on major cause of ESRD might be not helping us figure out the long term outcomes. As expected IgA and ADPKD have better survivals and some of the autoimmune and immunosuppressive prone GNs had worse outcomes.  

Saturday, June 6, 2015

OncoNephrology Conference 2015

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

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
Full brochure coming soon.

This conference is endorsed by
Image result for american society of nephrologyImage result for NKFImage result for ISNImage result for c-kin

Sunday, May 31, 2015

IN THE NEWS: Remote ischemic preconditioning and prevention of AKI post CABG



Remote ischemic preconditioning(RIPC)  has been used as a protective method from ischemic damage to distant organs.  Application of one or more brief cycles of nonlethal ischemia/reperfusion to an organ or tissue may protect a remote organ or tissue from a sustained episode of lethal ischemia/reperfusion.
In a recent study presented at Europe and published in JAMA,  Zarbock et al examine the effects of RIPC on the rate and severity of AKI in patients undergoing cardiac surgery. In a multicenter trial, 240 patients at high risk for AKI  were randomized to receive either RIPC  or sham control  after induction of anesthesia.

The amazing results showed that AKI was significantly reduced with RIPC (45/120; 37.5%) compared with control (63/120; 52.5%), with an absolute risk reduction (ARR) of 15%. Fewer patients received RRT after RIPC (7 [5.8%] vs 19 control [15.8%]; ARR, 10%) and RIPC reduced intensive care unit stay (3 vs 4 days). RIPC had no significant effect on myocardial infarction, stroke, or mortality.

A recent meta-analysis published in AJKD showed otherwise.  Mostly randomized trials were included ( 13) and total of >1300 patients. There was no differences in levels of post operative AKI and incidence of RRT, in hospital mortality and hospital stay.  A prior meta-analysis had shown similar results as well.

Can we start using this in clinical practice? It is innovative, inexpensive and easily possible.  But long terms risks and harms are not known. Clearly, there is significant risk of AKI post CABG and this might be the only preventive measure that we have that has come close to showing any benefit. 

As suggested by the editorial in JAMA, before RIPC is adopted for clinical use, the potential risks and adverse effects must be considered carefully.  

image source: circres.ahajournals.org

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