Thursday, June 21, 2018

Topic Discussion: Need for training in Kidney biopsies

Kidney biopsies are an integral part of Nephrology. In the last decade, nephrologists are slowly shying away from performing this procedure. Both in academia and private practice, the procedure is being slowly and surely diverted to dedicated hands of interventional radiology. In certain centers, the nephrologists still perform and teach fellows on doing this important procedure. Recently, 4 opinion articles in CJASN discuss the pros and cons on continuing to teach the kidney biopsy procedure to our fellows.

Bob Brown discusses a balanced form of approach. While the arguments for doing the kidney biopsy are obvious , the counterarguments that kidney biopsy performance should no longer be a requirement for nephrology certification are that about 65% of practicing nephrologists do not perform biopsies  and the standards for evaluating biopsy competency of graduating fellows are not defined despite the risk of the procedure. In United States nephrology training program directors survey, 45%–51% thought that biopsy competency should not be required for fellowship completion.

Stuart Shankland takes the con approach and discusses the reasons not to require fellows to be doing catheters and kidney biopsies. He takes a patient centered and safety approach.  Having the radiologists who do this on a daily basis perform the procedure provides a more safer environment than the nephrologists doing it.

Jeff Berns takes the pro approach and discusses the reasons that require the fellows to be doing catheters and kidney biopsies.

Suzanne Norby gives a program director’s perspective and provide a framework for the need for fellowship training.

Personally, I feel conflicted. As a fellow, I learnt doing kidney biopsies and enjoyed doing them. Since I am in teaching institution and part of a fellowship program,  I feel that teaching the fellows kidney biopsies is important and I make time for doing kidney biopsies and teaching fellows. If I was in community private practice, I doubt I would have done the same.  While it is a great asset to have, the time commitment is enormous from booking the room, getting supplies and setting up the table and so forth.  Divisions that have their own interventional nephrology suites or biopsy suites might have it easier and faster to perform these biopsies. A twitter conversation that started this discussion is very interesting to see. It adds to the 4 articles that were published in CJASN.  
Second set of tweets start a more interesting discussion

I am impressed and congratulate CJASN on this amazing venture on such articles that really bring the tough questions to the table for nephrology. First set of tweets are an unofficial poll that was stated on this topic.

Monday, June 18, 2018

Concept Map: Secondary IgA Nephropathy

A recent article in Kidney International discusses a forgotten concept in Nephrology, secondary causes of a particularly common GN- IgA nephropathy. While these disorders are associated with IgA nephroapthy, keep in mind this is by far the most common GN in the world- so might be true true and unrelated as well.

Wednesday, June 6, 2018

Monday, June 4, 2018

NephroWorldCup: Football and Nephrology: GOOAAALLLLLLL!!!

Image result for nephro world cupEvery four years the competitive world of sport comes to a stop. Millions of friends and family gather around the television in order to watch their most beloved nations compete in the largest sporting event on Earth: The FIFA World Cup.

From a team of international nephrologists, here comes a game to play along as you watch FIFA world cup for soccer(football). 

More often that in the World Cup, nephrologist and other professional around the world gather in meetings, congresses, symposia, etc. The objective is to learn about the latest research and meet the brightest minds in our medical field.  As in football, controversies arise, people choose sides, they root for their chosen trial, and they engage in small methodological skirmishes with the “referees” (the moderators at round tables).

Overall, both activities (football and nephrology) develop  camaraderie, foster learning, and generate personal fulfillment. 

Nephrology has grown its presence on social media and we decided to bring a new educational initiative into the world of nephrology social media. The ISN education team is very happy to announce that the combination football (soccer) and nephrology, and the creation of The Nephrology World Cup 2018.

Thirty-two (32) countries selected from the same roster as the 2018 FIFA World Cup will face off against each other in a first-of-its-kind educational experiment. The Nephrology World Cup Organizing Committee has selected a nephrology research paper published by a team of professionals from each country, especially if this paper was published by the local nephrology society. The selection criteria allows us to showcase some of the amazing scholarship and research that is being done around the world.  The ISN team has added user interactivity to make the Nephro World Cup both educational and fun.  

The friends from @ISNeducation bring you this educational initiative.  Feel free to root for your country and cultivate conversations amongst your colleagues and friends. The work has been done using open source tools and the game is free to play.

For rules and how to win prizes, see below for manual.

If you want to know more about this (rules, prizes, etc.) please follow any one these links:
Instruction Manual:
Registration and Group Play:
Facebook Conversations:

Play the 2018 Inaugural Nephrology World Cup!  Good luck and may the best nation win!

Monday, May 7, 2018

Topic Discussion: Intravenous Fluids and the Kidney

Specific fluid
Fluid Type
Effect on the kidney
Lactate Ringers

SMART  and SALT-ED trial, NEJM 2018 and SPLIT trial JAMA 2015

0.9% Saline

? more metabolic acidosis, ?AKI
SMART and SALT-ED trial, NEJM 2018 and SPLIT trial JAMA 2015

None to our knowledge

Hydroxyethyl starch

Bad, AKI, osmotic nephrosis leading to more RRT

Pentastarch( low molecular weight Hydroxyethyl starch)

Bad, AKI, osmotic nephrosis leading to more RRT


Bad, AKI, osmotic nephrosis



Tuesday, April 24, 2018

Topic Discussion: Renal Cell Cancer for the Nephrologist

An amazing review just published in Kidney International is a must read for all nephrologists. It takes us from an oncology and urology world and how the world of RCC ties into the renal hands.

The first part of the review focuses on the genetics and molecular aspects of RCC
In the risk factor section, besides genetics, it is important to remember some of the other non genetic risk factors such as Chronic end-stage renal disease on dialysis, Obesity,Smoking,Hypertension
Exposure to dry cleaning solvents,Exposure to trichloroethylene,Diuretics( this is interesting), Radiation therapy,Phenacetin,Arsenic,Cadmium,Sickle cell trait and disease,Nephrolithiasis
Chronic hepatitis C infection( another interesting point).

A bidirectional link is discussed with CKD and RCC that is very important to remember

The best part of the paper is how one approaches a patient with RCC and potential for AKI or CKD post.

Unfortunately, the treatment options for RCC post nephrectomy are potentially also nephrotoxic-- anti VEGF agents, TKIs, and now check point inhibitors.

A must read for all!

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