Nephro- hospitalists?- should we consider this

Not much has been written regarding the role of a nephro-hospitalists in the Nephrology literature. There is one perspective back in 2019, before the pandemic that discusses the evolution of nephrology as a medical specialty and addresses the challenges it faces, particularly the declining interest among medical trainees in pursuing careers in nephrology. The authors emphasize the importance of adapting to these challenges and propose a solution in the form of a nephrology hospitalist model.

The field of nephrology has evolved significantly from its early focus on kidney physiology to becoming an independent clinical specialty, particularly with the introduction of dialysis in the 1960s. While patient care was initially delivered primarily in hospitals, the growing population of individuals with kidney disease led to a shift in care to outpatient settings, with a recent emphasis on subspecialized training in transplantation, interventional, and critical care nephrology.

The decline in interest among medical trainees in nephrology careers is attributed to various factors, including a lack of mentorship, the complexity of kidney physiology, busy workloads, perceived lower compensation, and a perceived lack of innovation in therapies and dialysis.

To address these challenges, the authors introduce the concept of a nephro-hospitalist model, exemplified by the experience at Washington University in St. Louis. The model involves a dedicated nephrology hospitalist service comprising attending physicians focusing on inpatient care and medical education. Medical students and rotating internal medicine residents are preferentially placed on this service, and the model includes a flexible schedule of alternating periods of service.

The benefits of this model include improved teaching and mentorship for trainees, increased elective time for fellows, and the opportunity for attending physicians to foster specific interests. The authors highlight the positive impact on education and mentorship, which is crucial for attracting trainees to nephrology.

However, the authors also acknowledge the downsides to the model, including the need for an every-other-month schedule to prevent burnout and potential limitations in attracting new trainees. Financially, the model is described as roughly break-even, and the authors note that financial considerations should be weighed against the educational benefits.

The paper discusses other institutions that have adopted similar models with varying success and mentions the potential role of nephrology hospitalists in private practices, particularly to mitigate issues related to "windshield time" and electronic health record systems.

What have other fields done

Check out this regarding the role of onco-hospitalists and cancer hospitals.
Other fields such as GI and Neurology as well have adopted this model. 

It is possible that a full-time hospital-based nephrology model can be a valuable addition to nephrology education, providing increased attending contact and mentorship for residents and medical students. We should consider further exploration of innovative models to expose trainees to the unique aspects and satisfactions of nephrology, ultimately aiming to address workforce challenges and recruit future nephrologists.

Perspective: Interim report of ASN Task Force for Future of Nephrology 2022

 The ASN task force on the Future of Nephrology 2022 put out 10 important pointers for fellowship training. Here are the 10 pointers with my opinion on each next to it.

1. Enhance competency based Nephrology education: This is in line similar to COCATs in cardiology. 
I think this is a very important move as this will let us focus on the core topics in General Nephrology training. Overall, this is a win win for both fellows and programs

2. Individualize pathways for career goals: This is basically asking to create tracks so that each fellow can create a career niche. After basic general nephrology training, allow for time spent in various sub fields within nephrology( not an extra year of training). 
Personally, I am all for this one and have been promoting this at our center for last 6 years. This allows for selection of tracks and focus for each fellow. It makes their fellowship unique from the peers. Focused tracks can make this happen. At our center we do the following tracks and give a certificate for each graduate. But each track has requirements they have to fulfil under a small curriculum within a curriculum.  Yes, its time to just be creative over and over. 

3. Reconsider procedural training in Nephrology. Emphasis on removal of potentially placing of lines and performance of kidney biopsies. Instead, there should be focus on indications, knowledge of complications and if someone desires( individualized training), program should be able to offer the training. Emphasis on POCUS was mentioned.
This is the final straw for our procedures in nephrology but if you ask the fellows- most don't do it anyway post graduation- Its time for it to go. Smart Move by ASN. I don't think it should be required for ACGME and board exam to have done these procedures. Good focus on POCUS as we embrace the future. This is a win for fellows but not sure if a complete win for programs. Not all programs have faculty to teach POCUS. We need more faculty trained in POCUS to make this happen. Glad I learnt it from my fellow many years ago- truly has changed my practice.

4. Emphasize training in home therapies- Need more intensive training in PD and HHD.
This is a MUST for all. I think this is important for our patients and our trainees. A win for the fellows. Not a sure win for all programs as some programs may suffer due to lack of patients -- not their fault as its a system's problem at some centers. But this may raise the bar to make sure there is enough faculty who are comfortable to teach PD and HHD and enough volume. Not sure you need a third year for this but rather most fellows graduating should be able to comfortable prescribing and managing PD and HHD. Some fellows who want an academic career may want an extra year of training at specialized centers. 

5.Close gaps in current nephrology training. If there were gaps from the above 4 points, programs may need to partner with other societies to close those gaps.
I think this is a temporary solution. Eventually, this will evolve as most programs close the gaps

6. Promote well being of nephrology fellows. 
This was important and finally made it to a priority. This will help with burnout in our fellows. Working with NP/PA and restructuring programs will help with this matter. We must not forget our faculty and attending well being as we work on fellows well being. Neither should suffer.

7. Prioritize diversity, equity, inclusion and health care justice
I think this is extremely important. We need more diverse applicants and applicant pool in Nephrology. Diversity brings ideas and promotion of our field forward. 

8. Foster interprofessional practice.
This is important and our recent ASN Kidney News sept 2022 issue really highlights this. We are a kidney care team- all should work together. 

9. Ensure interdisciplinary practice. Working closely with cardiology, oncology, hepatology and other fields in medicine is critical for our training. 
This is a given but almost forgotten. Working with our colleagues closely will be important to foster collaboration and programs to help trainees for both sides. A classic example of this is centers that have created nephro-hospitalists,  cardio-renal services etc. 

10. Inspire lifelong learning
This is aspirational. This may happen but may not happen. This is individualized but if the program can create venues, programs to continue ongoing learning- this would be very helpful. 

Overall, I applaud the entire ASN workgroup on this venture!

GN Chat- a new initiative

 

The Glomerular Center of Northwell now runs a special monthly GN chat to discuss fun and interesting case based discussions of glomerular disease topics. This is on 3rd Tuesday of each month at 8AM EST

Register in advance for this meeting:

https://northwell.zoom.us/meeting/register/tJElf-iqqzgoE9edbml-AI1dNR07Q1LQOL-m 

After registering, you will receive a confirmation email containing information about joining the meeting.

Come learn GN in a coffee style manner with experts in the field- Purva Sharma, Jordan Rosenstock and Kenar Jhaveri

In the News: Nephrology training in the Pandemic Survey by ASN

 A survey done of renal fellows training during the pandemic has now been published.

The link is here https://data.asn-online.org/reports/fs_21/

Some key take home messages of this overall positive survey on our field.

1. Over 80% of fellows felt their program had successfully maintained education and conferences via video and over 80% felt that they were ready for independent practice. 

2. Over 80% of fellows saw patients virtually as outpatients and a small number during the inpatient rotations.

3. Burnout was high though during the pandemic ( women more than men)

4. Overall employment perceptions improved from years prior

5. More fellows RECOMMENDED nephrology as a field this time around( the silver lining of the pandemic)

6. Where are fellows going?  Nearly 90% start a clinical position, and 2% or so did general internal medicine. Remaining were industry, other fields and joint fields with nephrology

7. Median starting salary was 200,000 US$. Interestingly, IMGs got a higher base pay compared to USMGs. NO difference in female vs male salaries( a big win for Nephrology)

8.  Income guarantees ( by far ) was the most common incentive for the job they took, followed by MOC and CME support, signing bonuses, career development resources. 

9. Most fellows chose nephrology during residency. Sadly only 6% want to do a career in research. 

10.  And on a final note, during their training, only 14% placed dialysis catheters and did renal biopsies. This speaks volumes and perhaps its time we move on from this unfortunate loss of skills. Let's focus on training our fellows on knowledge and improving therapeutics. 

In the News: Performance trends of Nephrology fellows in certification exams

 A news flash paper published recently in JASN showcased the down trending test scores of nephrology fellows in certification exams. The authors analyzed the data from 2010-2019 and found that the pass rate has been falling below the bench marks. Interestingly, they found that the factors associated with this decline were lower internal medicine exam scores, older age and training in a smaller program. In addition, female sex and being IMG were also associated with a lower board score. 

The IM board score as a predictor can make sense as both exams evaluate knowledge and skills of reasoning. Age over 33 performed less well than younger candidates is interesting. This could be because of non medical factors. Even since 2009 when I took my boards, the knowledge level has changed. There is more and more to read and more diseases to understand in medicine. Residency has not changed, Fellowship years have not changed. While knowledge and science has advanced, we have not changed our ways to teach and perhaps even consider changing the timeline of residency and fellowship. Fellows have family and other commitments as well and a well balanced life-work-training is critical for our trainees. 

The fact that graduates of the least competitive nephrology fellowship programs(smaller programs) performed worse after regression adjustment indicates there might be a peer effect, or advantages of a structured program at a larger academic center. 

IMGs were less likely to score high.  The field of Nephrology has seen an increase in IMG applicants.  In 2019, IMGs comprised nearly 70% of those taking the nephrology exam for the first time, an increase of more than eight percentage points from 2010. We keep forgetting that everyone learns differently- not everyone has a structure of learning in multiple choice questions in rest of the world; there are language barriers and other factors that play a role as well. Fellowship programs need to explore non ppt format of teaching and novel ways to teach the same material for varied type of learners. 

Finally, women were found to have lesser scores. To my knowledge, not sure of any published papers showing this difference in test taking strategies. I don't think we need to take any stake in these findings as these might be not of any significance. The editorial nicely reminds us to not take this finding seriously. 

What should be done?
Why can't we test the fellows on what we really encounter rather than esoteric rare and confusing diseases. Why can't the tests really mirror the life of a renal fellow and attending?
Institutions need to take ownership on better techniques and strategies to help their fellows. Many residencies may not be training them in proper test taking techniques. Institutional and program resources must support trainees’ needs, protect their time, and ensure education is prioritized.  

I can say from my personal example of few fellow I trained- had trouble passing the boards due to their test taking abilities. Their patient satisfaction scores as attendings are off the roof and their overall understanding of both patient care and medicine is excellent. They may not be a good test taker, but they can manage a good census, take care of patients and call for help when needed and effectively communicate with other doctors. They win patient trusts, they do well with following up and most important of all- they care! and want to be Nephrologists that matter. 

While test scores are important, failures sometimes teach us to be better and improve our abilities to be the best at what we do. But regardless, this is a wake up call for our field to improve as instructors and teachers and not disappoint our students. 

ASN Kidney News All Education Issue 2021

 July 2021 is an entire issue of ASN Kidney News. See all visual abstracts related to the issue

2020: What a year for Nephrology

As we enter the end of 2020( finally), we are starting to see some hope for the vaccines as a lifeline as we enter the rising COVID-19 surge.  For nephrology, 2020 has been a positive and negative year. 

Let's start with the negatives:
1. Covid19 led to development of more AKI than we had imagined and several of those patients dying as a result. Very few survived the RRT-related AKI
2. Our dialysis patients had a tough battle leading to an increased mortality
3. Many transplant centers were on hold and several on the wait list had a high mortality and so did some of our transplant patients.
4. All conferences and meetings were virtual( taking away the networking opportunity for many)
5. All fellowship interviews went virtual( hard to assess candidates candidly)
6. Research ( non covid19) came to a halt and or was interrupted 

But there is a silver lining to the COVID19 pandemic for nephrology:

1. Increased data and outcomes research on AKI as a result of the pandemic
2. Rise of HOME dialysis ( which was dormant for years) came more to the forefront( including acute PD)
3. Rise of the Nephrologists as front line COVID19 warriors leading to perhaps more applications this year
4. SGLT2i studies infiltrating NEJM multiple times making a mark on diabetic and non diabetic kidney disease
5. Novel therapeutics in autoimmune renal diseases are on a rise
6. Virtual conferences allowed for more quicker and swifter transfer of knowledge ( and more attendance)
7. Collaboration on research rose super fast with trials such as STOP-COVID
8. Gender and Ethnic diversity was evident in Kidney week this year and kept it's strength in 2020
9. More incentives and compensations increases for nephrologists will reign in 2021
10. Increase interest in subspecialization in Nephrology 

Nephrology Workforce ( entire ACKD issue)

An entire issue devoted to Workforce in Nephrology just published in ACKD. Matt Sparks and Samira Faroukh really takes us via an amazing ride of articles. Here is a list of the topics and articles and a collection of visual abstracts. I really admire this issue and salute the editors on doing this task. As we are at the crossroads of nephrology renaissance- this issue is very timely. Hope we can inspire more residents and students to enter the ever growing nephrology workforce. 

Reenvisioning the Adult Nephrology Workforce: The Future of Kidney Care in the United States

Current State of the Workforce in Nephrology

Current Paradigms and Emerging Opportunities in Nephrology Training

International Medical Graduates in Nephrology: A Guide for Trainees and Programs

Current State and Future of Research in Nephrology

The Nephrology Clinician Educator: Pathway and Future

Opportunities for Subspecialization in Nephrology

Critical Care Nephrology Workforce

Transplant Nephrology Workforce

Interventional Nephrology Workforce

Palliative Care/Geriatrics Nephrology Workforce

Private Practice Nephrology Workforce

10 Years of Nephrology Social Media

10 years and a few months ago, I wrote the first nephronpower post. It was simple and about a historical event in nephrology. My inspiration was the Late Nate Hellman from Renal Fellow Network. What has transpired since then is truly amazing for the field of Nephrology.

Few of us started blogging at National conferences, some of us tweeting like a storm. Finally, the academic community noticed this and soon ASN, NKF and all wanted tweets and blogs of their events. The first landmark paper summarizing some of this was in AJKD in 2011.

Following that, was the birth of AJKDblog or then called eAJKD. This allowed for more collaboration and more social media to flourish in nephrology and leading to the ultimate- Nephmadness ( mastermind game by the Topf Sparks team) in 2013.

After 2013, nothing was stopping nephrology to take the lead in social media.
From NephJC to tweetorials to whatsApp to creation of NSMC-- happening so fast and furious!

Nephrologists quickly stormed the social media world to lead and show how it's done!
In NDT is a brief tutorial for how to be social media savvy.

Academic journals- AJKDBlog
Journal club- NephJC
Well ironed blogs- Renal Fellow Network
Online Successfully run interactive game for over 7 years- Nephmadness
Online academy of educators for future social media wannabees- NSMC
Every fellowship program trying to have a twitter account and social media presence.

What else can you ask for?
All this is summarized in recent issue in Seminars in Nephrology by guest editor Joel Topf and includes all various aspects of the social media
Here is a nice tweetorial by Chan on the entire issue

Seminars in Nephrology has an entire issue devoted to social media in the discipline of nephrology.

The mastermind @kidney_boy highlights the contents here:https://t.co/1XhYQLpEyS pic.twitter.com/OQs757SxmI

— Teresa Chan (@TChanMD) June 20, 2020

Introduction to social media
Tweet or not to tweet
Twitter based journal clubs
Tweetorials
Podcasting
Newsletters
Visual abstracts
Slack
Semi-private Apps ( WhatsApp)
FOAM quality 
NSMC

Congratulation to the nephrology community to being leaders in education via social media in medicine!

Coming in May of 2020- A glomerular disease conference at Northwell

An Update on Glomerular Diseases, 2020

#northwellGN2020

Saturday, May 2, 2020

7:30am to 6:00pm

North Shore University Hospital

300 Community Drive

Manhasset, New York  11030

@hofstrakidney

Registration information to follow in few weeks 

			Visiting Faculty Gerald Appel, MD Barry I. Freedman, MD Richard Glassock, MD Duruvu Geetha, MBBS Brad H. Rovin, MD Shikha Wadhwani, MD,MS
	Northwell Health Faculty Vanesa Bijol, MD* Steven Fishbane, MD* Kenar D. Jhaveri, MD* Hitesh H Shah, MD Purva Sharma, MD * Nupur N. Uppal, MD * Course Directors

8:00AM                            Introduction Kenar D. Jhaveri, MD 

8:15AM                            Membranous Nephropathy in the PLA2R era Richard Glassock, MD,

9:00 AM                           Thrombotic Microangiopathies, A novel approach, Vanesa Bijol, MD

9:45 AM                           ANCA and Anti GBM disease in 2020- some old and some new, Duruvu Geetha, MBBS

10:15AM                          Break and exhibits

10:30 AM                         SGLT-2 inhibitors, diabetic nephropathy and beyond!! Nupur N Uppal, MD

11:10 AM                         Treating the right clone- Paraproteinemias Kenar D. Jhaveri, MD

12:00 PM                         Lunch and exhibits

1:00 PM                            MPGN, C3GN..a paradigm shift. Shikha Wadhwani, MD,MS

1:40 PM                            Drugs, Chemo, Toxins—and the glomeruli.  Hitesh H Shah, MD

2:15 PM                            IgA Nephropathy- treat or not to treat. Gerald Appel, MD

3:00 PM                            Podocytopathies, Clinical approach and treatment.  Purva Sharma, MD

3:40 PM                            Treatment of Refractory Lupus Nephritis, Brad H. Rovin, MD

4:15 PM                            Break and Exhibit

4:30 PM                            Did you find my gene for the glomerular disease??. Barry I. Freedman, MD

5:00PM                             Case Studies in Glomerular diseases, Vanesa Bijol, MD Purva Sharma ,MD and Kenar D. Jhaveri,MD

In the NEWS: NephSim as an educational tool

Nephrology education related published work is sparse. NephSim, a mobile optimized website tool with cases and interactive approach was developed in 2018. Over 24 cases have been presented and discussed in this tool. Case contents have been amazing. But what the creators of this tool now did is- validate it with a peer reviewed publication. Recently published in JGME, a med ed journal, Farouk et al showcase the NephSim tool and discuss the results of their outreach of this tool and a survey that showed high rate of satisfaction and usability.

Innovation in Nephrology education is extremely important. Case discussions leading to differential diagnosis and then pathology and diagnosis helps in creating and making a Nephrologist a better diagnostician. The NephSim project also showcases the use of website, social media platforms such as twitter and other ways to share information.

This tool can easily be replicated in other fields in internal medicine or medicine. The ease of using and doing the cases makes it very accessible and able to be transformed in all fields in medicine. The drawbacks- survey response was low but enough to make major conclusions. But like most med-ed studies, it touches the first tier of outcomes- medical knowledge (self-assessed) and not addressing other ways of medical knowledge. We hope to see using some of these tools used( perhaps in combo)- such as NephSim, Nephmadness, Whatsapp, blogs, NephJC. Etc—to change practice patterns, behaviors and ultimately effect patient outcomes.

Topic Discussion: Do Renal consultations matter in surgical and cardiac ICU patients

AHA moment arrived when I saw this article in AJKD on interdisciplinary collaboration of nephrology with surgical and cardiac surgery ICUs. It was a qualitative study highlighting some of the conversations that happen in the CTICU with the nephrologists and what is “felt” about renal consultations.

https://www.ajkd.org/article/S0272-6386(19)30853-4/fulltext

This is an important topic that we encounter as consultants. Often, we get urgent calls from the ICU, for example CTICU , “ Doc, we need an urgent consult, this patient post CABG is oliguric now and crt rose from 1 to 1.4mg/dl and we need urgent CRRT, and we placed the dialysis catheter already for you…”
Now this situation is not uncommon… how does one respond to that..
Either you say, “ gee. Thanks for that and I will come evaluate and decide if I even need to use that catheter as they might not need dialysis..”  What is the role of the Nephrologist in some of the surgical run ICUs.? Are we seen merely as technicians or truly thoughtful physicians that make decisions that will or not alter the care of the patient..

The article really highlights this very important issue. Some of the major themes highlighted are listed below

1.      There was almost an absent influence of renal decisions in some of the surgical and CTICUs; this stemmed from many surgeons and intensivists not sure of the renal fellows decisions not going along with attending nephrologists decisions. In my opinion, many times and at many centers-they bypass fellow based consult services and call attendings only for that reason.

2.      Nephrology fellows and attendings found it hard to communicate to CTICU staff as the PA or NP would not really be making that decision and the final decision came from the surgical head of that patient ( who often is not in the unit)

3.      Nephrology fellows might not realize the hierarchy noted in some of the surgically based ICUs compared to MICUs.  This is interesting as the first time we encounter surgical culture in depth is during renal fellowship( 3 years in medicine- we usually are kept away from SICU, CTICU and NSICU)

4.      What I found totally astonishing was one of the comments made in box 2 by an NP that was interviewed is that “renal was the only service we had to call to get something done as We can’t just order dialysis” – and hence making us seem like just a dialysis ordering physician

5.      It also goes into details on who manages the fluid removal once CRRT has been started. It is an ongoing battle. Often this leads to conflict and at many centers, Nephrologists have given up CRRT ordering and management to ICU intensivists( sad but true)

6.      Due to our consult note and recommendations have no value- many times- there was early signing off of the consult- as “ if they are not listening to our recommendations anyway – why bother writing a note everyday…” Not uncommon to see in this unit.

7.      While Nephrologists thought they were best valued to understand AKI and noted a good nephrologist is a good internist. Meanwhile, surgical staff didn’t believe that and felt nephrologists were mostly dialysis gatekeepers and didn’t feel we understood AKI in the overall ICU status and ordering tests of diagnostic significance were not very valuable.

8.      The role of nephrologists being dialysis proceduralist clashed nephrologists value of preventive medicine mainly in the CTICU. From a surgical perspective, a consultation that doesn’t offer any valuable intervention such as dialysis to help the acutely ill patient is useless. – heard that one before many times

9.      The most common disagreements were on when to do dialysis, timing of initiation and managing fluids—the most common we see in practice anyway. It is not uncommon where I have written “ stop diuretics” but they are continued and then days later I am starting them on RRT.  But there have been also times where I have said “ stop diuretics” and they continued and they did better by not listening to me.  So in general, does our opinion matter?

10.   Interesting, surgical and CT ICU staff viewed dialysis as a tool to get rid of the kidney problem whereas we see it as a last resort before trying all medical maneuvers.  One comment was really funny, In box 3, one of the nephrologists interviewed said “ they view most of us as technicians. Just like anesthesia can just put the person to sleep, just put a tube and no big deal- anyone can do it, you can slap someone on dialysis, no big deal.”.  My favorite one I get called is “ can you come and spin him”

11.   Finally, due to history of these interactions, nephrologists and nephrology fellows avoided the controversial issues. Many times, this led to resignations from the case.

12.   Lot of these changes are due to different medicine vs surgical cultures.

How do we fix this? Can we fix this? The authors describe this is discipline siloing leading to ineffective collaboration amongst fields of medicine. This is important to break and learn. This will be critical as it can harm patients if gets escalated and neglect ensues. We need to understand the other persons perspective and realize that all physicians have one medical school, residency and fellowship—we all bring in some value to the patient. We need to respect and honor each other’s fields of medicine.

When I showed this article to one of our CT surgeons, his/her reaction was merely to dismiss it. My fellow and I were hoping for more of a conversation to improve this encounter.

Then the next day, in the CTICU, we see that the curtains are closed and one of the rooms was having open heart surgery happening in the middle of the ICU – for an urgent mater.  We were just amazed at the life saving nature of their field in medicine… it is just amazing what they can do. And I told my fellow, “ if they can make the ICU bed an OR instantly, their assumption is that dialysis can happen instantly and at any place- even in the OR..” We have to understand that they come from a different perspective.  Once we start understanding that, we may be more welcoming of their way of thinking. Similarly, at some point, perhaps they can understand our physiological approach to certain things and preventive nature of AKI and that dialysis is a procedure and not the first thing we should be doing..”

Topic Discussion: Artificial Intelligence in Nephrology

Artificial intelligence(AI) is on a rise in science. Using it in medicine and specifically nephrology is sure to come.

According to the dictionary, AI is “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages.”

Dr Eric Topol has been a big proponent of this concept in medicine for years and recently has written a book called “Deep Medicine “ that details the potential uses of this in medicine.

Basically, AI can help in three main ways: 1) diagnosis that is often challenging in various challenging syndromes and even basic common ones. 2) make the physician’s life easier and decrease paper work and finally leading to the third -the most important 3) spending more time at the bedside.

AI is done via creating an  artificial neural network (ANN ) which is simply a collection of artificial neurons organized in layers. In a recent article in AJKD, authors discuss the potential use of this concept in Nephrology. They describe using it for IgA nephropathy(IgAN) as a recognizable cause for AKI. The ability to identify the patients that will progress to ESRD with IgAN would be useful for prognostic and therapeutic reasons. Geddes et al hypothesized that there exists a function that associates clinical and biological parameters measured at the time of IgAN diagnosis (namely age, sex, blood pressure, proteinuria, serum creatinine level, and antihypertensive treatments) to the probability of developing progressive IgAN. The authors designed and implemented an ANN to approximate this function. The results showed that their ANN could predict the occurrence of progressive IgAN more accurately than experienced nephrologists (correct predictions, 87% vs 69.4%; sensitivity, 86.4% vs 72%; and specificity, 87.5% vs 66%). Hmm, now this might be interesting to help guide a lot of therapies in Nephrology. This might be very useful in transplantation and prognosticating even need for dialysis for the elderly CKD patients.

Interestingly, many AI algorithms have been approved by FDA that are used in clinical practice:- some examples are of Atrial fibrillation detection, EF ECHO determination, Coronary calcium scoring, CT brain bleed diagnosis, device for paramedic stroke diagnosis, breast density via mammography to name a few.  No nephrology related such algorithms are approved to my knowledge.

There is an entire journal dedicated for this in medicine now

https://www.journals.elsevier.com/artificial-intelligence-in-medicine

Nephrologists, let’s get started and catch on!

HATs off to Nephrology: The various HATs of a nephrologist

As I finished my 2 weeks on consults, I just realized why I love nephrology because it let's me wear various types of HATs

Day 1:- Consult 1: - Minimal Change Disease on kidney biopsy- starting steroids, no secondary cause. Nice GN to start the day ( putting on the GN hat)

Day 2: Consult 3: AKI on CKD in someone with CHF, getting diuresis but serum creatinine rising. Intern says, we stopped diuresis as AKI ensued.  On exam, +JVP, + B lines on our portal lung US exam, Ascites and + LE edema. Dear Intern, please don’t be nephrocentric but continue diuresis as this is renal venous congestion and bingo- 2 days later serum creatinine downtrends. Pre renal success shall we say( putting on the critical care or cardioneph hat)

Day 2: Consult 5: Na of 167, Diabetes Insipidus, bring on the ddavp please!( putting on my electrolyte hat)

Day 3: Consult 3: AKI in someone getting vanco-zosyn combination, rising vancomycin levels and creatinine going from 1mg/dl to 5mg/dl in 3 days. Kidney biopsy confirms ATN/AIN.  That vanco-zosyn combo is becoming lethal to the kidneys. How many drugs can we stop? – NSAIDS, PPIs, Vanco-zosyn. I feel like the medication police!( putting on my AKI hat)

Day 4: Consult 4: Hypomagnesemia severe enough to be admitted 3 times. PPI still on board and FeMg<2%.  Sorry but those PPIs are causing Ulcers for us the Nephrologists!( putting on my electrolyte hat)

Day 5: Consult 5: AKI in a 85 year old with MODs, septic shock and overall poor prognosis. Surprise question asked and dialysis not offered. Palliative care nephrology is important as well. Not every patient is an ideal dialysis candidate( putting on our palliative care nephrology hat)

Day7: Consult 6: Hypercalcemia and an elevated 1,25 vitamin D level- lymphoma, TB or Sarcoid and the only hypercalcemia that responds to steroids!!( putting on the onconephrology hat)

Day 8: Consult 2: AKI with someone with severe AS. Diuresis begins but guiding volume management is a tough decision. Severe AS scares me. Point of care lung US daily assessing for B lines guides management proves to be a great addition to our physical exam.( putting on the ICU nephrology hat)

Day 9: Consult 1: AKI, low platelets, low hemoglobin, rising LDH, down-trending haptoglobin and worsening HTN—bring on the TMA team. From what- virus, systemic disease, complement deficiency, not sure—but oh well onconephrology rocks! ( putting on the onconephrology hat)

Day 10: Consult 1: HTN HTN, HTN severe HTN—adrenal mass, and record high metanephrine levesl- pheochromocytoma in the house!, get the surgeons and endocrine on board( putting on the HTN specialist hat)

Day 11: Consult 2: Hyponatremia 127 but serum osmolality is 290. Hmmmm!! Paraproteins made an appearance and masquerading myeloma- more onconephrology! ( ofcourse this hat comes twice)

Day 12: Consult 3: Acute ESRD, doesn’t want HD--- but would consider acute PD –so urgent start PD done.. The new wave in PD care. Not every patient needs HD, you can in the right environment get urgent start PD and get PD arranged as outpatient- we need to make this mainstream. ( putting on the ESRD hat)

Day 12: Consult 4: AKI and proteinuria in someone with history of SLE. Kidney biopsy shows nodular sclerosis and diabetic nephropathy. No active lupus. Not all kidney biopsies in SLE are lupus nephritis.( putting on the Rheum-Renal hat)

Day 13: Consult 1: AKI, proteinuria - biopsy confirms Post infectious GN, ongoing infection treatment needed. ( putting on the GN hat)

 

Now with the above case listing- wouldn’t you feel so excited. This is why Nephrology is so much fun!! Which other field in medicine allows for so much variety!