SPECIAL: Resident's view on Nephrology

What Inspired me about Nephrology?  

I always found physiology interesting in medical school  In residency, I was faced with  many good choices  "Nephrology vs Cardiology vs Pulm critical care." After rotating through each subspecialty I was confident what was the best field for me- Nephrology. I enjoyed the multifaceted part of nephrology- the dialysis, transplant, electrolytes and glomerular diseases. As a resident, I was seeing inpatient consults but also had experience in the  outpatient clinics, transplant clinics, peritoneal dialysis patients, hemodialysis patients, and procedures ranging from simple "Procrit " shots to kidney biopsies and femoral catheter placements.  

Mentorship played a major role in my decision as well. Not only the field was interesting but the people who I dealt with were approachable and great physicians.  As opposed to other specialties, whereby i would be just another face in the crowd, nephrology made me feel special.  I feel like embracing a resident, taking the time out to  expose them to the field as much as possible, and having a one on one sit down with the chairman, program director, associate program director and attendings speaks for itself.  I am glad I am considering nephrology.

 -Seyyar Khan PGY3 Internal Medicine 

Rise of Interventional Nephrology

Interventional Nephrology – Opportunities Ahead

Over the past century, the field of nephrology has evolved with the successful performance of hemodialysis by G. Haas in 1925, cutting needle kidney biopsy in 1951 by Iversen and Brun, and kidney transplant by Murray and Harrison in 1954. Over the last 5 decades, the field of nephrology saw immense improvements in the technology that support these therapies leading to remarkable change in the quality of care. The introduction of Interventional Nephrology in the late 1990’s has invigorated enthusiasm to the field of Nephrology.

The “bread  and butter” of Nephrology practice revolves around providing adequate dialysis therapy. With the technological innovations, dialysis therapy is now mainly provided by the supportive staff and dialysis centers have been converted in to “well-oiled treatment factories”. Interventional Nephrology brings in a new ray of hope and turns a mundane fellowship into a challenging ‘hands-on skill’ oriented field.

The pioneers of the field, Gerald Beathard, Steven Ash and Jack Work were able to form the American Society of Diagnostic and Interventional Nephrology in 2000 (www.asdin.org), with a mission to promote the procedural aspect of the practice of nephrology. ASDIN has developed training and certification guidelines that are vigorous and well respected by most hospital credentialing committees.

Interventional nephrology includes a variety of procedures - renal ultrasonography, placement and removal of tunneled hemodialysis, placement of peritoneal dialysis catheters, angiography and balloon angioplasty for vascular access stenosis (including central veins), endovascular stent and coil placement for dialysis access dysfunction, and thrombectomy procedures for clotted vascular access. The training for these procedures, which began primarily in the private arena has evolved over the past decade and gradually is being adopted by academic centers. The new field has clearly made a positive impact on the care of dialysis access. Further, Interventional Nephrology is being recognized as a potential tool to attract new trainees and eventually improve the dwindling nephrology work force. The critical balance between the intellectual component, procedural skills and lifestyle hopefully will make it attractive for the future generation of trainees to choose nephrology as a career.

Post by

Dr Tushar Vachharajani

Interventional Nephrologist

In the News: Sub group analyses in Nephrology trials

A subgroup analyses is an evaluation of the treatment effect in subgroups of patients defined by baseline characteristics. The main purpose of doing these analyses is to provide a better understanding of the treatment effect heterogeneity. Often, these analyses tend to deviate from this purpose and mislead the reader and may potentially have adverse clinical practice implications.

To demonstrate fallacy of the subgroup analyses, a recent paper in CJASN by Fishbane etal conducted a thorough literature search of the nephrology RCT’s published between July1, 2010 and June 30,2011(included review of nephrology and transplantation journals and four general medicine journals-NEJM, Lancet, Annals of Internal Medicine and Archives of Internal Medicine) The authors found that approximately one third (37.3%) of the published nephrology RCT’s reported subgroup analyses. They found major deficiencies in reporting in the nephrology trials.

1. The majority failed to pre specify that a subgroup analyses would be performed (77.4%). Failure to prespecify diminishes the credibility of the results. 

2. There was an almost uniform failure to list all subgroup variables analyzed. Failure to do so suggests the possibility that numerous analyses may have been conducted in an effort to find a positive result.

3. Statistical testing was inappropriate, with a test of interaction reported in only 35.3% of subgroup analyses. 

4. It is very common to claim treatment effects based on separate tests for each level of subgroup. In addition, when subgroup analyses were discussed, there was a frequent failure to note the limitations of the analyses and discuss that the results should be viewed with caution. Positive claims are common in discussion sections, with general over interpretation of the importance of the subgroup results.

Fishbane et al summarize their recommendations for reporting of subgroup analyses. Subgroup analyses may be helpful for suggesting heterogeneous effects of treatments, but the results may be misleading and over interpreted. 

Post by Dr. Ashish Kataria, Fellow in Nephrology. 

Obesity and ESRD

CONSULT ROUNDS: Tumor lysis syndrome 2

What dialysis modality is the best for TLS?

On one hand you can have severe hyperkalemia that might require urgent hemodialysis and on other hand there is constant catabolic turnover that might require a continuous modality.

1. Treat the life threatening electrolyte disorder first namely hyperkalemia and might need few hours of HD followed by continuous form of dialysis (CVVH, CVVHD, CVVHDF) to prevent rebound hyperkalemia and combat the catabolic breakdown.

2. The phosphate clearance might be best achieved via a continuous modality in such cases.  High dialysate flows might be necessary.

3. Peritoneal dialysis is usually not recommended mainly because it cannot clear uric acid well.

Topic Discussion: Vitamin D receptor and Renin angiotensin system

Opiate addicts are prone to infection and this has been attributed to ongoing lymphopenia. Morphine is one of the commonly used opiates in pain management.  Morphine is also an active metabolite of commonly abused drug, heroine. Recently, vitamin D receptor (VDR) has been demonstrated to play a role in immune cell function. 

We evaluated the role of VDR in the activation of the renin angiotensin system (RAS) in morphine-induced T cell loss. Morphine treated human T cells displayed down regulation of VDR and the activation of the RAS. On the other hand, a VDR agonist (EB1089) enhanced T cell VDR expression both under basal and morphine-stimulated states. Since T cells with silenced VDR displayed the activation of the RAS, whereas, activation of the VDR was associated with down regulation of the RAS, it appears that morphine-induced T cell RAS activation was dependent on the VDR status. Morphine also enhanced reactive oxygen species (ROS) generation in a dose dependent manner; however, this effect of morphine was inhibited by an opiate receptor antagonist, naltrexone. These findings confirmed the role of opiate receptors in morphine-induced ROS generation. Interestingly, the activation of VDR as well as blockade of Ang II (by losartan, an AT1 receptor blocker) also inhibited morphine-induced T cell ROS generation. Morphine not only induced DNA damage in T cells but also attenuated DNA repair response; whereas, activation of VDR not only inhibited morphine-induced DNA damage but also enhanced DNA repair. Morphine also promoted T cell apoptosis; however, this effect of morphine was inhibited by blockade of opiate receptors, activation of the VDR, and blockade of the RAS.

These findings indicate that morphine-induced T cell apoptosis is mediated through ROS generation in response to morphine-induced down regulation of VDR and associated activation of the RAS.

For full review click here. 

Post by Dr. Pravin Singhal
Professor of Medicine

A resident's view

The renal elective in our institution has allowed now to have residents participate and see the side of nephrology that they might have never seen before- transplantation and peritoneal dialysis.  One of the residents penned her thoughts on her blog about the experience of seeing the transplantation side of nephrology.  Please check out this very well written commentary on her blog.