Donor evaluation and follow ups- a new ruling!

How do most kidney donor's do long term? Studies have shown that donors actually do better than normal population. Certain risks have been identified. Racial disparities also have been found. A recent New York Times posting discusses the advent of the donor follow up structure to me more strict. A better safe guard system, making sure the risks of donation are discussed with all donors and appropriate follow up for certain period of time were things that were discussed. Although long-term data on the donor evaluation is scarce, few living kidney donors are thought to suffer lasting physical or psychological effects. .The Organ Procurement Transplant Network/United Network for Organ Sharing (OPTN/UNOS) has increased the amount of data collected before and after donation and increased the duration of donor follow-up to 2 years, yet there is evidence that reporting is incomplete. A recent article from the Mt Sinai transplant center argued that the US government must provide funding to support a donor follow-up registry that can allow for meaningful and valid conclusions on how we are doing as a community for our donors. Based on the new policy discussed in the NY times article

1.       By 2015, transplant programs will have to report thorough clinical information on at least 80 percent of donors and lab results on at least 70 percent. The requirements phase in at lower levels for the next two years.Dr. Stuart M. Currently 9 of 10 hospitals would currently not meet the new requirement.

2.       The medical and psychological screenings that hospitals must be conducted for potential donors. ( this is usually done internally at most centers although may not be uniform)

3.       The new policies also require that hospitals appoint an independent advocate to counsel and represent donors, and that donors receive detailed information in advance about medical, psychological and financial risks. ( Donor Nephrologists and teams usually have separate meetings from the recipient evaluations and this is likely done at most centers but probably not standardized)

Perhaps these regulations and rules will make the process safer and better for our donors. 

IN THE NEWS: Nephrology NEJM showcase

Latest offerings in NEJM highlight nephrology articles:

One of them is comparing ultrafiltration to diuretic use in cardio renal syndrome(CARRESS-HF).
Interestingly, ultrafiltration performed inferiorly compared to a catered diuretic regimen in a randomized controlled trial. Does it end the role of UF? Or is SCUF still a consideration. An editorial attached still says slow and steady might be preferred.

ADPKD and treatment with aquretic treatment is the next major article. The TEMPO trial showed this using tolvaptan. Can this drug show promise in protecting renal function in ADPKD.

EVOLVE trial looked at cinacalcet in ESRD patients in a randomized trial and evaluated cardiac endpoints and found shockingly negative results.

ALTITUDE trial evaluated adding aliskiren to other renin angi inhibitors in DMII for cardio renal end points and found harm and no significant benefit.

3 negative trials
1 positive trial

Evidence based medicine keeps knocking off physiology based medicine in Nephrology.

First Annual ASN Fellows in Training Bowl( FIT Bowl)

This year the American Society of Nephrology 2012 Kidney Week at San Diego did  a case based fellows competition at a national level. My college Dr Hitesh H. Shah and myself had the honor to host and present a case to the fellows at ASN Fit Bowl. The competition was based on the recent work from our division on "case based debates".

The fellows were chosen ( 5 in each team) from different programs around the world. Adult and Pediatric nephrology training programs were included. A case was given out to them with scanty information 2 days prior to the event. The day of the case presentation and debate, the teams are challenged to order tests and imaging and try to come up with a differential diagnosis as they order the tests and get the final diagnosis. The tests appear on a power point board as options to choose from. Each tests carried negative and positive points. All tests needed an explanation to win the point. The team that got the most points would give their final diagnosis and ultimately read the biopsy slides. 

Dr Surya Seshan from Weill Cornell Department of Pathology was our pathologist on board to help them discuss the pathology findings. Audience included program directors, and many fellows who were attending ASN. Both teams did a fantastic job and got the final diagnosis. 

Hope to have ASN do this every year as it allows for fellows to look forward for something at ASN and have a friendly competitive spirit. It allowed fellows from different programs meet and get to know each other and work well together to come up with a diagnosis. 

We hope the fellows learned and had a good time.

Are Nephrologists and their patients ready for Natural Disasters?

As the world witnessed a major hurricane on the north east coast of USA last few weeks, were most dialysis facilities ready for such a disaster? Most dialysis patients are not prepared to effectively handle man made or natural disasters as suggested by a study done by UNC Chapel hill in 2011. This was based on a survey and they found that all dialysis centers had a disaster preparedness program in place, but most patients were not well-prepared for a disaster, only 43% of patients knew of alternative dialysis centers and 42% had adequate medical records at home that they could take with them in short notice. Only 40% had discussed the possibility of staying with a friend or relative during a disaster. Only 15% had a medical bracelet or necklace they could wear if they were forced to leave their homes. Age, gender, race, education, literacy, and income did not affect disaster preparedness. 
Following hurricane Katrina, the hospitalization rates of dialysis patients had increased. This might be a similar trend that was likely observed in hurricane Sandy. While certain hospital shut downs happened in NYC, there has to have been increased hospitalizations and transfers to other dialysis units. Such situation add to the patient's stress and misery of their disease burden. 
Fukagawa also discusses what nephrologists might be able to offer to their patients in natural disaster such as earthquakes.  A diary of a nephrologist during the recent Japan earthquake is worth a read. Crush injuries are not uncommon in such disasters and recommendations are present for that as well. Some novel innnovation have also been issued to help in such situations. 
In weather related emergencies, the nursing supervisors and dialysis nursing staff have exemplified their role and leadership. Most of the literature on disaster preparedness comes from the nursing literature. As a nephrology community, we need to be more aware and prepare our patients for weather related emergencies. 

Ref:
http://www.ncbi.nlm.nih.gov/pubmed/18156850
http://www.ncbi.nlm.nih.gov/pubmed/19260605
http://www.ncbi.nlm.nih.gov/pubmed/22866364

Topic Discussion: Cholemic Nephrosis

Bile cast nephropathy is also called cholemic nephrosis. What is that and what happens?

1. As bile passes via tubules, there is pigment nephropathy.
2. Pathology findings include: extensive acute tubular injury with bile stained tubular casts.
3. Macroscopic findings will include bile stained yellowish discoloration of the kidneys in jaundiced patients which become dark green after formalin fixation.
4. Most of the damage is distal nephron related.
5. The Hall's stain confirms bilirubin presence.
6. In one series(unpublished) from Chang A et al of liver dysfunction patients, 50% of jaundiced patients had intra renal bile casts and 12% of the autopsy cases had extensive involvement of both proximal and distal tubules. 85% of patients with hepatorenal syndrome had bile casts.  In the same series, bile casts were seen in 100% of patients with alcoholic cirrhosis.
7. Recent pathology discussion at ASN suggested that bile cast nephropathy is a more appropriate term for this entity.

eAJKD and NOD: ASN 2012

Check out the latest offerings from live updates from eAJKD
Nephrology on Demand also has eAJKD live blogging.

Clinical Case 63: Answers and Summary

MGUS HAS NOW SOME SIGNIFICANCE IN THE KIDNEY AND MONOCLONAL GAMMOPATHY OF RENAL SIGNIFICANCE(MGRS) IS EMERGING. REGARDING THE NATURAL HISTORY OF MGUS, WHICH OF THESE STATEMENTS ARE TRUE?( CLICK ALL THAT APPLY)

1.Approximately 1% of patients progress to myeloma over a year
2.Besides myeloma, MGUS can also precede the diagnosis of amylodosis or WM

3.Besides myeloma, MGUS can also precede the diagnosis of lymphoma

4.The first clinicians to identify these patients are usually hematologists

5.Over 50 years of age, close to 15% have MGUS

 Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic pre-malignant clonal plasma cell or lymphoplasmacytic proliferative disorder. MGUS occurs in over 3 percent of the general population over the age of 50. Besides myeloma, MGUS can also precede the diagnosis of amylodosis or WM and the diagnosis of lymphoma. Approximately 1% of patients progress to myeloma over a year.  This is usually picked up by non hematologist initially and then referred for bone marrow examination. Usually, nephrologists are one of the early diagnostician of this entity. The following signs or symptoms should be considered ‘red flags’ that necessitate further investigation: bone pain,generalized weakness, neuropathy, headache, macroglossia, nephrotic range proteinuria, lymphadenopathy, anemia, elevated creatinine, hypercalcemia. MGUS associated with renal disease such as proliferative GN, MPGN has now some terminology such as MGRS or monoclonal gammopathy of renal significance.

A nice review article is http://www.ncbi.nlm.nih.gov/pubmed/22920639