Topic Discussion: Music therapy and kidney transplants

Is there any role for music therapy in transplantation? Does a specific type of music or any calming music boost the success of a transplant?

Interactions between the immune response and brain functions such as olfactory, auditory, and visual sensations are likely. A recent study investigated the effect of sounds on alloimmune responses in a murine model of cardiac allograft transplantation. In that study, exposure to opera music, such as La traviata, could affect such aspects of the peripheral immune response as generation of regulatory CD4+CD25+ cells and up-regulation of anti-inflammatory cytokines, resulting in prolonged allograft survival. That is an interesting observation. It is plausible that the environmental or epigenetic changes are playing a role here and leading to a less stressed environment and more regulatory cells and hence better graft survival. A lot of "ifs" and potential relationships. Probably an area worth studying in organ transplantation. 

Not to long ago, a study from the Kansas looked at some aspect of this. The investigators evaluated the impact of music therapy with and without a specific emphasis on emotional-approach coping. This randomized, controlled trial aimed to use Active Music Engagement with Emotional-Approach Coping to improve well-being in post-operative liver and kidney transplant recipients (N = 29). Results indicated that music therapy led to significant increases in positive affect, music therapy using led to significant decreases in pain, and both conditions led to significant decreases in negative affect, an indicator of perceived stress/anxiety. Another study that had evaluated this in Minnesota: Results indicated there were significant improvements in self-reported levels of relaxation, anxiety , pain, and nausea. Although there was no reliability measure, there were significant increases in positive verbalizations and positive affect in liver and kidney transplant recipients. It appears that in both the above transplant related studies, music was a good way to relieve nausea.  It appears that music as an anti emetic therapy is an old concept. Does classical music have the same effect as opera versus rap versus techno versus listening in your own language is another question?

CLINICAL CASE 61: Answers and Summary

PREGNANCY STATE CAN LEAD TO THROMBOTIC MICROANGIOPATHY. WHICH OF THE FOLLOWING ARE MECHANISMS VIA WHICH TMA HAPPENS DURING PREGNANCY?( MULTIPLE ANSWERS POSSIBLE)

HELLP syndrome associated 35%

ADAMTS 13 deficiency associated 10%

Complement alternative pathway associated 13%

VEGF deficiency associated 35%

Unknown mechanism associated 5%

Obstetric nephrology is a field with significantly complex patients who have high risk of maternal and fetal complications. Thrombotic microangiopathy(TMA) during pregnancy can have a vast differential. There is a new way of thinking of TMA after the advent of the atypical HUS diseases. Pregnancy associated TMA accounts for 8-18% of all cases of TMA. Its a secondary form of TMA.

Acquired causes of TMA from ADAMTS13 is a cause that is definitely one form that can be see in pregnancy and non pregnancy states that clinically would present as TTP more than HUS.

Dysregulation of the complement cascade especially the alternative pathway would lead to the newly discovered forms of atypical HUS and this can also be noted in pregnancy. Unknown mechanisms would be the other big category in the this as well.

HELLP syndrome: is this really a TMA or not a TMA? AKI is associated with fair amount of cases of HELLP syndrome. The pathology in the liver suggestive of TMA and some forms of HELLP syndrome share same genetic features as some atypical HUS syndromes. Kidney biopsies have rarely been done and those have shown TMA.

VEGF deficiency: Pre eclampsia has now been associated with antiangiogenic factors that might lead to anti VEGF state just like what we might see in cases of avastin toxicity. The biopsy in such cases might be also suggestive of  TMA. 

A recent review in CJASN reviews this nicely. Figure 1 has a nice timeline of when these syndromes might best fit during the three trimesters. 

Publication trends by speciality among Internal Medicine residents

A recent study done published in the American J of Medicine suggests that internal medicine residents publish their research during residency and continue to publish up to 5-7 years thereafter.  There is an exponential rise in number of publications compared to many years ago.  Interestingly, what caught my attention was the subspecialty breakdown in Figure 5 of the manuscript.  Gastroenterology had the highest number of publications ( 2 publications per person-year) 5-7 years after fellowship training. Interestingly, hematology was next at 1.59 and nephrology quickly followed at 1.56. Cardiology was at 1.0.  Rest all were < 1.0.
This is a positive trend at least in our field to be in the top 3 publications trends of specialty as moving the field forward is important part of nephrology as well.

NEPHSAP review: Glomerular Disease: Hematuria Risk long term?

At Nephsap review, we discussed a question re asymptomatic isolated hematuria in an young adult and the discussion was regarding the long term risk to ESRD? Is it truly measurable risk?
Young adults often present with asymptomatic hematuria. This was elegantly studied by the researchers in Israel looking at close to a million sample size.  It was a retrospective cohort study using medical data from ages 16-25 (60% males and 40% females) who had been examined for fitness to the military.

Persistent asymptomatic isolated microscopic hematuria was diagnosed in 3690 of 1,203,626 eligible individuals (0.3%). After over 21 years, ESRD developed in 26( 0.7%) of the hematuria group and 529( 0.045%) without the hematuria group. This was a hazard ratio of 19.5.  A substantially increased risk for treated ESRD attributed to primary glomerular disease was found for individuals with persistent asymptomatic isolated microscopic hematuria compared with those without the condition. The authors concluded that the "presence of persistent asymptomatic isolated microscopic hematuria in persons aged 16 through 25 years was associated with significantly increased risk of treated ESRD for a period of 22 years, although the incidence and absolute risk remain quite low."

Hypercalcemia and hypokalemia- is there a link?

Interestingly, we do encounter this combination sometimes and likely has no connection.  This was indeed studied in a 1977 paper in Annals of Internal Medicine. They studied 103 patients with hypercalcemia in a cancer hospital with normal renal function and no history of taking potassium depleting agents. Interestingly, 32% were hypokalemic.  The cause of hypercalcemia is most cases was malignancy followed by primary hyperparathyroidism. Also, as the calcium levels were higher, the frequency of hypokalemia was greatest.

Why does hypercalcemia cause hypokalemia?

Perhaps the calcium delivery increases the na delivery to the distal tubule which in turn results in na-k exchange with loss of potassium. This is what might be postulated based on animal studies and prior human trials.  This above study was only done in the cancer ward and hence might have many other confounders that were not accounted for such as chemotherapy agents that cause low K, diarrhea in setting of infections, chemotherapy and so forth.  While the pathophysiology is plausible, the more likely explanation might be true-true and unrelated.

NEPHRONPOWER 1000th post: A tribute to a Nate Hellman

The 1000^th post on Nephronpower is dedicated to the pioneer in the use of Web 2.0 and blogging in nephrology- Dr. Nathan Hellman (Nate). 

       

Nate was the creator and founder of renal fellow network, the most influential blogging site in nephrology and in many ways- medicine. It’s his dedication and passion that inspired the creation of nephronpower.

Nate was a fellow in the Division of Nephrology at MGH-BWH Harvard University, died in 2010 at the MGH following a short illness. He was 36 years old. Hellman completed his residency training in Internal Medicine at the Hospital of the University of Pennsylvania in 2006 and spent the following year as a Fulbright research scholar at the Hôpital Necker-Enfants Malades in Paris, France. He joined the MGH in August 2007 as a clinical fellow in the Division of Nephrology. He was to be appointed a faculty member in the Division of Nephrology in July. A recent award has been created under his name. 

I asked one of his colleagues Dr. Anna Greka to comment and she said, "Nathan touched all of our lives with his warm heart and spirit, great sense of humor and remarkable intellect." 

       Blogging in nephrology was non existence before him. He made this possible. The nephrology community has embraced what he had been doing for many years prior to its prime time. It’s due to his passion and commitment, many physician based blogs exist in nephrology. A recent publication by a prior renal fellow network writer summarizes that.  It’s due to his commitment, now journal based Web 2.0 websites have come to exist in nephrology namely CJASN and AJKD.  Divisions around the world also have blogging sites now with ECU and Univ of Toronto leading the way.

       None of this would have been possible without Nate. Thank you, Nate for making a positive dent in nephrology education. Today, he deserves a standing ovation from the medical education world of nephrology. 

Special: Top 10 posts of all time on Nephronpower

10. KDIGO GLOMERULAR DISEASE GUIDELINES IgA nephropathy (2012)
9. CONCEPT MAP: Chemotherapy nephrotoxicity review (2012)
8. CONCEPT MAP: Types of Hypertension (2010)
7. CONCEPT MAP: Hyponatremia(2011)
6. TOPIC DISCUSSION: Wunderlich syndrome (2011)
5. Top Ten reasons to Love your kidneys (2011)
4. TOPIC DISCUSSION: Warfarin related nephropathy (2011)
3. TOPIC DISCUSSION: Lactic acidosis and dialysis (2011)
2. TOPIC DISCUSSION: DEXA SCAN in transplant patients (2010)
1. CONCEPT MAP: Hypercalcemia (2010)

Concepts maps in medical education are a common way to tie many concepts together. Best use of them are during rounds, or at a lecture to summarize or open a discussion. The best use is to "learn about the learner" and how they are thinking.