Promoting Palliative care in ESRD

A recent article in CJASN promotes 5 policies that are essential to provide good palliative care in ESRD.

1. Universal screening for palliative care(PC) needs:  How can this be done? Questionnaires and screening tools. One such example is the surprise question tool.

2. Incorporate PC measures in ESRD QIP: The advance care planning and documentation of code status can be a start. What has been done thus far has not touched PC.

3. Train the nephrology workforce to deliver PC: This is the most essential piece. With the current fellowship structure, is this possible? Are the faculty in major academic centers even comfortable? Lot of work to be done in this area. A recent study showed that PC experience of renal fellows is very poor.

4. Payment reform for PC services: Incentive always works

5. Fund PC research: Hope this will also happen as well.

The last two policies will only work when big health systems and medical schools promote the science of palliative care. It's about time sub specialists train in PC irrespective of their specialty- cardiology, GI, heme/onc, critical care or renal.

TOPIC DISCUSSION: Renal biopsy findings in Diabetics

A recent study looked at patients who had diabetes and had a biopsy at Columbia Univ path registry.
They wanted to see what other findings are seen besides diabetes. Most of these patients had atleast 10 years of diabetes. Prior reports have suggested IgA and Membranous GN as the most common non diabetic findings in these patients.

1. 37% had Diabetic nephropathy
2. 36% had non diabetic renal disease alone
3. 27% had diabetic neph and another disease
4. In the non diabetic renal disease alone:- FSGS , HTN, ATN, IgA neph, membranous GN, Anca disease comprised most of the diagnosis in that order of frequency.
5. ATN was the surprise finding that had not been reported prior reports.

Interesting and useful data. This is probably lower than expected as most that get a biopsy had a clue for an alternate illness in the kidney. The ones that don't get a biopsy also might have dual disease states that often get missed.

http://www.ncbi.nlm.nih.gov/pubmed/23886566

ANIO-ASN Dinner evite

The American Nephrologists of Indian Origin (ANIO) invite you to join
us for a reception and dinner at the American Society of Nephrology
Meeting 2013 in Atlanta.

Date:  11/8/2013 at the Peachtree special events and conference center

200 Peachtree Street, Suite 206, Atlanta, GA 30303
7:00 pm  onwards

RSVP  at  anio.asn@gmail.com to attend.

www.an-io.com

Clinical Case Answers and Summary 75

What is the mechanism of injury of carfilzomib induced renal injury?

Carfilzomib (Kyprolis, Onyx) is a next-generation epoxyketone proteasome inhibitor that is approved for the treatment of relapsed refractory multiple myeloma. The phase 2 trial  that initially raised interest in this agent was a single-arm study of patients with refractory multiple myeloma who received carfilzomib 20 mg/m2 intravenously twice weekly for 3 weeks in cycle 1 and  then 27 mg/m2 for subsequent cycles. Increased serum creatinine was the most frequently reported renal adverse event, affecting 25% of the 266 patients in this study.

Case report and discussions with experts suggests its more likely to be a pre-renal insult. Glomerular disease is less likely the cause of the renal toxicity. In a patient who has multiple myeloma with renal involvement, nephrotoxicity caused by the disease can be hard to distinguish from nephrotoxicity caused by an agent. 

Non renal causes of microalbuminuria

Non renal causes of Microalbuminuria

Fever
Infection
Non specific Inflammation
Prolonged elevation in blood pressure
Hyperglycemia
Hypercholesterolemia
Exercise

Courtesy of Dr George Bakris.

ROADMAP: Did we forget to use this map?

Microalbuminuria is an early predictor of diabetic nephropathy and premature cardiovascular disease( so we think). Some people might argue its a word that needs to be taken away from the medical dictionary. In 2011, NEJM published the ROADMAP trial.  They wanted to show if the use of ARB would delay the onset of microalbuminuria or albuminuria in patients with Type 2 DM. In a randomized trial, over 4000 patients were either in olmesartan arm or placebo for close to 3 years. The primary outcome was the time to the first onset of microalbuminuria. 

Interesting results:
1. The target blood pressure (<130/80 mm Hg) was achieved in nearly 80% of the patients taking olmesartan and 71% taking placebo; 
2. Microalbuminuria developed in 8.2% of the patients in the olmesartan group  and 9.8% in the placebo group 
3. The serum creatinine level doubled in 1% of the patients in each group. 
4. Greater number had fatal cardiovascular events in the treatment arm — 15 patients (0.7%) as compared with 3 patients in the placebo arm (0.1%) (P=0.01), a difference that was attributable in part to a higher rate of death from cardiovascular causes.

This is striking. Causes:- was it hyperkalemia? was it lower blood pressure than we think should be for DMII. This was reviewed by FDA as well. Other renal blogs had mentioned this trial as well.

IN THE NEWS: Conservative management in CKD, and no dialysis

A recent study published in a non nephrology journal highlights a critical point that is often missed by nephrologists. Although there is data coming out from prior studies that conservative management might be better for certain groups of patients then offering dialysis, more studies need to confirm this. This study is a retrospective observational study that looked at conservative management vs offering dialysis.

Some key points

1. The renal replacement therapy group survived for longer when survival was taken from the time estimated glomerular filtration rate at different GFRs.
2. When factors influencing survival were stratified for both groups independently, renal replacement therapy failed to show a survival advantage over conservative management, in patients older than 80 years or with a World Health Organization performance score of 3 or more. 

3. Acute hospitalizations were more in the RRT arm

4.Seventy-six percent of the conservative management group accessed community palliative care services compared to 0% of renal replacement therapy patients ( THIS is a striking number).

I would urge all to read the renal physician associations statements regarding palliative care in nephrology.

http://onlinelibrary.wiley.com/doi/10.1111/nep.12064/abstract
ASN had a series of videos on this topic as well.
Finally, a nice blog post on GeriPal on this topic on HD patients.

Image source: www.gloryhpc.com