ASN and NBPAS

Recent changes to MOC and criticism of ABIM, where does nephrology stand.  Bold move by ASN to interview with founder of the new organization National Board of Physicians and Surgeons(NBPAS).

I think starting this discussion now is so critical. Hats off to Tod Ibrahim and ASN to take this initiative as we need to redefine that is reasonably priced and truly looks at clinical work that we do.

http://asn-online.org/media/podcast.aspx?p=kidneynews&e=2015_06_25_Teirstein.mp3

IN the NEWS: GN Types and ESRD

How do different GN types do on ESRD? A recent USRDS analysis looked at this very question.

1.      Over 84,000 patients were found to have GN that were on ESRD In the time period reviewed

2.      Interestingly IgA nephropathy had the fewest other comorbidities and the lowest use of hemodialysis

3.      Crude mortality was also lowest in IgA nephropathy patients

4.      Highest mortality was in Lupus nephritis and diabetic nephropathy patients when compared to IgAN

5.      Patients with ADPKD had a relatively favorable comorbidity and laboratory profile, comparable with that in IgAN.

6.      Overall, LN patients did the worst of all GNs.

7.      Cardiovascular disease accounted for the highest proportion of deaths within all GN subtypes, ranging from 34.2% in vasculitis to 44.6% in FSGS.

8.      The highest proportion of infection-related deaths was observed in LN

9.      There were marked survival discrepancies that persisted even after adjustment for socio demographic and clinical factors.

10.  Some GN subtypes (e.g., IgAN) conferred a particularly favorable prognosis, superior to that in ADPKD as stated above but, LN displayed shortened survival, similar to in patients with ESRD caused by diabetes.

These are some very important findings of the study. Categorizing GNs as on major cause of ESRD might be not helping us figure out the long term outcomes. As expected IgA and ADPKD have better survivals and some of the autoimmune and immunosuppressive prone GNs had worse outcomes.  

OncoNephrology Conference 2015

We are conducting a one day symposium on OncoNephrology: Cancer, chemotherapy and the Kidney at Hofstra NSLIJ School of Medicine on Sept 26th, 2015 from 7:30AM to 4PM
The conference will highlight and review the latest happenings in OncoNephrology

Talks and Speakers highlighted;

AKI in Cancer Patients;  Joseph Bonventre, Harvard Medical School
Chemotherapy Toxicities:  Mark Perazella, Yale University
Targeted Therapy and the Kidney: Kenar Jhaveri, Hofstra University
Hypercalcemia of Malignancy: Naveed Masani, Winthrop University
Anemia, CKD, ESKD and cancer: Steven Fishbane, Hofstra University
Renal Cancer, an update: Thomas Bradley, Hofstra University, NSLIJ Cancer Institute
Paraneoplastic GN; Hitesh H Shah, Hofstra University
TMA:  Bradley Dixon, Cincinnati Children Hospital
Post Kidney Transplant Cancers: Vinay Nair, Mt Sinai Medical Center
Paraproteinemias, an update: Gerald Appel, Columbia University Medical Center
Cases with the Onconephropathologist: Glen Markowitz, Columbia Medical Center

Course directors:  Kenar Jhaveri, Steven Fishbane and Thomas Bradley( Division of Nephrology and Hematology/Oncology at Hofstra NSLIJ School of Medicine)
Planning committee: Kenar Jhaveri, Steven Fishbane and Thomas Bradley, Hitesh H Shah, Pravin Singhal, Jyotsana Thakkar and Rimda Wanchoo( all from Division of Nephrology, Hofstra NSLIJ School of Medicine)

To Register: go here
Full brochure coming soon.

This conference is endorsed by

IN THE NEWS: Remote ischemic preconditioning and prevention of AKI post CABG

Remote ischemic preconditioning(RIPC)  has been used as a protective method from ischemic damage to distant organs.  Application of one or more brief cycles of nonlethal ischemia/reperfusion to an organ or tissue may protect a remote organ or tissue from a sustained episode of lethal ischemia/reperfusion.

In a recent study presented at Europe and published in JAMA,  Zarbock et al examine the effects of RIPC on the rate and severity of AKI in patients undergoing cardiac surgery. In a multicenter trial, 240 patients at high risk for AKI  were randomized to receive either RIPC  or sham control  after induction of anesthesia.

The amazing results showed that AKI was significantly reduced with RIPC (45/120; 37.5%) compared with control (63/120; 52.5%), with an absolute risk reduction (ARR) of 15%. Fewer patients received RRT after RIPC (7 [5.8%] vs 19 control [15.8%]; ARR, 10%) and RIPC reduced intensive care unit stay (3 vs 4 days). RIPC had no significant effect on myocardial infarction, stroke, or mortality.

A recent meta-analysis published in AJKD showed otherwise.  Mostly randomized trials were included ( 13) and total of >1300 patients. There was no differences in levels of post operative AKI and incidence of RRT, in hospital mortality and hospital stay.  A prior meta-analysis had shown similar results as well.

Can we start using this in clinical practice? It is innovative, inexpensive and easily possible.  But long terms risks and harms are not known. Clearly, there is significant risk of AKI post CABG and this might be the only preventive measure that we have that has come close to showing any benefit. 

As suggested by the editorial in JAMA, before RIPC is adopted for clinical use, the potential risks and adverse effects must be considered carefully.  

image source: circres.ahajournals.org

ASN Fellows Survey on Workforce 2015

Nephrology Workforce Annual Fellows report in 2015 is being collected by ASN via a survey. 

This survey, being  performed by colleagues at Geoorge Washington University, will be very useful to understand our workforce related concerns. A prior survey done in 2014 had some alarming results.

See link below at ASN website.
http://asn-online.org/education/training/workforce/home.aspx

The Workforce committee of ASN has spent the last 5 years or more attempting to draw conclusions about fellowship trends and workforce needs from fragmented information. This is one of our few opportunities to gather good data and have it analyzed by those with expertise in healthcare workforce studies.

I think the fellows in the USA should take this opportunity to help out the field of Nephrology. You should try to  must  complete the survey you received from ASN. 

Topic Discussion: Non uremic causes of calciphylaxis

Calciphylaxis, or calcific uremic arteriolopathy(CUA), is a well-described entity in end-stage kidney disease and renal transplant patients; however, little systematic information is available on calciphylaxis from nonuremic causes.

A review I found in CJASN from 2008 discusses non renal causes of CUA.

Besides renal disease, the non uremic( CKD and ESRD) causes are: the top 4 being the most cases of. The remaining were just 1-2 case reports.  Most of these patients listed below had normal renal function, over 50% had normal calcium and >60% had normal phosphorus levels and 50% had low or normal pth levels. One most keep these causes in mind when ESRD or CKD does not explain the cause of CUA.

Primary hyperparathyroidism
Malignancy( Classically breast, melanoma, gall bladder, myeloma)
Alcoholic liver disease
Connective tissue diseases
Chemo induced protein C and S deficiency
Crohn’s disease
Vitamin D deficiency
POEMS syndrome
Diabetes

NK cell leukemia and lymphomas and renal disease

NK cell neoplasms have a wide range of clinical, morphologic, and immunophenotypic characteristics. Aggressive NK cell leukemia usually affects young patients in their 20-30s with equal sex incidence and shows a rapidly progressive clinical course.  Often they don’t respond well to chemotherapy and prognosis is poor.

Kidney involvement in these cancers is rare but here is what I found?

One case report of a collapsing FSGS published in AJKD in 2011. Initially, in this case, the first biopsy was read as FSGS NOS and then a repeat one had collapsing glomerulopathy.

Another recent case series describes cases of renal diseases seen with all types of non-Hodgkin’s lymphoma.  They describe 20 cases. T/NK cell lymphoma was in 4 cases. 2 of the 4 cases had crescentic GN, 1 had minimal change disease and 1 had infiltrative disease. 

A very early description of minimal change disease has been described in a case report in 1980s of a large granular cell lymphoma.

So in summary, NK cell neoplasms likely are related to cause some glomerular involvement-likely podocytopathies such as minimal change to FSGS. Cases of crescentic GN have also been described.