Sweet hydrothorax: A PD complication

Acute hydrothorax is an uncommon but a well-recognized complication of peritoneal dialysis. No single test is definitive for diagnosis. Diagnosis becomes a challenge.

Peritoneal dialysis-(PD) related hydrothorax was first reported in 1967 by Edward and Unger in JAMA( see attached). Transudative pleural effusion develops, more commonly involving the right side, and usually occurs immediately after starting PD or a few days later. The patients may remain asymptomatic or have sudden dyspnea, decrease in ultrafiltration, or pleuritic chest pain.

How do we diagnose it?

Presence of high pleural-fluid glucose concentration.

Pleural fluid concentration of glucose >300mg/dl might be diagnostic.

Others have hypothesized that, given dynamic movement of dialysate, an absolute glucose-concentration level cannot be used to diagnose PD-related hydrothorax. The pleural fluid-to-serum glucose concentration gradient of greater than 2.77 mmol/L (50 mg/dl) was proposed as the cut-off to diagnose the condition.

In general, any pleural-fluid glucose concentration greater than serum is considered to be highly supportive of PD-related hydrothorax.

Imaging:

1.Radionuclide scan (for example, Tc-99 m DTPA) is associated with sensitivity of 40% to 50%.
2.The methylene blue test has been used where its injected and dye is traced from the peritoneum to the pleura. In one study showed no sensitivity and is associated with a risk of chemical peritonitis.

Some case report examples in literature

http://www.pdiconnect.com/content/27/3/296.full.pdf

http://www.sciencedirect.com/science/article/pii/S1755001708001103

Check out this powershow that reviews the management of this entity.

CASE BASED DEBATES SESSION AT ASN 2013

This year ASN is doing a Fellows In Training( FIT) Bowl again and we shall be doing a mystery case based debate with two fellow teams.
Case based debates are a fun challenging debate sessions that we have invented at our institution that has been a monthly event at our fellowship. Fellows get a brief discussion of a case and then have to choose tests from the power point slide on the left( sample example) and get closer to the diagnosis. Each tests comes with positive and negative points and can get you closer or far from the diagnosis. Costs and what the tests entails have to be known. Finally, the team with the most points reads the kidney biopsy findings. A pathologist will then discuss the case.
This is going to be held on Nov 8th 2013 from 2-4PM at Rm B311 hosted by myself and Dr Hitesh H Shah. Following case debate, there is going to be fellows jeopardy competition.
All fellows in training should try to attend as this will be a fun event.

Quick Chemotherapy toxicity quiz flashcards using quizlet.com

A glomerular disease simple flashcard using quizlet.com

Harvard Macy Digital Citizen 2013 course

As I am teaching in and attending the Harvard Macy course on Digital Citizen this year, I am live blogging and tweeting some sessions. Check out the live tweet summaries and blogs on eAJKD.org

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