The Week in Nephrology is back after a spot of vacation. Again the twitter world was full of reviews this week, on a variety of topics and I have collected a few here. Feedback and suggestions welcome. DM me @dr_nikhilshah with your ideas.
Neesh Pannu (@nipannu) and others published a new risk prediction score for #AKI requiring renal replacement therapy post cardiac surgery using variables available pre-op like - congestive heart failure, Canadian Cardiovascular Society angina class III or higher, diabetes mellitus , baseline estimated glomerular filtration rate , increasing hemoglobin concentration, proteinuria , coronary artery bypass graft (CABG) plus valve surgery (v. CABG only), other cardiac procedure (v. CABG only) and emergent status for surgery booking. This new tool published in CMAJ improves the prediction over the previously available Cleveland Clinic Score.
An excellent review on the pathophysiology and treatment of Lupus Nephritis from Kidney International was just published. And published in NDT is a comparison of all the Lupus Nephritis treatment guidelines. A nice 1-2 for #Lupus Nephritis this week.
In a recent study published in CJASN, a group of investigators studied the outcomes of use of various induction therapies and the use of steroids in deceased donor kidney transplants. The data suggested that rATG may have better outcomes in patients on a steroid avoidance protocol.
A review from Nature Reviews Nephrology - Phil Halloran authors an informative review on the molecules of kidney transplant disease states from transplant biopsies. #mustread
A fascinating review on the role of infectious diseases and its impact on kidney diseases was published by Vivek Jha (@vjha126) and N.Prasad in AJKD. Though this articles relates to the Asia Pacific region, Veeraish Chauhan(@DrVC_kidney) makes a compelling argument for all nephrologists (incl Western Hemisphere) to pay heed, in his AJKDBlog post.
- Nikhil Shah (@dr_nikhilshah)
Mycophenolic acid inhibits the rate limiting enzyme in de novo purine synthesis. Its action is not limited to T and B cells. It has some effects on non-immune cells like mesangial cells and podocytes. This review paper in Pediatric Nephrology sheds light on the molecular mechanisms of the anti proteinuric effect of MMF.
The conundrum of selecting the most appropriate vascular access for elderly patients who choose hemodialysis is explored in this review by Tushar Vachharajani (@tvachh), Kevan Polinghorne (@kevanp2) and others in Nature Reviews.
SGLT2 inhibitors are getting increasing footage in the press with the recently published trials. The FDA has strengthened its kidney injury warning for this group of drugs and as Dr Alice Cheng(@AliceYYCheng), endocrinologist from Toronto reminds us that SGLT2 inhibitors are part of the SADMANS - Sick day medication mnemonic.
ICYMI - An 2010 Seminars in Dialysis paper from Dr Jula Inrig on antihypertensive agents for the hemodialysis patients was doing the rounds on twitter this week. Good bookmark!
The new classification of donation after circulatory death (DCD) donors (Modified Maastricht Classification) was published recently in Transplant International.
- Nikhil Shah (@dr_nikhilshah)
Rates of parathyroidectomy similar and stable over last decade at 5.4/1000 patient. Rates of all cause mortality in these patients were better than the last decade, however there was significantly increased mortality in patients with cardiovascular morbidity and peripheral vascular disease. Study published in CJASN.
Peritoneal Dialysis International published the ISPD Peritonitis Recommendations 2016 Update.
The old adage of hypertension leading to progressive CKD has been blown out of the water by a study from Norway published recently in Kidney International. They studied a representative population of nearly 1600 hypertensive individuals aged 50 - 62 years with no DM, CKD or cardiovascular disease. These patients were followed for a median of 5+ years and the GFR decline was <1 ml/min/year with neither the baseline systolic or diastolic BP being significantly associated with it.
Though published some time ago, this excellent paper from NDT reviews all the major landmark trials in management of diabetic renal disease. Worth a re-look if not bookmarked earlier.
Take a look at a comprehensive review from Dr Agati et al on Obesity related glomerulopathy in Nature Reviews.
Nanotechnology in medicine and its specific role in kidney diseases. Check this interesting review in Kidney International.
Journal of American Heart Association has selected 5 #mustread papers related to Hypertension including the one related to "Life's Simple 7" paper relating to healthy lifestyle predicting development of CKD - The targetsbeing- nonsmoker or quit >1 year ago; body mass index <25 kg/m2; ≥150 minutes/week of physical activity; healthy dietary pattern (high in fruits and vegetables, fish, and fiber‐rich whole grains; low in sodium and sugar‐sweetened beverages); total cholesterol <200 mg/dL; blood pressure <120/80 mm Hg; and fasting blood glucose <100 mg/dL .
The Endocrine Society has published clinical practice guideline for detection, diagnosis and treatment of primary aldosteronism.
Acid Base Electrolyte
Lactic acidosis - A review ofcurrent and future directions towards management of Lactic acidosis. Published in AJKD.
American Society of Transplantation has a webpage dedicated to patient information packets for all transplants including a recent one on Pediatric Kidney transplant. Excellent resource for all patients.
The role of Tregs in kidney disease especially in kidney transplantation is discussed in this review from Kidney International.
The focus of the June issue of Transplantation is Living Donors! Excellent selection of papers from around the world.
Another negative RCT. A study from the Netherlands, published this month in NDT. investigated the role of extended course of maintenance azathioprine (4 years) vs standard course (1 year) in patients with positive cANCA at remission. There was no difference in the relapse rate in both the arms and hence extended azathioprine maintenance is of limited benefit.
Patient engagement and patient centered investigations are becoming centerstage especially in CKD, ESRD and Transplantation. This recent publication in CJASN looks at patient centered outcomes in glomerulonephritis. Very timely.
The sympathetic nervous system, HTN and renal denervation 101! A comprehensive review on the pathophysiology of SNS in HTN and the various trials investigating the role of RDN. Published in JASH
CKD - ESRD
Another study from the the Netherlands published in April in CJASN. This is a single center observational study comparing outcomes in patients >70 years of age choosing conservative management or RRT. They concluded that patients >70 year old with > 3 comorbid conditions (incl Cardiovascular comorbidity) or patient age > 80 did not have a survival advantage in choosing RRT over conservative care.
An excellent review on pulmonary ultrasound to detect and characterize extra vascular lung water in the European Heart Journal recently. This technique may have potential role in assessing the fluid status of our dialysis patients.
The artificial wearable kidney has been in news for some time now. The first FDA approved trial was recently published in JCI Insight. This demonstrated that WAK is a possibility, however the trial was stopped early due to technical reason related to the device. This serves as a proof of concept for this method of dialysis pending further improvements in the device.
The Lancet published a Series of 3 review papers related to ESRD recently. The first is a review of the heart and the vascular system in dialysis. The second is controversies and problems of volume control and hypertension in dialysis patients and the third is a paper integrating DOPPS and USRDS data on factors affecting outcomes in ESRD patients worldwide. #mustread
#HemoPause - a checklist from the St Mike's Hospital in Toronto is being designed to prevent medical errors in dialysis patients who are inherently complex and may have multiple comorbidities and polypharmacy. The feasibility study of this checklist was published recently in Clincial Kidney Journal.
- Annals of Internal Medicine brings a Nephrology Update - 11 of the most important trials in Nephrology and Hypertension in 2015 - All served on a platter!!
- Blast from the past, a 2013 Nature Reviews Immunology paper on the interaction of kidney with the immune system. It discusses the mechanisms of immune mediated kidney disease and, conversely, how kidney disease affects the immune system.
Acid Base Electrolytes
Pathophysiology of Renal Tubular Acidosis: Core Curriculum 2016 - from AJKD
- Hyperkalemia treatement - Harel and Kamel from St Mike's in Toronto published a systematic review in PLOS on the emergent management of hyperkalemia - 10 units of regular insulin bolus with 50 gms glucose or 20 units of regular insulin with 60 gms glucose - does the job!!
- #AKIKI RCT re: Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit - showed no difference in 60 day mortality between early or late start. Published in NEJM this month. . "Breaking News" NephJC coming soon.
- A double whammy - Also published in JAMA this week and presented at the #ERAEDTA16 were the results of #ELAIN RCT which showed that early RRT initiation (Stage 2 AKI) significantly reduced 90 day mortality, duration of RRT and length of ICU stay. The " Breaking News" NephJC will discuss both these trials and promises to be a thriller!!
- An excellent one page editorial summary of the role of statins in dialysis patients following the long term followup data from the 4D RCT. From Kidney International.
- Swapnil Hiremath summarizes the Canadian Hypertension Guidelines 2016 (CHEP) incorporating the SPRINT data in an AJKD Blog post.
- CTS Data published in NDT this month shows the benefit of induction therapy in high risk kidney transplant recipients and no significant effect in low risk recipients.
- Dr Haas presents the Banff Classification 2013 A minireview published in AJT on the nuances of the Banff 2013 update and the studies attempting to validate the classification.
This week we bring two resources for both physicians and nurses caring for ESRD patients.
- Starting off with guidelines published in PDI - A syllabus for healthcare professionals for teaching Peritoneal Dialysis to patients and caregivers. Get it here ($wall alert).
- Dr Schell presents a guide for nephrologists on communicating with the elderly on their choices regarding dialysis.
- Pediatric kidneys are at risk of worsening function in the setting of non renal transplant patients. This article sets out recommendations on how one should monitor the kidney functions in children with non-renal transplants and guidelines on when to refer the patient to a pediatric nephrologist.
- We all love to advice about diet and hypertension, and several studies have shown that diet does affect the BP. Coming this week is a systematic review and meta-analysis of studies looking at various kinds of dietary interventions' effect on the BP. The DASH diet still wins with the highest net effect of nearly 7/4 mmHg decrease in BP. This was published in Hypertension.
Blog posts of note
We present two brilliant essays by our newly minted interns of #NSMC (Nephrology Social Media Collective)
- Benjamin Stewart wrote an essay on the the nephron number and the GFR talking about the "Super-Kidney" or the elite kidneys and what nephron endowment means to the GFR. GIve the blogpost a read on Renal Fellow Network and follow him on twitter.
- Our next post was by renal transplant fellow Silvi Shah who describes the implications of pregnancy and kidney transplant in a question answer format. Again Renal Fellow Network features this blogpost.
- Rounding off with my favourite topic - Home Hemodialysis - I came across this excellent essay by a Home Hemodialysis patient in Australia, who describes the econo-socio-political advantages of home hemodialysis and also talks directly to patients (peer-2-peer) about the advantages of HHD. The poem at the end is a touching reminder to all physicians on what a patient really wants for himself. Read it here.
- Nikhil Shah