Background, summary
Brian Rifkin
PREVENT, Detect, Treat: What’s New in the 2025 ...

This week, we will discuss the AHA/ACC 2025 hypertension guideline update. Wow, have eight years flown by?

PREVENT, Detect, Treat: What’s New in the 2025 Hypertension Toolkit
Background
swapnil hiremath
In ESRD is spironolactone an overACHIEVEr?

This week, we will discuss the ACHIEVE trial. Will spironolactone achieve CV benefits in ESRD?

In ESRD is spironolactone an overACHIEVEr?
Background
joel topf
#NephJC Summer Bookclub: Everything is ...

The summer book club started in 2015, with one of the best books we have done in book club, Atul Gawande's Being Mortal. I think it should be required reading for all physicians. So now, in 2025, it is the NephJC Summer Book’s tenth anniversary (which represents our eleventh book). The history has been rich:

#NephJC Summer Bookclub: Everything is Tuberculosis by John Green
Background
Cristina Adriana Popa
High or Low Phosphate? Are we Missing the ...

This week, we will discuss the phosphate targets in dialysis. Are you aiming for HIgh or Low?

High or Low Phosphate? Are we Missing the (P)oint?
Background
Brian Rifkin
Mind The Gap: When eGFR Creatinine and Cystatin ...

This week, we will discuss the clinical significance of eGFRdiff, the difference in eGFRcys (cystatin C) and eGFRcr (creatinine).

Mind The Gap: When eGFR Creatinine and Cystatin C Disagree

news

TWiN: The week in Nephrology (March 1 2016)

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

    The #NephJC survey closes soon

    Thank you for all of you who have responded and filled out the #NephJC survey - over 300 respondents so far! We wanted to give a heads up to the rest of you - the survey will be closing soon. Wednesday 12 midnight Eastern is the deadline. We would love to hear from any of you who haven't had a chance to voice your opinion. So please go ahead and let us know what you think and how we can improve. 


    The #NephJC survey

    The #NephJC team has designed a survey - to get to know more about you and your opinions. It's a simple, short survey, that will not take more than a few minutes (we promise) to complete. We would really like you to complete all the questions, though the ones where we ask more about you are optional. The overall purpose of doing this survey is two-fold. Firstly, we would like to hear more about what you like, what you don't like and how we can improve what we are doing with #NephJC. The second purpose is to know a little bit about you - all of you, who are following us on twitter or on facebook, who tweet at the chats or who lurk, or who get our weekly mailer.

    Needless to say, completing the survey is completely voluntary. None of your information will be divulged. We do have institutional review board approval (from the Ottawa Hospital Health Sciences Research Ethics Board) to conduct this survey.

    Lastly, this survey is conducted with Google docs. This makes it simple and easy, but please answer to the best of your ability, truthfully, and complete it only once.

    thanks!

    The #NephJC team

     

    Oral or IV Iron: Follow up from a previous #nephjc chat

    A few months ago, we discussed this trial from Rajiv Agarwal and his team from Indiana, which found increased serious adverse vents with IV iron, in CKD patients. The latest issue of Kidney International now has some interesting correspondence, with two critical letters, and a substantive reply from Rajiv Agarwal.

    Rajiv Agarwal

    Rajiv Agarwal

    Among the criticism is one from Iain Macdougall and Simon Rogers, questioning the methodology - and why these results are different from the FIND-CKD trial (free PMC link), which did test a different IV iron formulation (iron carboxymaltose in FIND-CKD, iron sucrose in REVOKE), against a lower dose of oral iron. The reply from Dr Agarwal is worth reading in full, but this table highlights the details.

     

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    The Neph-Twitterverse discovers Twitter polls

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    A few weeks ago, the folks at twitter announced they were rolling out Twitter polls. Previously, tweeps would use manually counting responses or the RT-if-you-agree Fav-if-you-don't approach. This is how the polls were supposed to work:

    So what, you might say? A few users (notably @conradhackett from Pew research) played a lot with them, sample poll:

    The ease of setting one up, and the option to just click and be done were some of the major selling points. But it wasn't clear if would be just a passing fad or something more. I used one at the #KidneyWk, but there were few responders

    Then Matt decided to poll the #nephjc followers after the suPAR chat

    And Thomas Hiemstra decided to design his next #DreamRCT on therapy for Membranous nephropathy with a series of tweets:

    Second scenario

    And it wasn't long before Graham Abra re-ran an older question on the utility of urine eosinophils in allergic interstitial nephritis

    another one on the duration of steroids in SLE, in remission

    So we guess polls on twitter are here to say. Nephrology tweeps find it awesome (and I can say so with confidence, backed by facts, or shall we say, a poll?)

    Swapnil Hiremath

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    The #nephJC #RIPC stats and @storify

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    Both the chats were quite stimulating, we saw quite a number of new voices (whom we hope to see again!)

    Hector did a great job, again, of storify-ing. Thanks again to Preeti Malani, Ed Livingston and the rest of the JAMA staff for their support. Look forward to the #JAMbag next time!


    #NephJC does #RIPC Tues Aug 11 and Wed Aug 12. And thanks to @jama_current

    RIPC = Remote Ischemic PreConditioning

    We hope to see many of you in one of these chats. Thanks again to Preeti Malani, and the folks at JAMA for supporting us - both with providing a toll-free access to the article (at this link), and for providing some prizes - cool JAMA swag! 

    So for discussion, the topics will be

    • T0: Do you use a risk score to stratify patients pre-op for risk of AKI? The authors in this study used the Cleveland Clinic risk score, but there are others. If you use a risk score, which one do you use?
    • T1: Do you agree with the inclusion exclusion criteria? especially GFR < 30 as an exclusion? How about the particulars of doing the RIPC? 50 mm Hg > systolic or 200 mm Hg, whichever is lower for 5 minutes X 3. Is the sham acceptable? Lack of blinding the investigators an issue?
    • T2: Dive into the results. What do people make of the difference in secondary outcomes (less effect in mild AKI?). The biomarker outcomes are also intriguing, do you agree with the interpretation?
    • T3: What happens now? The authors think of this as a phase-2 study. What outcomes would you like to see in the next study? Intervention is simple and cheap - or is it? 
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    #NephJC does #pericytes: part 2

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    Part 2 continued to be epic - with first author Rafael Kramann joining in this time. Check out the storify from Hector below -

    And the stats were equally impressive - overall picture captured by this tweet from Matt:

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    #NephJC does #pericytes - part 1

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    Not #parasites or ... #pedicure?

    This was a fantastic chat last night, with great questions from Mal Parmar, Scott Brimble, Dylan Burger and others; clear and articulate answers from Ben Humphreys - and a link heavy tweeting from Matt Sparks. The transcript will read almost like a review article - or commentary.

    Stay Tuned for the EU/African chat, occurring in just over 2 hours at 8 pm *BST* - with first author Rafael Kramann joinin in this time.

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    In the Literature...

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    We mentioned the #MICE project in the newsletter a few days ago (what newsletter?? Check out and sign up - low volume, once a week, will keep you updated) - authored by Tejas Desai, Edgar Lerma, Ryan Madanick et al. It's published on the Winnower platform and has already accumulated some interesting reviews, including Chi Chu & Francesco. Two in particular stand out for their insightful comments - out-rivalling any peer review you may have seen, by Len Starnes and David Goldfarb, the latter written in his incomparable signature style.

    Another fun paper (CoI alert: includes Swapnil and Joel as co-authors) is a 'Ten Steps for Setting up an Online Journal Club' - available here ($walled). This was a fun experience - crowd-sourced, written from start to end in a matter of days, and shepherded quite ably by Teresa Chan to publication. 

    The power of Twitter

    Last week, NPR ran a story on their Shots Blog based on a paper from JAMA Surgery, Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care. The story was one sided, and without balance. The truth is that irresponsible nephrologists are not the primary reason patients don't start dialysis with a fistula. Swapnil saw the post and went on a bit of a Twitter rant discussing the limitations of both the post and the article on which it was based. As is typical for our Twitter renal community, a number of other nephrologists chipped in with poignent observations and tweets. It quickly became a great academic discussion on the difficulties with fistulas.

    I collected the relevant tweets and published a Storify of the entire event.

    A few hours after I published the Storify I received an e-mail from Nadia Whitehead, the author of the NPR post. We did a 15 minute phone interview where I was able to provide some balance to the original article and I urged her to call Swapnil for some more feedback. She did that and posted a follow-up article a few days later. 

    I think this is a pretty good example of why doctors need to participate in social media in open networks like Twitter rather than behind the locked doors of private physician networks like Doximity and Sermo. We need to be engaged in the same media and networks that the public is immersed in so we can be heard and reman relevant. I think it also shows the value of curating these discussions with a tool like Storify. I played a minimal role in the discussion but she reached out to me, primarily, I imagine, because I was the author of the Storify. The Storify is what triggered the action on her part.

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    #NephJC has RSS subscribers?

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    A few months ago, we mentioned how to subscribe our feed with RSS. 

    At that time, we had one subscriber (Swapnil) - and to our great surprise, it seems to be that RSS is back. Just see below:

    Unless there are spam RSS subscriptions somehow....

    In some other news, we would like to thank Marjorie Lazoff for mentioning us in the LITFL blog  - go check out their literature review here. 

    Swapnil Hiremath, M.D.

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    The AUA v ACP guidelines. Fight!

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    Tonight's and Wednesday's #NephJC is going to focus on the ACP guidelines. But it is important to recognize that a different group looked at the same data and came up with very different conclusions of what CPG should look like.

    The systemic review that is the primary source...

    The systemic review that is the primary source...

    ...was the same in both clinical practice guidelines.

    ...was the same in both clinical practice guidelines.

    The American Urological Association Guideline (PDF) consists of 27 guidelines covering:

    • Evaluation
    • Diet therapy
    • Pharmacologic therapy
    • Follow-up

    The AUA did consider 18 additional studies that were not part of the AHRQ analysis. The recommendations are graded and the authors interpreted the grades thusly:

    1. Clinical Principle. This is a statement about a component of care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. My sense this is, that these recommendations are so woven into the fabric of stone care that people would not be able to get a study of these practices past an IRB.
    2. Expert Opinion. This is a statement, achieved by consensus of the Panel, based on clinical training, experience, knowledge and judgment for which there is no or insufficient evidence.
    3. A or B level evidence translated into Standards
    4. C level evidence becomes Recommendations
    5. Options are non-directive standards that may or may not be based on evidence. There is only one and it was evidence grade B

    Background

    • The prevalence of stones is increasing. It has gone from 5.2% in 1988-94 to 8.8% in 2007-2010.
       
    • It is affecting more women so that it is much male dominated. The male:female ratio has slipped from 1.7:1 in 1997 to 1.3:1 in 2002.
    • They looked at the diet studies that used stone formation as the outcome. Those studies found that increased water intake reduced stones. It found beneficial effect by avoiding cola. 
       
    • They looked at multicomponent diets and described the ability of a low sodium, normal calcium, low animal protein to reduce stones more than a low calcium diet.
       
    • Two other studies restricted animal protein as part of a multicomponent diet and was unable to find any advantage.
       
    • The authors point out that changes to urinary stone risk factors has not been validated as an intermediate endpoint.

    The authors are transparent about one of the primary gaps in the use of diagnostic information about the nature of a stone in the therapy for that stone.

    One caveat, all the RCTs diet studies were done in stone forming men.

    The Guidelines

    The 27 guidelines themselves are pretty straight forward and read like a description of what takes place in a well run stone clinic. The authors are again transparent, labeling many of the guidelines as Clinical Principle and Expert Opinion. In terms of the final score it looks like this:

    Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).

    Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).

    Here is the breakdown by section:

    Not surprisingly, only pharmacologic therapy has received significant RCT&nbsp;attention.

    Not surprisingly, only pharmacologic therapy has received significant RCT attention.

    The AUA and ACP guidelines are based on the same evidence but ultimately look very different. The ACP guidelines look at this evidence desert and provide guidelines so sparse they end up functionally useless. The AUA, on the other hand, hitches the evidence to common sense, scientific innuendo, and long-held medical habit to provide fairly comprehensive guidelines that primary care doctors and part-time stone-physicians can use to actually take care of patients. The AUA guidelines paired with the AHRQ evidence analysis are documents I would have every fellow add to their iPad library. The ACP guidelines? Not so much.

    In the end the ACP guidelines read like political statement protesting the sorry state of stone evidence, while the AUA guidelines provide a practical manual guiding stone care while still being transparent about the poor state of evidence.

    Joel Topf, MD