Background
Brian Rifkin
STAMP of Approval: Tacrolimus vs MMF in ...

This week, we will discuss a pediatric nephrology trial: is tacrolimus superior to MMF in FRNS and SDNS?

STAMP of Approval: Tacrolimus vs MMF in Pediatric Nephrotic Syndrome
Background
Cristina Adriana Popa
Advance-HTN: Return of the systolic order – ...

This week, we will discuss a NEJM trial on uncontrolled hypertension: lorundrostat, an aldosterone synthase inhibitor, aims at the hormonal dark side driving resistance.

Advance-HTN: Return of the systolic order – Lorundrostat’s role in restoring balance
Background
swapnil hiremath
Double Trouble: ddAVP and the Bleeding Biopsy

This week, we will discuss a double header: two single centre ddAVP trials in kidney biopsy from India.

Double Trouble: ddAVP and the Bleeding Biopsy
Background
Cristina Adriana Popa
Kidney Allografts-Play With Fire, Get Burned

This week, we will discuss the prognostic role of microvascular inflammation in kidney transplantation. Can the capillaries whisper their damage in lesions before antibodies speak? Maybe this study compels us to treat the injury we see, not just the disease we can name…

Kidney Allografts-Play With Fire, Get Burned
Background
swapnil hiremath
Metformin- Should I Stay or Should I Go

This week, we will discuss another target trial emulation study. The FDA says to stop metformin at a GFR of 30. Are they right?

Metformin- Should I Stay or Should I Go

The book club is coming!

On July 13th and 14th we will be doing the first NephJC book club on Atul Gawande's excellent Being Mortal.

Don't lose hope the book has some supremely uplifting chapters like the story of Bill Thomas bringing life to a nursing home with pets, lots of pets:

To get ready for the book club I found this article about the twitter book club #1Book140. Pretty interesting. My favorite part of the article is

“But so what? For me, 1book140 was more enjoyable for its intimacy. Most of all, I liked how nice everyone was. So often the Internet is a place of derision and insult. But on 1book140, participants respected one another without having to be told to be nice.”

I would be so happy if the conclusion of people take away from NephJC is that the people are nice and the conversation civil.

Thoughts on tonight's #NephJC Social Media Chat

Last night I was reading John Weiner's personal reflection on social media in medicine. He posed the question of whether the definition of professionalism is fixed and we need to adapt our social media use to these standards or do we adopt our measure and expectations of professionalism to new tools and personal behaviors. His words:

For example, a joint initiative of the Australian Medical Association Council of Doctors-in-Training, the New Zealand Medical Association Doctors-in-Training Council, the New Zealand Medical Students’ Association and the Australian Medical Students’ Association has produced a document called ‘Social media and the medical profession’ (Mansfield et al., 2011). The advice includes, inter alia, this statement:

Our perceptions and regulations regarding professional behaviour must evolve to encompass these new forms of media.

I would argue that perceptions and regulations of professionalism, once properly espoused and documented, should be applied universally, in any day and age, and for any circumstance or technology. This is declared, for example, in the Royal Australian and New Zealand College of Psychiatrists Position Statement ‘Psychiatry, online presence and social media’ (RANZCP, 2012) where, although there are specific allusions to social media behaviour in the document, there is an over-riding clause that clearly states:

they must ensure their social media use and Internet presence upholds the ethical and practice standards required for Fellowship of the College. (RANZCP, 2012)

Others argue that social media is somehow different. After all, it has immediacy and reach and permanency. I cannot accept that a smart, well-educated student who has achieved entry to medical school does not know these properties of social media.

This question seems to be at the center of any discussion of professionalism in social media, we need to at least understand what we mean by professionalism. While at first blush it seems that standards are only standards because they do not change. But on deeper thought, it is clear society has evolved. Imagine 1985 Marty McFly driving his Delorean to 2015 Brooklyn. What would be his reaction to people:

  • publicly share vacation photos for the world to see
  • millions of public diaries open to the world
  • restaurants full of people snapping and sharing pictures of their food
  • people "checking in" to share their current location when they get to every social engagement

He would be shocked at this narcissistic hellscape. Our ideas of privacy have undergone radical changes in just a few decades. It seems to me that the codes of professionalism must evolve with the standards and behaviors of the time or they will lose relevancy and become just an exercise in conservatism.

Please join us for this chat tonight at 9PM Eastern or tomorrow at 8PM GMT (3PM Eastern/Noon Pacific), it should be great.

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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 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

NephJC: GMT chat slightly delayed this week

In case you were all wondering where the EU/African leg of the PD/CHF #NephJC chat disappeared, it will be held - albeit with a week's delay - on Wednesday June 3rd. It is all for a good reason. It has been quite busy for the Europeans this week - as you must have seen with all the furious tweeting from Charlie Tomson, Daniel McGuinness, David Arroyo, and many more including our very own Paul Phelan (who also wrote some excellent AJKD blog posts).

But, better late than never - and we hope many of you join us this week for the PD/CHF #nephjc chat.

Need any more evidence that #NephJC rocks?

You may have seen the evidence pyramid before, with animal studies and case reports at the bottom, and systematic reviews on the top. 

Well, an interesting paper was published a few days ago, in the Journal of Medical Internet Research. Go ahead, click on that link and check it out. 

It is a systematic review of all twitter-based journal clubs (and they seem to have captured all that were existing at that time). They have then examined the impact of these journals clubs using many different metrics. Interestingly, the one that immediately stands out is in table 2:

Table 2 from Roberts et al, http://www.jmir.org/2015/4/e103/

Table 2 from Roberts et al, http://www.jmir.org/2015/4/e103/

There's only one journal club with over a million impressions. Take a bow, all of you who have ever participated in a #NephJC chat!

The paper does make for interesting reading, apart from what we mention above. Some of the analyses agrees with our thoughts after the first dozen #nephJC chats. 

Tonight's #Act4Kidneys Chat. Join us at 9 PM EDT

The chat begins at 9PM EDT, in just an hour. The topics will be:

  • Topic Zero: What is an advocacy day? What can law makers do to help kidney patients and the field of nephrology?
     
  • Topic one: 20 million Americans have kidney disease. The NIH spends only $29/patient. This is low compared to heart disease and cancer. Why is that?
     
  • Topic two: One of the primary asks of #Act4Kidneys is The 21st Century Cures. What is this? What will this do for patients? What will this do for investigators.
     
  • Topic three: The other ask for the "CKD Improvement in Research and Innovation Act" what is this and what will it do for our patients.
     
  • If we are not going to the hill this week, what can we do to support these initiatives. Should we throw money at anyone? Call people? 

From the ASN Advocacy and Public Policy page:

On Thursday, April 23 in Washington, DC, dozens of ASN members are heading to Capitol Hill to talk with Congress about important policies related to kidney patient health and kidney research.

Join their ASN Kidney Health Advocacy Day efforts by asking your members of Congress to support newly introduced kidney legislation – the Chronic Kidney Disease Improvement in Research and Treatment Act of 2015 (H.R. 1130, S. 598).

This bill will address key needs for patients with kidney disease: eliminating barriers to transplantation, improving our understanding of kidney failure in minority populations, and investing in life-saving kidney research.

Join ASN in calling on Congress to support this important, bipartisan bill now. Click here to send a message to your members of Congress asking them to sign onto this vital legislation.

click the image to down load the 21 page house version of the bill.

click the image to down load the 21 page house version of the bill.

Here is the House Committee on Energy and Commerce website about the 21st century cures.