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
Background
Brian Rifkin
KDIGO 2025 ADPKD Guidelines Review

This week, we will discuss the first iteration of KDIGO’s 2025 guidelines on ADPKD.  These guidelines are a result of a decade of global collaboration between physicians, researchers, advocates, and patients. The guidelines incorporate ADPKD-specific care as well as many general CKD management practice points.


KDIGO 2025 ADPKD Guidelines Review

TWiN (This Week in Nephrology 22 Feb 2016)

  • AVOID-HF - another one bites the dust. The largest trial of ultrafiltration in acute decompensated heart failure was teminated early for poor recruitment. It was also a trial designed to overcome the deficiencies of previous HF studies. Of the 224 patients recruited (<30% of planned) there were not differences in the outcome and no worsening in the renal function. However there was more hypotension and more infections. The article is here ($wall) and the editorial is here. 
  • This BMJ Sytematic Review and meta analysis generated a lot of chatter on twittersphere. It looked into outcomes with use of RAASi versus other anti hypertensive medications in patients with DM. There was no difference in mortality, cardiac or renal outcomes in either group. 
  • In keeping with the Transplant topic of this week's NephJC  here is a collection of Transplant themed tweets
    • This one published in Transplant International explores the economic and clinical consequences of UTI, sepsis and pneumonia in the first year. 
    • Retransplantation with a previously mismatched HLA antigen can be a trigger for a memory immune response. In this registry analysis published in JASN there was no effect of repeated HLA mismatches on all cause or death censored graft loss. However there was increased hazard ratio in patients with class 2 repeated mismatches or if they had previous graft nephrectomy. 
    • Hector Madariaga rocks again with this fantastic storify of a twitter conversation about treatment strategies of Antibody mediated rejection. 
    • C1q+/C3d+ denovo allograft antibodies were shown to have poorer 10 year graft survival in a pediatric transplant population. Check it out here.
  • Another Systematic review and meta analysis showed that correction of anemia using ESA did not improve the health related QoL in patients with CKD. This was published in the Annals. 
  • This cJASN article explores the outcomes of a cohort of patients with primary FSGS treated with steroids/CNIs or conservatively. The response to immunosuppression was better than conservative management, however there were no differences between steroids or CNIs as first line immunosuppression 

 

Blogs of Note

  • Dr Fred Coe comes up with a superb  blog post on interpretation of the stone work up, equally useful for patients and physicians. Must see. 
  • For the lighter side of Nephrology but no easier!! Check out a collection of crossword puzzles in nephrology on Dr Jhaveri's blog. 
  • And finally a blog post on peer to peer conversation in living transplant donation. Makes interesting reading when the donor also happens to be a nephrologist. 

 

 

TWiN - The Week In Nephrology (15 Feb 2016)

  • Starting this week comes a provocative study published in AJKD by Kam Kalantar-Zadeh regarding the use of incremental HD/Twice weekly HD in patients with substantial residual kidney function. Read it here. Also read the counter argument in an AJKD editorial.
  • How the evolution of dialysis and related technologies guided the ethics of "how resources should be used and who should have access to them" . Dr Butler and colleagues explore the healthcare delivery system through the history of dialysis in a recent CJASN article.
  • Retweeted and liked this week was a January article published by Dr Kenar Jhaveri in CJASN "Nephrologists as Educators: Clarifying Roles, Seizing Opportunities" . It identifies eight attending roles of the nephrologist which can be converted into educational opportunities.
  • A new drug and a new target for TTP ? This NEJMeditorial discusses the Von Willebrand Factor as the new target and Caplacizumab as the drug. The Phase 2 results of the TITAN trial were published in the same issue.
  • Dr Bargman and Dr Lee discuss the utility or futility of studies exploring the survival of patients by dialysis modality in this CJASN article. The quality of life and not the length of life maybe the deciding factor for the individual patient.
  •  

 

BLING - BLogs In NephroloGy (15 Feb 2016)

BLING (BLogs In NephroloGy) 8 Feb 2016

 

 

 

TWiN (The Week In Nephrology 8 Feb2016)

  • The ASN Innovations in Kidney Education Contest results were revealed this week. Check out their creations here.
    • Water Homeostasis by John Danziger, MD Nephrologist, Harvard Medical School
    • Urine Trouble Board Game by Dorey A. Glenn, MD Fellow, University of North Carolina Kidney Center
    • CRRT Simulator ppt by Kamalanathan K. Sambandam, MD Nephrologist, University of Texas Southwestern Medical School
  • Renewing the discussion on organ trafficking in kidney transplantation are 6 Open Access (Organ Donation and Procurement) articles from Transplantation Direct. You can get them here.
  • Tweeted out this week were the ERA EDTA guidelines on the use of Tolvaptan in ADPKD. Follow this link (Open Access)
  • Ketoanalogues - Should do we still think about them? This latest article from JASN explores a vegetarian diet with ketoanalogue supplementation which showed retardation of CKD progression.
  • From our Pediatric Nephrology friends comes 2 articles of interest
  • One more Belatacept story this week. Published in AJT were results of a new trial which looked into immune manipulation post transplant. They studied the lymphocyte reconstitution after Alemtuzumab induction followed by Belatacept and Rapamycin therapy and showed a reduced rate of acute rejection commonly seen with nondepleting induction with belatacept maintenance.
  • NEJM article on Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. Get it here.

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

 

TWiN (The Week In Nephrology) 1 Feb 2016

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.

 

#NephJC is now part of Altmetrics

Altmetrics is a company that tracks realtime references, reads and mentions of research articles across the web and social media. They give authors and institutions a sense of what research is moving the needle faster and more comprehensively than reference tracking could. The work NephJC does will now be part captured as part of this goal.

When I read the following on their website, I knew that NephJC and Altmetrics were natural partners:

“Scientists are increasingly discussing papers online, but on social media sites, rather than on publisher’s sites. There’s huge value in being able to see what your peers - and people in other fields - have said about an article. Up until now, this has been difficult to achieve.”

Our spotlight just got a little brighter.

#AmyloidosisJC on staging renal involvement in AL amyloidosis

You have a patient with 5 grams of proteinuria and normal renal function. The biopsy lights up with congo red like rudolph's nose

You check the serum free light chains and conclude your patient has AL amyloidosis. The family wants to know will he need dialysis? How long until he does?

¯\_(ツ)_/¯

The patient starts bortezomib and seems to be doing well. How do you know if his kidneys are improving? What do you look at?

¯\_(ツ)_/¯

These are the questions covered intonight's #AmyloidosisJC on:

A staging system for renal outcome and early markers of renal response to chemotherapy in AL amyloidosis

The amyloidosis nerds did a nice summary at Amyloid Planet.

 Hope you can join us for a spirited discussion.

,

The Neph-Twitterverse discovers Twitter polls

,

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

The Benefits of Nephro-Twitter. Or how I learned to stop fearing and love Twitter

Last week this tweet came across my feed and was widely and justifiably retweeted:

It became clear to me, that nephrology needed a similar essay:

Dr. Katie Kwon answered my call. Her essay:

My first foray into Twitter was about five years ago. Twitter was in the news a lot and I kept coming across online articles filled with viral tweets that were funny, pithy, and current. Those articles made Twitter seem like a virtual Algonquin Round Table. However, my first login didn’t look anything like that. Twitter asked for my email address book, then signed me up to follow people I already knew. I didn’t have the first idea how to go about seeing tweets from strangers on topics I found interesting. It was all too much work, and I quickly gave it up.

Then I attended ASN 2013. Since starting my nephrology training, I’ve tried to go every other year. I’m in private practice with two other colleagues, so ASN is my biannual chance to chat with other nephrologists. Slowly, painfully, I’ve grown my professional network. At first I would meet up with other alumni from my fellowship program and the faculty. Then, when our dialysis units were acquired by a small chain, I got to meet some other medical directors from around the country. It was nice to attend meetings knowing more than three people. But I knew I’d get a lot more out of ASN if I knew more people, and could learn their viewpoints on the presentations I was attending.

At the 2013 meeting, I had the opportunity to meet Joel Topf. He’s a nephrologist that I had long admired for his blog, and I had made comments on several of his posts that I particularly liked.  He sent me a message that he was presenting a poster at ASN, so I decided to stop by. His poster was about the use of social media in nephrology, an area where’s he’s an influential evangelist. After our conversation, I signed up for a new Twitter account.

This time, the experience made a little more sense. I learned that one’s Twitter feed is determined by who you follow. I started by following Joel and then anyone else he tweeted at. Pretty soon I had a nice stream of commentary from nephrologists from many different countries, most of it focused on the ongoing meeting. I began to notice the hashtags and how you could also search for those to pick up the threads of a conversation about a particular topic.

Using my iPhone, I carefully pecked out a few tweets about the presentations I attended. I tried to tweet pearls that normally I would have written down in a notebook, rarely to be seen again. I was delighted when these tweets got starred and retweeted by new followers. It was even more exciting when respected faculty members, whose names I knew from journal articles, would add their thoughts and provide links to additional material. It enhanced the learning from each session I attended. I wound up with a deeper understanding and different perspectives. I even made a few real-life acquaintances and met some for lunch. It was the most productive ASN meeting I’d ever attended.

Returning home, my Twitter use became much more sporadic. I had set up the app to send me a notification if a lot of the people I followed tweeted about a particular topic. In this way I learned about some breaking trials and other events in the broader field of medicine, including the MOC debate. I rarely tweeted my own content, but Twitter is very forgiving of long periods of inactivity. You won’t lose followers as you might if you took a break from blogging. When I did have something to contribute, or a question to ask, it was easy to jump right back in. I discussed a few tough cases on the Nephrology On Demand forum, which I learned about from Twitter.

I returned to ASN for the 2015 meeting. This time I was able to start tweeting  right away – thankfully, my phone remembered my Twitter password. I started by reading the comments from other people attending the plenary session. Their annotations and insights deepened my understanding of a topic that would otherwise be intimidatingly basic science in its orientation. I followed many more conference attendees who seemed to have valuable things to say. Then I realized that I could virtually attend multiple simultaneous sessions. This was great! I no longer had to miss talks that seemed interesting but conflicted with others I also wanted to see. I learned about great presentations on exciting topics as they unfolded in real time, and sometimes switched rooms midway through a session. The conference felt more dynamic and I was confident I was spending my time there wisely.

One session on Friday focused on the ongoing battle over MOC and the ABIM. This was a topic I had continued to follow for the past few years, and I was disappointed that it was so sparsely attended. However, the low turnout wound up having an unexpected benefit, which was a clear field for me to tweet about it. I tried to sum up each main point the speakers made, then highlight the comments from the audience. This was the first time my tweets seemed to resonate. My followers retweeted my reporting to their followers, and my audience grew. The instantaneous feedback that what I was doing had interest and value was fun and exciting.

I left ASN this year having met interesting colleagues across the country, both virtually and in real life. (Twitter is a great way to get people to visit your poster at ASN.) I picked up some tips to organize my feed, which made it easier to participate in the Nephrology Journal Club the next week. The discussion was about the SPRINT hypertension trial. It felt like being back in fellowship again, in a good way. I got to benefit from the analysis of hundreds of colleagues, both those who participated and through the links to commentary that they provided. I am in the process currently of writing a talk for our local primary care doctors about SPRINT, and the Twitter conversations I participated in are providing great material for my analysis.

Twitter has allowed me to connect with many more nephrologists than I would have managed to meet through more conventional means. Those relationships have real value, helping me stay current in my field and giving me varying perspectives on controversial topics.  While I love my practice in a small Midwestern town, Twitter has provided the discussions that I enjoyed during my training years in a big academic center. I feel more connected to my profession and my practice of medicine will only continue to improve as a result of my participation.

Quick start to Twitter as a nephrologist:

  1. Sign up. Keep your Twitter name short; 140 characters goes quick and a long name uses up more of them.
  2. Follow Nephrology Journal Club (@NephJC) and note the time of the upcoming discussion.
  3. Use tchat.io in your browser to follow the #NephJC discussion. Follow anyone who tweets something interesting. When you follow someone all of their Tweets show up in your feed. hand picking your feed will make Twitter more useful.
  4. Unfollowing is easy and it’s not fraught with emotion, unlike defriending on Facebook. Sometimes you’ll follow someone, only to find that the majority of their tweets are in a different language that you don’t understand. Unfollow them! If your feed is cluttered with irrelevant tweets, Twitter gets to be a slog.
  5. If someone is writing about an interesting topic marked with a #hashtag, just click on the hashtag to see other tweets with that hashtag. You can pick up more interesting people to follow.
  6. Start to tweet. Retweets are easy; bonus for adding your own viewpoint. Tweet about meetings or lectures you attend. You’ll get more out of it than jotting down notes you won’t read again. People will ask you questions or offer more resources. Your learning just doubled!
  7. It’s the internet; some people are weird, rude or hostile. Twitter has a block feature that prevents a person from reading your tweets or communicating with you. I don’t hesitate to block anyone who bothers me. I don’t want to use up any emotional energy worrying about a fleeting online interaction.
  8. Nephro-Twitter is a friendly place. If you start a message with someone’s username (i.e, @KatieKwonMD) your tweet will go directly to their feed, but not to your other followers.  If you include their username in the body of your tweet, all your followers can see it. Reach out to people, ask them questions, point them to links you think might interest them. That’s how interesting conversations start.

Kidney Week Wrap-up: How will we remember #KidneyWk 2015?

Kidney Week 2015 may be remembered for a number of different social media moments. The Tweet-Up was a raging success and finally broke through to become what Matt and I envisioned at the Denver Kidney Week in 2015. The success of the tweet-up was largely driven by Satellite Healthcare and their invaluable assistance with promotion and logistics. We can’t thank them enough. Additionally Kidney Week 2015 was marked by both a NephJC and NephMadness poster presentation. This Kidney Week, Matt was invited to give a talk on electronic medical education and he crushed it. But the biggest event, the one I hope we remember 2015 for, was the graduation of the first class of interns from the Nephrology Social Media Collective (NSMC).

Matt, Scherly and Chi with their diplomas and #DreamRCT mugs

Matt, Scherly and Chi with their diplomas and #DreamRCT mugs

We had four very different interns and they each had individually unique experiences with the internship:

Scherly Leon is in her last year of nephrology fellowship and is on a mission. She was already the ASN Public Policy Fellow when she started the Social Media internship. She is tuning her Twitter feed to be a carefully crafted curation of nephrology and social justice content. If you aren’t following Scherly (https://twitter.com/SLeonMD), you are doing it wrong. I think everyone is excited to see what she does with her growing skills as a public physician.

Chi Chu was the only intern who was not a nephrologist and we needed to apply more thought on how to make his experience particularly relevant for him. Chi participated in all of the events and his Which nephrotoxic antibiotic are you? was epic. Likewise his DreamRCT entry was equal parts creative and audacious. He will make an awesome nephrologist someday...if we are lucky enough to get him.

Hector Madariaga was a natural for the NSMC internship and did great work from day one. However, by June it was clear that we were under-utilizing him. So we brought him into NephJC in a more formal way. For the last six-months Hector has been NephJC’s chief archivist. He is in charge of creating the Storify’s from every chat. We hope he will continue to be a key member of the NephJC team. Future editor-in-chief?

Nikhil Shah is the intern who least needed the NSMC internship. He was doing great work before the internship and we just hitched our wagon to his shooting star. His SocialKidney project is an essential tool for tracking social media conversations online. His inspirational story on how he got hooked on nephrology was picked up by MedPage today.  It will be great to have his creativity on the NSMC team in the future.

There were several more interns in the inaugural class:

The fifth student was us. We learned a lot about what does and does not work in a social media internship. We are going to be better next year. We got lucky by requiring participation in NephJC, that turned out to be an exceptional learning tool. But only because the interns didn’t merely tune in and lurk, but actively participated and engaged in the chats. It was a great (if not accidental) flipped classroom experience.

With the graduation of our inaugural class we are excited to open the application period for the second class of NSMC interns. If you are interested or have questions, feel free to send us an e-mail. If you want to apply for a spot drop us an e-mail and explain:

  • Who you are 
  • Why you want to do the social media internship
  • What experience do you already have with social media (Do not be embarrassed to say none. Do not be embarrassed to say you are really good at Facebook quizes)

The due date for the application is January 24. We will make our decisions and start the program on February 1

 Send applications to NephrologyJC@gmail.com


Spironolactone primer

Resistant hypertension is an important clinical problem. It is commonly defined as inadequate blood pressure control despite use of three antihypertensive agents of different classes at optimal dosages; one of the three should be an appropriately dosed diuretic. About 10-15% of hypertensive patients have resistant hypertension.

The magical powers of aldosterone antagonists first started to be publicized in the late 90's and in 2003 Calhoun showed a dramatic effect among patients with resistant hypertension:

“A total number of 76 subjects were included in the analysis, 34 of whom had biochemical primary aldosteronism. Low-dose spironolactone was associated with an additional mean decrease in BP of 21 ± 21 over 10 ± 14 mm Hg at 6 weeks and 25 ± 20 over 12 ± 12 mm Hg at 6-month follow-up. The BP reduction was similar in subjects with and without primary aldosteronism and was additive to the use of ACE inhibitors, ARBs, and diuretics.”

This was backed up by additional observational data as part of the ASCOT trial experience. The investigators found dramatic efficacy from modest doses of spironolactone among the 1,411 patients that received spironolactone as a fourth line agent:

“During spironolactone therapy, mean blood pressure fell from 156.9/85.3 mm Hg (SD: ±18.0/11.5 mm Hg) by 21.9/9.5 mm Hg (95% CI: 20.8 to 23.0/9.0 to 10.1 mm Hg; P<0.001); the BP reduction was largely unaffected by age, sex, smoking, and diabetic status. ”

The first randomized, placebo controlled trial in resistant hypertension was published in 2011. The ASPIRANT trial (PDF) showed a more modest, but still clinically significant reduction blood pressure.

An important caution when looking at spironolactone data is that it appears that black patients  are more sensitive to increases in aldosterone, so one could predict more modest blood pressure improvements with spironolactone in a European population. See Tu et al. (Full text).

Another critical aspect of resistant hypertension is addressing non-adherence. 

“A mass spectrometry urine toxicology screening of antihypertensive drugs reported that 53% of patients with resistant hypertension were non-adherent to treatment. Of these, 70% were incompletely adherent and 30% were completely non-adherent. Reduced adherence was not attributed to a particular antihypertensive class. Another urine analysis study found that 23% of patients referred for renal denervation were completely non- adherent to their prescribed antihypertensive treatment.”
— From Rossignol et al. The double challenge of resistant hypertension and chronic kidney disease.

This is why PATHWAY-2's attempt to measure minimize non-adherence is so important.

This week's chat on PATHWAY-2 represents the first randomized controlled trial against an active control group. The fact that aldosterone rises above other fourth line agents to provide meaningful advantages in the treatment of resistant hypertension is important.

We are coming to a new age in hypertension management. On November 9, at 2:00 PM at the AHA meeting in Orlando the SPRINT Trial results will be released. This will almost certainly result in a wave of more aggressive blood pressure control. Almost simultaneously we now have access to the first of the next generation potassium binders, patiromer. This brings the hope of avoiding the most frightening of the side effects from aldosterone antagonists, hyperkalemia. These three seemingly unrelated events are going to be major influences on the treatment of hypertension going forward.