TWiN

We are in the process of recalibrating and redesigning #TWiN. DM your suggestions to me. @dr_nikhilshah

TWiN (The Week in Nephrology) 4th July 2016

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)

TWiN (The Week in Nephrology) June 20 2016

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.

Multiple Myeloma - 2016 update on diagnosis, risk stratification and management was recently published in the American Journal of Hematology by Dr Vincent Rajkumar(@VincentRK) from Mayo.

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)

And now Hector Madariaga(@HecmagsMD)  brings you the best of #ATC2016Boston in a 5 part storify collection.

TWiN (The Week in Nephrology) June 13 2016

ESRD

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.

CKD

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.

DM

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.

General

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.

HTN

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.

Transplant

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.

TWiN (The Week In Nephrology) June 6 2016

Transplantation

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.

GN

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.

HTN

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.

TWIN for 23 May 2016

• General

  • 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!!

• AKI

  • #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!!

• Dialysis

  • 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.

• Hypertension

  • Swapnil Hiremath summarizes the Canadian Hypertension Guidelines 2016 (CHEP) incorporating the SPRINT data in an AJKD Blog post.

• Transplant

  • 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.

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

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)

• Hector Madariaga published an excellent summary on Immunosuppression in identical twin kidney transplantation. Published on the Renal Fellow Network.
• Clinical Kidney Transplantation Course 

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
  • First a very informative educational review on the lifelong implications of measurements of kidney functions in neonates.
  • Secondly guidelines on management of neuropathic bladder in children from the Bristish Association of Pediatric Urologists.
• 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.