The #EXTRIP #NephJC wrap up

This chat was really special. We had a lot of new participants - experts from the toxicology world, and many individuals sharing their experience. Many scintillating conversations (with some prominent disagreements!). Should we dialyse someone with asymptomatic high Lithium levels (yes), is rebound of lithium levels after we stop dialysis a bad thing (maybe not) and should we really dialyse in acetaminophen toxicity (ahem...see the storify and make up your mind on that one!).

If you haven't yet, check out all the summaries on UKidney. The full texts of the EXTRIP guidelines are easily available on their website too.

Lastly, remember - we have an emergency session of #NephJC *next week* on June 28 and 29. #NephJC staff is working overtime to cover the EMPAREG-Renal outcomes.

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.

The AKIKI & ELAIN AKI #NephJC wrap up

The AKI timing chats were very ....fast-paced? Lot of great input from the authors, Stephane Gaudry (who made it to both chats) and John Kellum. We had over 80 participants in all

And for those who missed it, check out the great curations via our exemplary storifier, Hector:

#NephJC on AKI timing: some comparisons

Firstly, check out Joel's post here if you haven't already.

A nice comparison from the methods man, Perry Wilson, is available here, with some great points and comparative tables.

Some more comparisons:

NephJC Summer Book Club Selection

Thanks everyone for voting. The results are in and Eric Topol's The Patient Will See You Now won.

The voting looked like this:

But the reason we asked how likely you are to read the book was so we could weight the votes. The weighting worked like this:

• 0.2 for I'll read it if I have time
• 0.4 for I'll read it if it is the book I want
• 0.6 for 50-50
• 0.8 for I will buy and start
• 1.0 for scout's honor

This turned out to not really affect the results

So Topol's book it is. The Patient Will See You Now examines how changes in technology are forcing a democratization of medicine and empowering patients in an unprecedented way. This seems like an important theme for today medical climate. The exact date of the chat has not been fixed but it will likely be mid to late July, so start reading. Watch the blog for summaries of all the chapters, similar to how we covered Being Mortal.

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.

Next #NephJC: Timing of renal replacement therapy in AKI

Next week, on May 31 in American and June 1 in Europe, we will be discussing the two major AKI studies looking at the timing of renal replacement therapy:

AKIKI https://t.co/HbpI0AkhPj

Vs

ELAINhttps://t.co/RVqRSDPm1c

Fight!

— Graham Abra, MD (@GrahamAbra) May 22, 2016

Look for a formal background post later this week.

Stop the presses!

Landmark trial dropped in the NEJM yesterday. We will be covering AKIKI on May 31 and June 1 instead of the Pip/Tazo trial. Sorry for the change in plans. We will reschedule Pip/Tazo and AKI, probably for the first week in July, but with ERA-EDTA approaching who knows?

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The DIABOLO #NephJC chat wrap up

Ted Cruz drops out, the primaries are over!

Thanks everyone for voting for what you want covered in NephJC.

The #NephJC primaries (see https://t.co/LtGiykk0y1 … for details): You would like to discuss:

— Nephrology Jrnl Club (@NephJC) April 29, 2016

The winner is a prospective RCT to see if this Pip/Tazo+Vanco toxicity is real. The reference is here. Back ground from NephMadness 2015 here and ALiEM discussed it here. We will be discussing this on May 31 and June 1. There is an #AskASN chat on May24 pushing us back a week.

Don't forget Next Tuesday/Wednesday we go all Acid-Base for a discussion of acetazolamide.

study 

The NephJC Book Club Returns. Vote for your choice.

Last summer we did a book club on Atul Gawande's Being Mortal. The NephJC team blogged its way through every chapter and we did a discussion of the book during one of our Tuesday/Wednesday chats. We think the summer is a great time to slow down from the rapid digestion of medical literature and enjoy a slower paced book. We couldn't decide on a book among ourselves so we are turning to you to pick this Summer's book. Here are the choices:

1. When Breath Becomes Air by Dr. Paul Kalanithi. NYT Review.

2. The Patient will See You Now by Dr. Eric Topol (@erictopol) NYT Review. 

3. How doctors think by Dr. Jerome Groopman. NYT Review

4. On the Move by Dr. Oliver Sacks. NYT Review

5. The Laws of Medicine: Field Notes from an Uncertain Science by Dr. Siddhartha Mukherjee. Los Angeles Times Review

Next NephJC is May 10th and 11th

We will be discussing the DIABOLO trial of acetazolamide to shorten mechanical ventilation. The Tuesday chat will be at 9PM EDT and the Wednesday chat will be at 8PM London, Noon PDT.

The article can be found at the JAMA website or via Pubmed.

Take a look at Joel's summary of the article.

See this summary by The Bottom Line

Coverage by MedPage Today