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
Background
Cristina Adriana Popa
REGENCY: A B-Cell Super Destroyer in Lupus

This week, we will celebrate in advance World Kidney Day by discussing the results of OBInutuzumab in active lupus nephritis. The LUNAR trial (rituximab versus placebo) was “almost” positive, but not quite there. Would Obi overpower its cousin ritux? ✨

REGENCY: A B-Cell Super Destroyer in Lupus
Background
Cristina Adriana Popa
Hunting Primary Hyperaldosteronism: are MRAs a ...

This week, we will continue with February’s aldosterone leitmotif: do mineralocorticoid receptor antagonists (MRAs) truly blind the diagnostic in unilateral hypraldosteronism? Is this the article the mythbuster? Draw your own conclusions

Hunting Primary Hyperaldosteronism: are MRAs a blindfold in adrenal vein sampling?
Background
Brian Rifkin
Undercover Aldosterone

This week, we will discuss the origins of primary hyperaldosteronism in normotensive patients. Could this undetected anomaly be the cause of idiopathic hypertension and CKD?

Undercover Aldosterone

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.


NephJC 22: GMT chat

The American chat (mostly by virtue of its longevity) still has more participants and tweets, but the GMT (EU/African) chat makes up by being fun and entertaining. Tom Oates, Paul Phelan, Francesco and their merry band of tweeters make for delightful reading. Jungle Juice, scud missiles and more. See some highlights below


Palliative care chat #HPM on Wednesday at 9EST

March is Kidney awareness month and in honor of that, Pallimed, the Hospice and Palliative Care Blog is talking about intersection of nephrology and palliative care. They asked NephJC co-creator, Joel Topf to host their chat. This happens on Wednesday. Topf wrote the introduction:

Have you ever read a journal article and as soon as you finished the abstract you had this forbidding feeling that if the authors actually proved what they claimed to have discovered your medical life will never be the same?

This happened when I read, Functional Status of Elderly Adults before and after Initiation of Dialysis by Tamura et al. in 2009. 

The study simply looked at mortality and functional status of nursing home residents who initiated dialysis. The cohort consisted of 3,704 Americans. The average age of this predominantly white (64%) female (60%) cohort was 74 years. The outcomes were horrifying:

  • Within three months of starting dialysis 61% had died or had a decrease in their functional status
  • By one year that figure was 87%
  • By one year only 1 in 8 patients had maintained their functional status from before dialysis

While this study did not track patients who deferred dialysis it is hard to imagine they could do much worse. The view of dialysis as a way to improve functional status by clearing uremia leading to improved nutrition and other downstream benefits was revealed to be a false hope. Instead we have a treatment that appears to be too rough for frail, at-risk patients and left them significantly worse than they were before dialysis.

The discussion section of the article had a sentence that should be embroidered to every nephrologists white coat: 

“...kidney failure may be a reflection of terminal multiorgan dysfunction rather than a primary cause of functional decline, and thus the initiation of dialysis may not rescue patients from an inevitable decline.”

As nephrologists we need to elevate conservative, non-dialytic, therapy to be a clear option for patients, one that should be discussed along with peritoneal dialysis and transplant. Conservative care should not merely be a last resort when all other options have been exhausted.

I hope you will join us as we discuss the intersection of nephrology and palliative care this Wednesday at #hpm chat.

from NephJC live to the Lancet

You might remember Perry Wilson, the young dapper nephrologist from Yale who presented his trial on AKI alerts at NephJC live a few months ago. He was tweeting as @nephrolalia - and has now renamed and rebranded himself as @methodsmanmd, which is quite apt given his recent blog posts and succinct and snappy videos up at MedPage Today. 

More notably, the data he presented at #NephJC live has been published today - with some great additional analyses, in the Lancet. We sure know how to pick winners - so the next time we come calling, pick up the phone!

Tweet of the Week: Urine Eosinophils and NephroCheck

Dr. Faubel nailed the best comment about NephroCheck by reminding us while we pick apart the particulars of NephroCheck that we have some other dragons to slay:

And then Edgar slides in with the appropriate #NephPearl (How does he do that so fast?)

#NephJC 20: Who checks the checkers? Storify Part 1: EST chat

Last night we were off to a rollicking start with a great #NephJC chat - in great part due to the participation of Azra, Jay and Sarah! Joel took no time - burning the candle at both ends to do some storifys. 

Here is the entire unedited archive with all the tweets from both chats:


Topic 0: Introduction, and How we do diagnose AKI?

Topic 1: Discussing DISCOVERY, SAPPHIRE and TOPAZ

 

Topic 2: ROC Curves and Diagnosing Aki with Nephrocheck

 

Topic 3: What happens now?

 

The GMT chat today was also very intense - Storify will follow shortly!

KDIGO AKI staging

Tonight's journal club requires knowledge of the KDIGO acute kidney injury stages. These are nearly direct translations from the previous AKI staging systems.

  • RIFLE: the first system. KDIGO 1, 2, 3 roughly corresponds to R, I, F. The primary difference is KDIGO categorizes people with just a 0.3mg/dL rise in Cr as AKI, RIFLE does not.
  • AKIN: As far as I can see AKIN 1, 2, 3 is identical to KDIGO 1, 2, 3.

New for NephJC tonight: Topics

In case you haven't signed up for our mailing list (really - why not? go there and do it now!)  - We are going deep on the FDA approved NephroCheck™, a new test for the early diagnosis of AKI. This is not industry sponsored BS, just honest, crowd-sourced, EBM.

For this #NephJC we have three topics we want to discuss:
 

*please preface your tweets with the topic: i.e. T0, T1 and so on*


Topic Zero: How are you currently diagnosing AKI?

  • Is it all FENa and a microscope slide? 
  • What do you think of the KDIGO AKI stages?
  • How do you use oliguria?

Topic 1: Evaluate their strategy for developing a novel test for AKI.

Three studies in 2 papers:

  1. Discovery: the scientists tested 340 biomarkers and came up with a pair that performed best. N=522.

  2. Sapphire: validated the biomarker from Discovery in a unique cohort. N=744.

  3. Topaz: A separate study just to validate the results of Sapphire. N=420.

Is this a compelling story line? Is this a fair way to discover and validate a test? Do you agree with the conclusions?

Topic 2: Evaluating a test.

  • On ROC the area under the curve was 0.82. Good enough?
  • Two cutoffs are provided, one is sensitive (92%) and the other is specific (95%). How will you use that?

Topic 3: So what?

  • How will having a 12 hour lead time change your management?
  • Should we expect trials designed to change the course of AKI to use NephroCheck™?

GMT NephJC gaining steam

Tom Oates and his merry gang of GMT chatters shattered previous records for the Euro/Afro chat. Great work guys!

Not quite up to the pace of the western hemisphere, but gaining fast.

In a related note, NephJC.com reached 4,000 page views in a month for the first time in January.