Student mentorship : early on with KDSAP

KDSAP( kidney disease screening and awareness program) is a program in Boston part of the Harvard Nephrology Division that mixes community screening and student mentorship. This community outreach program is called KDSAP and it enables high school and college students to perform kidney disease screening along with a paired mentor. While providing and volunteering their time for screening of the local population, the students are being exposed to renal medicine and nephrology and better yet: medicine in general. Mentorship breeds the emergence of fine physicians perhaps from this well structured program. Kudos to the team at Harvard for starting a channel of enthusiasm for medicine and service for the high school and college students. Check out a recent summary on this venture in Nephrology times and their main website at KDSAP

In the News: Is Normal Saline good enough?

A recently published study in JAMA evaluated prospectively normal saline (chloride based) to non chloride based fluids in the ICU setting. The outcome was to evaluate the precipitation of AKI.
Interestingly, a LR type solution was the opposite counterpart.  While there was no difference in mortality, ICU stay and hospital stay or even the need for dialysis after discharge, the chloride based solution had a higher incidence of AKI and need for in-hospital dialysis.  This study might be a tradition changer for many "internal medicine" physicians as we have traditionally argued with the surgical colleagues regarding use of " LR vs. Normal Saline" in almost all circumstances. An editorial with this also takes us through a historical perspective.

Nodular glomerulosclerosis

Differential diagnosis for nodular glomerulosclerosis on kidney biopsy

The differential is vast but a good way to differentiate is via IF staining
If Immuno is positive, either monoclonal or polyclonal:
Think:- Monoclonal IF:- MPGN, or paraprotein related disease such as LCDD or amyloidosis
If polyclonal IF:- Immunotactoid, fibrillary,cryoglobulinemia and other organized deposits seen in fibronectin GN

If Immuno is negative( more common): 
Diabetic Nephropathy
Chronic TMA
Chronic ischemic disease or hypoxia
Smoking associated nodular sclerosis and or related to metabolic syndrome

Check out a recent quiz on eAJKD on this topic.
Check out the concept map on this to simplify.

Interesting fact: Turtle urine

Recently, a study from Singapore published in National Geographic confirmed that turtles urinate via their mouth. Turtles put their head in the water but are not doing for breathing,drinking or any other purpose but urea losses. The investigators found that when studied, 50 times more urea than was present in the mouth discharge was found in the water that turtles were kept in. A special gene was discovered that found a specialized protein that expels urea via mouth. 

This is very interesting science and we hope that this will help humans one day and patients on dialysis. Is this gene even exist in humans? Perhaps but not as highly expressed. Would we want to have this gene? Check out the entire article at 
http://news.nationalgeographic.com/news/2012/10/121012-turtles-urine-pee-mouth-science-animals-weird/

Quiz to determine elderly death risk on dialysis

Check out this latest report in Nephrology News and Issues.
http://click.nnienews.com/?qs=2f609ee016859ea511fbdb0d5a048955db8ce64ad9c58801b9ba1417fe28e421a2ac6a19128603fd

Concept Map: Hypophosphatemia

A recent article in Am J of Kidney Diseases goes through a pathophysiology of diagnosis of hypophosphatemia. A concept map summarizes that article. Please review and comment to add more causes if you can.

In The News: Basic research in nephrology?

A recent editorial observational piece in JASN Oct 2012 discusses a downward trend in decline of basic science publication in high index journals in nephrology. This study compares publications in JCI and NEJM in nephrology and then looks at % articles in renal, heart, GI in JCI by discipline and its a sad decline after a surge in 1970s and 80s. What the author proposes is that we ( as a community) need to embrace and have publications/sessions at our meetings on topics that are rarely discussed at large national nephrology meetings:- Renal cancer, hypertension, stones, and infectious diseases( UTI and complex microbial urinary tract disorders).  Expansion of our field is very important. While we have managed to embrace genetics and immunology, we have yet to conquer some of the more common illnesses that we see clinically and move that part of the field forward.

Topic Discussion: Anemia mechanisms

What are the mechanisms of anemia in CKD?
A recent article in JASN Oct 2012 issue discusses this as a science in renal medicine.
Figure 1 in the article is worth exploring as it summarizes the literature on this topic.

1. Decreased EPO production
2. Uremic inhibitors to action of produced EPO
3. Shortened RBC survival in the uremic state
4. Blood loss during dialysis
5. Decreased iron absorption due to uremic state
6. Other losses of iron via dialysis, chronic bleeding, dysfunctional platelets, blood trapping
7. Impaired iron release from stores
8. Hepcidin excess impairs iron absorption

Topic Discussion: Glomerular disease in Myeloma

Myeloma cast nephropathy is classically a tubular interstitial disease. Glomerular diseases in myeloma can  be classified as either with organized deposits or amorphous deposits.

1. Organized deposits;- AL amyloidosis ( Usually lambda), Type I and II cyroglobulinemia ( Usually kappa), Immunotactoid GN ( Usually kappa)

2. Amorphous deposits: MIDD ( LCDD, HCDD, LHCDD) - usually kappa if light chain, Proliferative GN with non organized monoclonal Ig deposits ( kappa)

Just another way to think of these patterns in myeloma.

Topic Discussion: Myeloma and the kidney- why?

Why do the free light chains affect the kidney? How does the injury happen?
Research in this matter has revealed significant insight.
The three mechanisms are:

1. Direct toxic effects of the free light chains on the proximal tubular cells leading to apoptosis , cytokine generation and cell injury.
2. The light chains have direct inflammatory effects mediated due to excessive endocytosis through the tandem endocytic receptors. This leads to increased inflammatory cytokine production and damage.
3. The free light chains can bind to Tamm-Horsfall protein and lead to myeloma cast formation leading to the intratubular obstructive damage that we clinically observe.

A nice review can be found in ACKD.