Sketchnote in Nephrology: Medicine

A great read for educators and learners is the book called The Sketchnote Handbook – The Illustrated Guide to Visual Note Taking, a new book released by Mike Rohde.  Sketchnotes  are visual diagrams of a lecture that has some writing and some figures to allow a different form of note taking. 
In physiology, especially complex renal physiology such note taking strategies might be useful for certain type of learners. This allows for a larger bigger overall understanding and can allow for details as well.  Many of us might be doing this already when we take notes( perhaps draw a flow chart) for better understanding of the topic being discussed. Sketchnotes are about hearing and capturing meaningful ideas and not how well you draw.  This book gives a way to take notes differently from what one might have traditionally done.  A picture can tell you more than a detail description of a nephron sub-segment. In one study in Plastic Surgery, a picture told more than words.  
Sketchnote will allow you to think out loud and clear your misconceptions. 

Some examples of discussions and mentions of use of such tactics in medicine are linked below.
33charts view on this topic.
Sketchnote version of the recent Med 2.0 2012 conference in boston
Pediatric Surgery

CRRT Update

A nice review in NEJM current issue Dec 2012, there is a clinical perspective review on CRRT use in AKI.
Dr. Tolwani reviews the implications of CRRT and the current state of practice. From the indications to the different clinical trials, the review nicely summarizes last few years of research and practice.
Two great tables to take home: Table 1 discusses the different modalitis( CVVH, CVVHD and CVVHDF) and compares it via solute transport, replacement fluid and flow rates. It is a nice summary table for many trainees to review.  Important to emphasize the true indications for use of CRRT and then which one of the above to choose. The access is an important component discussed as choice of vein should be in order of IJ>femoral>subclavian. In addition, anticoagulation is important as many times, heparin cannot be used in such cases and citrate based CRRT might be needed. Data on that are slowly emerging. Finally, dosing of drugs and antibiotics is important consideration in CRRT.

NEWphrologist in the making!

The Jan 2013 issue of ACKD has a focus on the role of the nephrologist in the intensive care units( medical, surgical, neurosurgical, cardiac). Vast topics from sepsis, care of a ventilated patient, critically ill ESRD patient are discussed in the entire issue. Interestingly, a new name is given to the role of the nephrologist in the intensive care unit- newphrologist. Definitely a growing field in nephrology and at some centers - a separate service. Not sure if the name justifies the function of the intensivist nephrologist.

Nevertheless, check out the entire issue on ACKD.

Blogging in nephrology: Local versus National conferences

Desai et al show in a study that scientific blogs can be a great tool in sharing and viewing scientific local meetings. Most of the recent literature and live blogging that has been done has been of national meetings. Most non academic practitioners want to hear about the happenings are national meetings. In Nephrology, many online blogging sites have done this in the last 4 years.  The data presented here in this manuscript suggests that while the number of viewers were less in local meeting blog posts, the minutes spent and time spent were equally comparable to national blog posts. The authors suggest that this would be a great way to share and use local conference material. Bogoch et al looked at blogging site of intern morning report and had subjective rating scales but knowledge content was not looked at. 

Overall,this manuscript is a step in the right direction and allows for openness of presentation of data in national and local conferences via blogging. Both conferences can be equally useful to the learner.  

Interestingly, publishing in formats as such( F1000 research journal) when peer review is also open and allows for free commenting before completely being accepted for publishing allows for more information to be discussed and an open dialogue. More and more journals should be moving to such platforms of publishing( at least partly). There might be red tape and other factors preventing this. The Plos Journals are a great example of the futuristic journal platform. Cost, and potential bias based reviews might be reasons why this might be not as attractive to many journal editors. 

CLINICAL CASE 66: Answers and Summary

ESRD PATIENT ON HEMODIALYSIS PRESENTS WITH HYPERGLYCEMIA OF 800. HOW WILL YOU TREAT?

Severe hyperglycemia in oliguric or anuric ESRD patients is not associated with features of a glucose-related osmotic diuresis as is seen in other patients but is more likely to be associated with hyponatremia, hyperkalemia, and acute intravascular volume expansion and instead of giving fluids and insulin, one must resort to good insulin therapy and prompt dialysis. A prior post discusses this in more detail. Hence the most appropriate answer is Insulin and dialysis.

microRNAs and renal disease?- more data

Epigenetics refers to a heritable change genetic code that is mediated by a mechanism specifically not due to alterations in the primary nucleotide sequence.  These epigenetic changes can lead to medical condition changes. Recent studies have shown that epigenetic modifications orchestrate the epithelial-mesenchymal transition and eventually fibrosis of the renal tissue.

MicroRNAs (miRNAs) are short non-coding RNAs regulating gene expression at the post-transcriptional level by blocking translation or promoting cleavage of their target mRNAs. Increasing evidence shows that miRNAs play central roles in gene transcription, signal transduction and pathogenesis of human diseases. Epigenetic changes might be resulting via the miRNAs.

MicroRNAs( miRNAs) have been the focus of many renal disease spectrums from glomerular diseases to transplant rejection. A recent study in Experimental and Molecular Pathology is one of the first to examine the role of miRNAs in HIVAN. The investigators showed that 11 miRNA were downregulated in HIVAN when compared to controlled mice. Further examination showed that miR-200 and miR-33 were the two that had effects on the podocytes specifically. 

This begs a question of looking at miRNA in many renal diseases. Another study recently published looked at urinary miR-21, miR-29 and miR-93 as novel biomarkers of fibrosis in patients with IgA nephropathy. Lupus Nephritis had miR-638, miR-198 and miR-146a compared to controls. 

Interestingly. miR-155 and miR-126 are elevated in ESRD patients as potential markers of inflammation. miRNAs have been studied in diabetic nephropathy as well. 

The list can go on and on... And we are sure to see more role of miRNA in clinical use perhaps in near renal future. Still unclear is how these numbers will be very helpful. Repeat studies to confirm that certain miRNA are markers for lupus flare versus diabetic nephropathy are needed. They might assist in a decision to biopsy or not to biopsy? Or are they mere markers of prognosis. More global decision has to be made on how to use these tests in future use:- markers, or targets for potential treatments....

ASN: Geriatric Nephrology Videos

ASN launched a new five-part video series, "Improving Dialysis Rounds for Geriatric Patients," produced by the ASN Geriatric Nephrology Advisory Group and made possible with support from the Association of Specialty Professors. The publicly available, free video series, accessible online and, covers important aspects of care of aging patients, including assessment, treatment decisions for patients with advanced kidney disease, care of elderly patients receiving chronic dialysis, recognition of physical and mental decline, the importance of quality of life, and of shared decision-making between patients, caregivers, and providers.

Have a look at this great educational resource.

IN THE NEWS: Contrast Nephropathy

Preventing contrast nephropathy has always been a research topic. From anti oxidants to hydration to dialysis all have been suggested. Hydration likely to be the only winner thus far.
Two recent studies need to be highlighted that have come out in the cardiology literature.

1.  Tamai et al from Japan studied a moderate size subgroup of patients with significantly high doses of bircarbonate infusion( close to 800meq/L) compared to standard bicarbonate infusions(160meq/L) pre cardiac cath at a rate of 3ml/kg/h for one hour. As expected urine pH was higher in the first group but statistical significant rate of decline of contrast induced nephrolopathy as well in that group. Potassium values didn't change much. 48 Hour GFR change was much more in the standard bicarbonate group. Interestingly, baseline renal function was around 1.3-1.4mg/dl with some difference in both groups making this study weaker. Also, while initial Na concentrations were similar, wonder what 24 hour Na levels were in these cases. Interesting study to bring back alkalization as a potential prevention for contrast nephropathy.

2. Marenzi et al show that fluids with match diuresis might prevent contrast induced nephropathy compared to standard fluid therapy The MYTHOS study looked at 250ml Normal Saline bolus followed by furosemide to keep urine output >300cc/h and then do the cardiac procedure versus a standard fluid infusion model. Contrast induced nephropathy rates were much lower in the case where urine output was high. Another interesting concept and study to look at this problem

Both studies: single centers, small studies, many limitations. Have a look but they might catch on in the cardiology world and we might be seeing some of this happening at our centers.

Kidney SMART: For medical students

ASN initiative to spark research interest in nephrology for medical students.  After completing one year course in medical school, students can attend a one week renal physiology course with great sessions.
And then they get to attend the ASN kidney week during their later part of medical school.
It mirrors from the fellows course at Mount Desert Island Biologic Labs.
Check out the official website at Kidney SMART

ANCAs and Alpha-1 antitrypsin- any link?

Alpha 1- antitrypsin (AAT) is a major inhibitor of proteinase 3.  In one with AAT deficiency, it has been postulated that there may be an increase in proteinase 3 activity due to inability of AAT to inactivate the proteinase 3.  This imbalance may lead to ANCA vasculitis.  See below for some interesting aspects of this association. One study looked at an association of the allele of AAT deficiency and relation to ANCA disease. While a cause and effect cannot be proven, this is an interesting association. As early as 1993, this assocaition was encountered and studied. Interestingly, another study that looked at AAT inhibitor phenotypes and levels examined in 40 ANCA positive cases of systemic vasculitis, an excess of PiZ and PiS alleles were associated with the development of pulmonary haemorrhage and alpha-1-proteinase inhibitor levels were lower in the subgroup with pulmonary haemorrhage. However, this allelic imbalance and reduced alpha-1-proteinase inhibitor level was not confined to antiproteinase 3 positive patients and did not appear to be associated with other organ involvement or disease severity.

Post by

-Mala Sachdeva, MD

Clinical Case 65: Answers and Summary

A 34 YEAR OLD FEMALE ON HEMODIALYSIS GETS PREGNANT. HOW WOULD YOU ADJUST THE PRESCRIPTION ON DIALYSIS TO HAVE THE BEST OUTCOME FOR MOTHER AND BABY?

Change to Peritoneal dialysis

  7 (9%)

 

Since the largest data suggests poor outcomes, would suggest to not continue pregnancy

  2 (2%)

 

Daily dialysis for total of 12-15 hours per week

  38 (50%)

 

Three times a week dialysis as her regular prescription

  6 (7%)

 

Three times a week dialysis but goal pre-dialysis BUN<35-40mg/dl

  23 (30%)

 

Pregnancy has been reported in dialysis patients. Over 70% of 80 pregnancies reported in one large series, had resulted in surviving infants and no maternal deaths. The largest case series to date of pregnant HD patients is 52 patients over 20 years. In that experience, HD was performed daily but total weekly treatments were shorter( 12-15 hours per week). UF was avoided and over 85% of pregnancies ended up with surviving infants. Most were pre terms. BUN concentration is <35mg/dl. In other words, pregnancy can be successfully tried in HD patients in the right circumstances and in the experienced centers. Most answered the question correctly. 

Consult Rounds: Distal RTA and Sjorgren's Syndrome

Distal renal tubular acidosis in Sjorgren’s Syndrome (SS):

1. One of the mechanisms is an absence of the H-ATPase pump on intercalated cells in the collecting duct.  

2. Also, Sjogren's syndrome (SS) leads to autoantibodies directed against carbonic anhydrase II.

This leads to less proton excretion.

3. Severe hypokalemia might also suggest that there is a combined proximal and distal RTA.
4. Full blown fanconi syndrome has been described in SS as well.

5. Severe hypokalemia can occur in SS despite no RTA and is thought to be due to tubular damage induced sodium wasting with subsequent increased distal sodium delivery.  

6. Chronic hypokalemia can lead to a nephrogenic diabetes insipidus(NDI)

7. Regarding NDI, the largest series is an Italian series 21% of patients were noted to have an abnormal urinary concentrating ability. Lymphocytic infiltrates of the collecting duct might be the cause. 

8. A nice attending rounds in CJASN discusses hypokalemic metabolic acidosis. 

Ethics in Dialysis practices

" You stole my patient when she was admitted to a hospital I don't go to". " How come all my dialysis patients are being taken away by the other group in town as they open a new unit?"

These are concerns and ethical issues that many nephrologists in practice face as competition arises between practicing groups. A recent CJASN article highlights many issues that we face ethically when such issues arise.  This paper is almost as close to a policy statement re such unethical practices that are business minded and not patient centered.
Key points that are discussed have to deal with how one group can refrain from soliciting other groups patients and keep their business interests aside while taking care of patients.

Tips suggested are:

1. Rescual ( don't get involved in care of the other group's patients)
2. Avoid soliciting
3. Full transparency to the patient if you have to get involved.
4. Avoid self referrals to one's unit or office
5. Provide a collegial environment( while competition is good, we all went into this profession for patient benefit)

Glad an article to this regard is published in nephrology. Its worth applauding the authors on a topic that is often faced by many of us in a competitive environment; and to highlight that such tactics that are often used are unethical and remove us far far away from our professional oath.

Communication Skills Training for Dialysis Decision-Making and End-of-Life Care in Nephrology

Communication is an essential component of nephrology care, yet nephrologists receive little training in communication. We developed a communication workshop for nephrology fellows, NephroTalk, to address common communication topics encountered including:  giving a diagnosis; discussing the risks and benefits of treatment options; and addressing end-of-life decision-making, especially in elderly, medically complex patients. Our curriculum, modeled after OncoTalk a successful communication skills program for oncology fellows, was comprised of didactic and practice sessions with simulated patients and nephrology cases.

The workshop consisted of one-half day divided into two sessions. Sessions addressed common communication scenarios in nephrology: delivering bad news and defining goals of care when the patient is doing poorly. For each session, an overview presentation highlighted the skills to be practiced including a faculty demonstration of the skills. After each overview presentation, fellows were divided into small groups each led by a facilitator for skills practice using standardized patients. For each practice session, the facilitator followed a reflective process-oriented framework that focused on identifying the practicing fellow’s goal and providing the tools to accomplish this goal.

The skills taught included the following: giving information using Ask-Tell-Ask; recognizing and responding to emotion using the NURSE acronym; open-ended questions to elicit care goals and end-of-life preferences; and using “wish” statements to respond to unrealistic goals.

Twenty-two fellows participated in the workshop from University of Pittsburgh and Duke University. We measured perceived preparedness using pre- and post- workshop surveys. Overall, perceived preparedness following training increased for all communication challenges including; delivering bad news, expressing empathy, and discussing dialysis initiation and withdrawal. Fellows rated the course highly and recommended it to other fellows. Qualitative comments highlighted how the training would impact future practice: “Listen more intently, limit use of medical terminology further, give patients more opportunity to express feelings.”

NephroTalk is an interactive communication workshop to enhance nephrology fellow communication skills using didactics and practice sessions to address common communication tasks in nephrology. From this work, future direction would involve disseminating our curriculum to other institutions and enhancing the education of nephrology educators and attendings. 

For the a full article on this, check out: 

http://www.ncbi.nlm.nih.gov/pubmed/23143502

http://www.ncbi.nlm.nih.gov/pubmed/23078102

Special post by

Jane Schell MD

MGRS: Monoclonal Gammopathy of RENAL SIGNIFICANCE: A new name for an old entity to define treatment

What happens with we find renal pathology findings and they confirm a monoclonal strain of B cell clone. A bone marrow is done and there is MGUS revealed. Is that now MGUS really undetermined or insignificant.  A new term now referred to MGUS disorders with renal biopsy findings as MGRS( monoclonal gammopathy of renal significance). These patients are hard to treat as they are never classified as having a hematologic disease. They are usually classified as MGUS with MIDD or MGUS with MPGN.  Other diseases that have been identified to be consistent with monoclonality are fibrillary, immunotactoid and certain cryoglobulinemias. 

A lot of the MGUS patients with renal disease have been receiving no treatment or undertreated given the confusion. No one receives standard therapy for MM at the time of diagnosis.

How do we treat these disorders? A recent article by Leunget al in Blood summarizes some suggestions: Treating the underlying clone, myeloma-based treatments have shown more response rates although lymphoma based treatments have been used as well.  The authors think that these disorders don’t require treatment from a “tumoral” standpoint but from a renal deterioration standpoint it’s needed. Hence the term MGRS fits better for this entity.

Diseases that are now associated with MGRS( or could have been classified)

1.     MIDD

2.     AL amyloidosis

3.     Fibrillary GN

4.     Type I and II Cryoglobulinemic GN

5.     Immunotactoid GN

6.     GOMMID

7.     Proliferative GN with monoclonal deposits

8.     MPGN