Nephrologist are Incrementalists and Superheros

Dr. Atul Gawande recently wrote this amazing article on amazing heroism on incremental care. 

This article discusses the difference of episodic heroic medicine vs incremental care. Who cares of you when episodes of urgent care and then there is care of chronic illnesses.

Who are the physicians that take care of you "episodically"?- the Er doc, the cardiologist when you have chest pain, the surgeon when you need emergent surgery.  Who are the incrementalists-- the primary care docs, ID docs for HIV patients, family docs, pediatricians.etc...

He makes an amazing argument of payment to those docs as well. He says that the interventionists make most of their income on defined, minutes- hours long procedures such as hip replacements, endoscopies, cardiac procedures. etc.,and then move on.  Hence payment is high for those specialists. On the other hand, the lowest paid specialties such as pediatrics, endocrine, family medicine, ID, and I would add nephrology here as well are incrementalists and are not paid that well.  Almost certainly at the bottom are geriatricians and palliative care specialists. All are incrementalists, they produce value by improving lives long term and over time but not well compensated.

The article does an amazing job describing the two types of physicians and how each type make such an amazing impact on the patient's lives. While some are "acute" life savers; others are "long term" life maintainers.  Both are important to maintain balance in medicine. Nephrologists are not mentioned in the article but I would say they are both episodic care providers and incrementalist.  We have times were we are urgent life savers for taking care of the hyperkalemia and dialysis but then the long term care of the CKD patient, ESRD patient and transplant patient is incrementalist side of the nephrologist.  Yet, we fall in the bottom half of the payment model.  Incrementalists need to be rewarded as well. Being a surgeon, Gawande raises and brings an important issue to the forefront for us internists out there. Bravo for supporting and thinking of us and what we do. We make a difference in incremental ways and it matters!

Worth read in the New Yorker

http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care

IN the NEWS: Vancomycin induced CAST nephropathy

Recent literature has linked AKI with vancomycin and zosyn and it was thought that the higher vancomycin levels might have been the culprit.

http://aac.asm.org/content/57/2/734.full

https://www.ncbi.nlm.nih.gov/pubmed/23402420?dopt=Abstract’

It was also assumed that the injury was either AIN or ATN. Few biopsies done in these cases were suggestive of ATN in the past( vancomycin mainly). Personal experience, I have seen ATN from vancomycin as well that is biopsy proven.

In JASN,  Luque et al might have discovered what is the mechanism behind vancomycin toxicity. The biopsy of a single case presented showed tubular casts entangled with uromodulin.  EM showed vancomycin particles in the tubular cast when immunogold labeling was used.  Staining with anti-vancomycin antibody revealed the specific accumulation of vancomycin in the tubular lumen mainly. Similar to myeloma casts, this leads to an intratubular obstructive ATN. A CD68+ macrophagic infiltrate was also observed surrounding the casts and within the kidney’s interstitium, suggesting that pathologic casts might induce an inflammatory process. To further confirm the pathogenicity of vancomycin-associated casts, they  retrospectively examined eight additional renal biopsies with ATN that had been performed in the clinical context of high-vancomycin trough levels preceding AKI. Similar findings were noted in the biopsies.  Vancomycin trough levels ranged from 35-106mg/dl in the 8 patients.  50% of the patients required dialysis. To confirm, they did in studies in mice and injected vancomycin and observed effects in the kidney.Kidney injuries have been visible as early as two days after vancomycin injection.

In summary, this article is the first to describe the novel form of injury an antibiotic can give.This can explain the sometimes noticed rapid rises we noted in some cases of acute ATN with vancomycin and perhaps even other antibiotics.

Should we be giving pre and post hydration like we do for acyclovir when giving vancomycin to prevent AKI?

Check out this amazing paper! Kudos on thinking out of the box and finally giving us a potential mechanism!

http://jasn.asnjournals.org/content/early/2017/01/11/ASN.2016080867.full?sid=3ef58699-863c-4696-a720-754c288e21eb

 

IN THE NEWS: Preventing rejection while using immunotherapy in organ transplants

Use of immunotherapy such as CTLA-4 and PD-1 inhibitors have been sparingly used in renal transplant patients due to the concern for rejection.  Several cases and one recently published in NEJM last year showed severe acute cellular and antibody mediated rejection with use of PD-1 inhibitor therapy. In the limited number of patients who have received these agents, it appears that PD-1 inhibitors could be more prone than CTLA-4 antagonists to cause rejection in the transplanted kidney. This is especially true when the patients receive anti–CTLA-4 agents before PD-1 inhibitor treatment. 

We reported now in NEJM a creative solution of preventing rejection in a patient getting nivolumab (PD-1 inhibitor). By using a prophylactic approach of higher doses of steroids and mTOR inhibitors, we were able to successfully prevent rejection along with successful treatment of the cancer as noted in the supplementary files of the letter. Immune check point inhibitors have revolutionized the treatment of many types of cancers.With this approach, it is possible that these agents can be perhaps safely be used in the organ transplant patient.

We recently reviewed entire literature on the use of immunotherapy in the organ transplant world. As stated above, the rejections were mostly seen in PD-1 inhibitor based therapy compared to CTLA-4 therapy. In addition, the 2 cases of liver transplant where these agent were used and 1 case of heart transplant didn’t lead to a rejection episode.  But in the renal transplant patients, 5 cases have now been reported of leading to acute cellular and antibody mediated rejection when PD-1 inhibitor was administered. The above NEJM case suggests a potential treatment strategy.

Renal effects of immunotherapy are not minor.  AIN, podocytopathy and electrolyte disorders have been reported. It is important for the general nephrologists to know about these effects.Two recent reviews discuss this elegantly.

http://www.karger.com/Article/FullText/455014
http://ndt.oxfordjournals.org/content/early/2016/12/23/ndt.gfw382.abstract

NKF Spring Meetings: Pre course on Point of Care Ultrasound for the Nephrologist

We shall be providing with NKF(Spring Clinical Meetings 2017) the first ever Renal
course on point of care Ultrasound pre course: this is the practical training of using a portable ultrasound in volume assessment, renal and bladder sonogram for daily use on "rounds".  See below for details but the link on NKF website for Spring meetings has more details

https://www.kidney.org/spring-clinical/program/physician-highlights

NKF Spring Clinical Meetings: Point of Care Ultrasound for the Nephrologist

From

04/18/2017     7:30 AM

To

04/18/2017     12:30 PM

Walt Disney World Swan and Dolphin, Orlando, FL

Description

The renal consultant needs knowledge of lung ultrasound to determine volume status, renal and bladder ultrasound to evaluate for obstruction and knowledge of vascular access guidance to assist in placement of catheters. This course will focus on the above elements in point of care ultrasonography. 

• Image acquisition will be practiced on human models using high-quality ultrasound machines and supervised by experienced faculty. Training sessions give you practical, hands-on training with a 1:3 teacher-to-learner ratio, so you benefit from personal instruction.
• Image interpretation during group sessions under the supervision of experienced faculty members offers relevant practice. Numerous ultrasound images demonstrating normal and pathologic findings will give you a comprehensive learning opportunity. As you improve your skills, you will be further challenged with unknowns and case-based image sets.
• Knowledge base will be enhanced with lectures that focus on important aspects of point of care ultrasonography applicable to the renal consultant. Discussions will have immediate application within your practice.

Learning Objectives:

Upon completion of this course, participants will be able to:

• Discuss how to perform lung ultrasonography and ultrasonography of the renal system.

• Identify appropriate uses of ultrasonography in renal practice.
• Demonstrate appropriate image acquisition techniques required for renal ultrasonography.
• Interpret image-based clinical cases to help identify abnormalities.

Faculty:

Paul Mayo, MD

Mangala Narasimhan, MD,

Daniel Ross, MD

Kenar Jhaveri, MD

Topics:

Breakfast and Introductions

Lung Ultrasound for the Assessment of Volume Status

Hands on Lung Ultrasound
Image Interpretation Lung Ultrasound

Break

Vascular Access/ IVC Size

Hands on Vascular Access/IVC

Image Interpretation Vascular Access/IVC

Renal Bladder Ultrasound

Hands on Renal Ultrasound

Image Interpretation

Wrap-up and Evaluation

  

4.25 credits/contact hours

REQUIRED: Separate registration fee of $60 for NKF Members, $75 for Non-Members, $40 for Fellows/Residents. Includes light breakfast, and CME credits. Participation is limited, so register early.  

In the NEWS: US Nephrologists, dialysis and pregnancy

Pregnancy occurs among 1–7% of women on chronic dialysis. Data on how dialysis is provided in ESRD patients who get pregnant in the US is lacking. A recent survey published reveals the latest update on this topic. 

While the response rate is small, the information might be important. Limited providers might have this experience of providing for dialysis for the pregnant patient. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. More dialysis time is associated with better volume and electrolyte control. The frequency of preterm delivery and intrauterine growth restriction tends to correlate with BUN levels. There is an inverse association between BUN level and birthweight and adverse fetal outcome, with more favorable outcomes when the serum urea level is <75 mg/dL. The survey shows that most US nephrologists target a BUN of <50 mg/dL (66%) and 21% aim for a target predialysis BUN of <20 mg/dL. Intensive dialysis is a necessary important finding that is now becoming norm for patients who are pregnant.  Both maternal and fetal outcomes have improved.

What was interesting in the study was "Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week."
Why would that be?.  The authors think that it might be for two reasons: increased hours on HD leading to more vasoconstriction and tighter volume control leading to pre eclampsia. Also since this was a survey, the diagnosis of preeclampsia was dependent on the nephrologist recognizing it and perhaps a "diagnosis" labeling problem. 

Pregnancy on dialysis is becoming frequently encountered, pregnancy care should be part of the health maintenance plan of women of childbearing age on dialysis. OB-Nephrology should be considered a sub field in Nephrology and should become part of academic centers as a career paths for nephrologists and training of fellows. 

Nephrology Crosswords: Transplantation in a box

Here is a nephrology crossword on transplantation as the topic published in Kidney International Jan 2017 issue.

http://www.kidney-international.org/article/S0085-2538(16)30338-6/abstract