KDIGO 2021- ANCA vasculitis management

 Check out the latest update in 2021 of treatment of ANCA vasculitis at KDIGO

1. Kidney biopsy is highly recommended in most cases

2. For induction- they recommend that steroids in combination with cyclophosphamide or rituximab be used for new onset AAV. 

3. For patients with GFR that is declining of crt >4.0mg/dl, there is limited data for rituximab based treatment. The combination of cyclo+ ritux can be used in that setting - RITUXIVAS protocol.

 

    4. When to do cytoxan vs rituxan?

5. Reduced dose steroids have shown similar results as high dose steroids( PEXIVAS trial)

6. Dosing for Rituxan and cyclophosphamide

7. Consider plasma exchange with crt >5.7 requiring dialysis or with rapid rise in crt and diffuse alveolar hemorrhage with hypoxemia or overlap syndrome with Anti GBM

8. Maintenance therapy

In the News: WhatsApp in Onconephrology

A recent study published looked at using a "mastermind" chat using WhatsApp for onconephrology discussion. This group was created using Whatsapp in 2019. Since then close to 100 members are part of an ongoing online discussion. This study evaluated the 2 years of chat content via a survey, keywords and a full qualitative thematic analysis.

1. The keywords showed the figure below- The bigger the font, the most commonly discussed topic. 

2. In terms of thematic analysis, the 3 common themes that emerged were: collaboration, case discussions and knowledge sharing.

3. In terms of the survey, the key figure is below.  It is interesting that after uptodate.com, the chat was used by many for knowledge discussion and topic question answering. This is fascinating and could be because many of the topic experts and uptodate.com chapter writers were on this chat. 

Use of mastermind chats like this should grow in medicine. This allows for small subspecialty fields to have like minded individuals e-meet and discuss tough clinical challenges, share important knowledge and eventually collaboration for research. A recent paper on CDK4/6 inhibitors causing ATN was a result of collaboration led by this chat. 

Check out this amazing tweetorial by Prakash G on this.

Our manuscript Utility of WhatsApp® for onconeph education is out @CKJsocial @kdjhaveri @Sebi_Lapman , authored by 2 phenomenal students Simoni Khashi and Nitya Wanchoo, Quality analysis done by Kayla Kinuf @HofstraU @HofstraKidney @UCKidney @uofcincy @UCincyMedicine Tweetorial pic.twitter.com/ll46aCv7x2

— Prakash Gudsoorkar MD, FASN, FNKF (@prakashneph) December 16, 2021

American Society of Onconephrology

We have come a long way in the last 13 years. The origins  of this field can be traced back to 2005 when the first book on this topic was released by Eric Cohen et al. The field of oncology has continued to rapidly evolve since then, and the advent of tyrosine kinase inhibitors, chimeric antigen receptor T-cell (CAR-T) therapy, and immunotherapy has further necessitated the development of this new subspecialty. Onconephrology has since become its own rapidly-growing subspecialty. As many of you know my passion for this field has been evident on my blog for the last decade. With the help of the amazing founding members team, this organization was created this fall of 2021.

The website is at https://www.ason-online.org/ and twitter( @onconephsociety)

The mission is to promote research, clinical activities, and education related to onconephrology. 

More specifically, the primary objectives of this society shall be to further the investigation of onco-nephrology and reach a better understanding of the basic mechanisms involved as follows:

By informal group discussion of material that is of cross disciplinary interest as it pertains to care of patients with kidney disease and cancer.

By exchange of ideas pertaining to clinical experiences and experimental research

By consideration of problems encountered in onco-nephrology research. 

By the promotion of good fellowship and mutual trust among members of this organization.

By fostering education and identifying gaps in knowledge as it pertains to onconephrology.

Membership will be soon available. Let's welcome the beginning of the next phase of this field in nephrology.

​

Topic Discussion: CDK4/6 inhibitors and the Kidney

Selective estrogen receptor inhibitors and aromatase inhibitors are the mainstay of therapy for hormonal receptor-positive (HR+) breast cancer; however, most metastatic HR+, human epidermal growth factor receptor 2-negative (HER2-) progress and acquire resistance to endocrine therapies. Cyclin-dependent kinase 4/6 inhibitors (CDK4/6 inhibitors) comprise a new class of drugs that overcome this resistance.  Three CDK4/6 inhibitors—palbociclib, ribociclib, and abemaciclib—have been approved for HER2-negative metastatic breast cancers, usually in combination with hormone therapy. 

Interestingly, the renal community has seen elevated serum creatinine associated with these agents. Several early trials of palbociclib and ribociclib did not describe the incidence of AKI, whereas clinical trials of abemaciclib have reported that up to 25% of patients experienced a rise in creatinine. In vitro studies of abemaciclib have shown that the drug and its major metabolites inhibit renal transporters like organic cation transporter-2, multidrug and toxin extrusion-1 (MATE-1), and MATE2-K, potentially leading to a reversible rise in creatinine without actually changing GFR. Cases have been described that show this pseudo-AKI. 

More recently, biopsy proven cases of acute tubular injury also have been noted- 6 cases with tubular and interstitial damage.

Finally, a search of the FAERs database revealed that, in addition to AKI, metabolic disturbances like hypokalemia, hyponatremia, and hypocalcemia may occur while on CDK4/6 inhibitors. Hyponatremia has been reported with ribociclib and with abemaciclib and grade 2 hypokalemia was reported in 20.8% of patients taking abemaciclib. 

In summary, the common renal associations with CDK4/6 inhibitors are

Pseudo AKI, ATI, hyponatremia, hypokalemia and hypocalcemia

KDIGO 2021- GN Management Guidelines: MPGN

 The recent KDIGO guidelines are here

One of the most important changes is getting rid of the MPGN1, 2 and 3 classification and using the novel pathophysiology based classification and recognizing that MPGN is a pattern of injury

The diagnosis of the C3GN and DDD is tough and requires the extensive assays and testing on complement cascade.

Treatment really depends on the cause.

For idiopathic causes of MPGN pattern of injury, consider a limited course of steroids
For RPGN of idiopathic cause, steroids + cyclophosphamide
For MPGN with low GFR< 30, supportive treatment only

For C3GN, and no signs of MGRS, and failed MMF and steroids, eculizumab should be considered
 

Topic Discussion: Pre eclampsia and APOL1

 This ASN 2021, I heard an interesting lecture and realized some novel associations with pre-eclampsia(PEC) and APOL1 gene mutations. 

Here are some interesting findings.

1. Black women have a higher risk of PEC their White counterparts.
2. Reidy et all showed that it is the FETAL not maternal APOL1 renal risk variant that is associated with PEC in Black women.

3. Some other studies showed that PEC was associated with the maternal G1 and not the G2 allele

4. In Blacks in Ohio, INFANT APOL1 genotype was associated with PEC

5. Recent study in AJKD, found that APOL1 kidney risk variants in Black mother and infant pairs of women of African American origin had higher risk of PEC compared to Haitian women. PEC was higher with maternal and fetal APOL1 genotype discordance, an effect driven by the African American mother-infant pairs. 

6. None of the published studies assessed if the mother’s APOL1 genotype conferred preeclampsia risk independently of the fetal APOL1 genotype, although in African Americans both the maternal and fetal APOL1 renal risk variants appear to increase risk if an APOL1 genotype discordance exists.

7. Experimental data support the hypothesis that APOL1 renal risk variants mediate preeclampsia. APOL1 levels, APOL1-derived peptides, and APOL1 autoantibodies have been linked to preeclampsia. Sedor's team showed that transgenic mice that expressed APOL1 using the nephrin promoter developed a pregnancy-associated phenotype characterized by hypertension, proteinuria, and seizures, which was more severe in transgenic animals with an APOL1 kidney risk variants transgene compared to reference. 

Overall, this is fascinating as we learn regarding the risk of PEC and APOL1 risk variants. It appears that fetal variants of the gene may be more important here.. the story continues to evolve... Stay tuned..

KDIGO 2021- GN Management Guidelines: Infection associated GN

The recent KDIGO update 2021

Bacterial infection associated GN- 4 main types

Post infectious GN
Shunt nephritis
Endocarditis associated GN
IgA dominant infection related GN

All 4 of them usually have low complement levels.  No RCT for treatment
Antibiotics or surgical treatment for respective infections

Viral infection associated GN- 

Hep B- Hep B DNA >2000 IU/ml, need treatment with anti Hep B agent and no avoid immunosuppressive agents as can accelerate the viral infection.

HIV disease: HAART therapy is recommended for all HIVAN and HIVICK diseases.

Hep C associated GN:  A kidney biopsy should be performed in HCV-positive patients with clinical evidence of glomerular disease. Patients with mild or moderate forms of HCV-associated GN with stable kidney function and/or non-nephrotic proteinuria should be managed first with a DAA regimen. Patients with severe cryoglobulinemia or severe glomerular disease induced by HCV (i.e., nephrotic proteinuria or rapidly progressive kidney failure) should be treated with immunosuppressive agents (generally with rituximab as the first-line agent) and/or plasma exchange in addition to DAA therapies. Patients with HCV-related glomerular disease who do not respond to or are intolerant of antiviral treatment should also be treated with immunosuppressive agents.

In the News: Performance trends of Nephrology fellows in certification exams

 A news flash paper published recently in JASN showcased the down trending test scores of nephrology fellows in certification exams. The authors analyzed the data from 2010-2019 and found that the pass rate has been falling below the bench marks. Interestingly, they found that the factors associated with this decline were lower internal medicine exam scores, older age and training in a smaller program. In addition, female sex and being IMG were also associated with a lower board score. 

The IM board score as a predictor can make sense as both exams evaluate knowledge and skills of reasoning. Age over 33 performed less well than younger candidates is interesting. This could be because of non medical factors. Even since 2009 when I took my boards, the knowledge level has changed. There is more and more to read and more diseases to understand in medicine. Residency has not changed, Fellowship years have not changed. While knowledge and science has advanced, we have not changed our ways to teach and perhaps even consider changing the timeline of residency and fellowship. Fellows have family and other commitments as well and a well balanced life-work-training is critical for our trainees. 

The fact that graduates of the least competitive nephrology fellowship programs(smaller programs) performed worse after regression adjustment indicates there might be a peer effect, or advantages of a structured program at a larger academic center. 

IMGs were less likely to score high.  The field of Nephrology has seen an increase in IMG applicants.  In 2019, IMGs comprised nearly 70% of those taking the nephrology exam for the first time, an increase of more than eight percentage points from 2010. We keep forgetting that everyone learns differently- not everyone has a structure of learning in multiple choice questions in rest of the world; there are language barriers and other factors that play a role as well. Fellowship programs need to explore non ppt format of teaching and novel ways to teach the same material for varied type of learners. 

Finally, women were found to have lesser scores. To my knowledge, not sure of any published papers showing this difference in test taking strategies. I don't think we need to take any stake in these findings as these might be not of any significance. The editorial nicely reminds us to not take this finding seriously. 

What should be done?
Why can't we test the fellows on what we really encounter rather than esoteric rare and confusing diseases. Why can't the tests really mirror the life of a renal fellow and attending?
Institutions need to take ownership on better techniques and strategies to help their fellows. Many residencies may not be training them in proper test taking techniques. Institutional and program resources must support trainees’ needs, protect their time, and ensure education is prioritized.  

I can say from my personal example of few fellow I trained- had trouble passing the boards due to their test taking abilities. Their patient satisfaction scores as attendings are off the roof and their overall understanding of both patient care and medicine is excellent. They may not be a good test taker, but they can manage a good census, take care of patients and call for help when needed and effectively communicate with other doctors. They win patient trusts, they do well with following up and most important of all- they care! and want to be Nephrologists that matter. 

While test scores are important, failures sometimes teach us to be better and improve our abilities to be the best at what we do. But regardless, this is a wake up call for our field to improve as instructors and teachers and not disappoint our students. 

KDIGO 2021- GN Management Guidelines: FSGS

 FSGS has been the waste basket diagnosis for years. KDIGO finally has adopted the primary vs secondary FSGS way of thinking to make it easier to treat FSGS and diagnose the 99% of the secondary causes. Check out these amazing figures from the supplement

Treatment wise:  If primary FSGS- steroids 1mg/kg dosing for 4 weeks and then taper over 6 months

If not, then try CNI( cyclosporine vs tacrolimus)- goal 100-175 or 5-10 range for each drug
After 6 months, no response- considering MMF, anti cd20 agents but data on both is small. 

If secondary cause- treat the secondary cause or conservative management. SGLT2i may make it there next iteration. 

KDIGO 2021: GN Management Guidelines: Membranous Nephropathy

MN management has changed in 2020 onwards thanks to two trials published in 2020-2021 that showed that cyclophosphamide/steroids is superior and rituximab is not the main player yet. 
The figures below summarize the main points of the GN 2021 KDIGO update 

Detective Nephron: Next Venture Oct 2021

 Here is the next DN case of AKI

http://onlinedigeditions.com/publication/?m=15191&i=724592&p=36&ver=html5

KDIGO 2021: GN Management Guidelines: IgA nephropathy

 

The three figures from the recent KI GN update 2021 summarizes IgA nephropathy.

Basically, At this point, given negative studies for steroids, only thing we have that has strong evidence is conservative management. Interestingly, SGLT2i did not make it to the guidelines.  ACEI/ARB+ SGLT2i might be the best treatment options we have for IgA Nephropathy. 

The one place where immunosuppressive meds will help is Crescentic IgA nephropathy and IgA with MCD. 

Here is the final table on all meds and their data from KDIGO

Does immunosuppressive meds help IgA nephropathy? Do we await the budesonide directed therapy approval, do we await more supportive agents such as ET1 antagonists or Aldo antagonists? Time will tell. Till then, IgA nephropathy is still the hardest GN to treat as we don't have clear options for treating the pathophysiology of the disease. 

Consult Rounds: Hyponatremia and AKI- need CRRT- what do we do??

 

Hyponatremia correction is challenging but manageable.
Offering and prescribing CRRT in the ICU is also doable by most nephrologists.

Here comes the challenge.

You are called, “ anuric patient, Na 110, K 5.4, BUN 90, Crt 6.0mg/dl) and altered mental status”
Now you are confronted with correcting the Na slowly and providing good dialytic clearance as well given anuria and hyperkalemia.

CRRT has advantages in its ability to correct plasma sodium values in a predictable and slow manner. Compared with standard hemodialysis machines, where the lowest dialysate sodium concentration is 130 mEq/l, CRRT solutions can be customized to any desired sodium level, allowing for personalized therapy. 

To act on these advantages and prescribe CRRT to target an increase in serum sodium no >6 mEq/L per day, there are three options: either (1) customize the CRRT circuit or (2) customize CRRT solutions. (3) add D5W infusion separate line with standard CRRT

So how is this rate calculated if we were to use Method 3( the easiest of the 3 options)

If D5W rate will be used – the formula is (140 -- target Na value)/( 140 X clearance)
So if we take 110 meq/L as the starting Na value and goal is in 24 hours to be 118. Given the patient was symptomatic, using 3% saline bolus- we get him to 112-113meq/L range. Then if we do 30cc/kg/hour clearance of CVVHDF, that would be roughly 2.4 liters/hour and hence the rate of D5W would need be 375cc/hour. If we use clearance of 25cc/kg/hour- then around 300cc/hr of D5W would be needed.

In an article by Rosner et al, in CJASN, method 1 is well discussed using this figure- changing the post filter fluid or replacement fluid to sterile water( d5W) and rate calculated similarly as stated above.

For method 2: Adding sterile water to commercial dialysis solutions to achieve a desired final sodium concentration would be next way. For instance, if a 5-L bag of replacement solution has a sodium concentration of 140 mEq/L, then the addition of 1 L of water would result in a final sodium solution of the replacement solution of 116.7 mEq/L. 

An important caveat, once desired Na is reached, D5W needs to be changed back to standard replacement fluids and or D5W drip discontinued. 

In the NEWS: Immunotherapy and the Kidney( new data in 2021)- AKI and electrolytes

Immune checkpoint inhibitors (ICI) are a novel class of immunotherapy drugs that have vastly improved cancer care for patients. Data on AKI has been evolving. 

In a multicenter international study just published in JITC by Gupta et al involving 30 sites across 10 countries, researchers collected data on 429 patients with ICI-AKI and 429 control patients who did not develop ICI-AKI. Armed with the largest ICI-AKI database to date, the team of researchers was able to identify predictors, recovery potential and survival outcomes of those patients with ICI-AKI.

One of the most important findings from the two-year study reveals that among patients who take ICI again – even after an episode of ICI-AKI – only 16.5 percent developed recurrent ICI-AKI, which shows that most patients can still take these life-saving medications safely.

Additional findings show that in renal-recovery occurs in approximately two-thirds of patients with ICI-AKI. Early treatment with corticosteroid is associated with a higher likelihood of renal recovery. Lower baseline kidney function, proton pump inhibitor use and extrarenal immune-related adverse events are independent risk factors for developing ICI-AKI.

A related paper recently published in the journal Kidney International by Wanchoo et al looking at the scope of electrolyte disorders that are seen with ICI. Hyponatremia, hypokalemia and hypercalcemia were the most common findings. SIADH is the most common cause of hyponatremia and adrenal disorders led the way in the cause of hypercalcemia. 

Hypocomplementemia and the Kidney

 When we are faced with AKI and classically low c3 and c4, certain diseases come to mind.

A classic figure that has been used for years is below:

I think we can divide the low complement diseases and the kidney with glomerular processes and non glomerular processes

The glomerular diseases that are classically associated with low complements are:

MPGN pattern( all forms, c3GN, DDD, immune complex related MPGN), Lupus related GN, Cyro related GN, infection associated GN( both post strep and endocarditis), but we should not forget Fibrillary GN ( especially if MPGN pattern of injury is noted) and heavy chain deposition disease(HCDD). Finally, we should not forget TMA with complement disorders can cause low c3 in some cases.  In other words, immune complex is the main pathology that is driving the hypocomplementemia. 

Non glomerular diseases that can be associated with low complements should be kept in mind- classically atheroembolic disease and IgG4 diseases( fair amount have low complements)

Here is a mnemonic that many use- CHAMPS ( created by NephSim)

Topic Discussion: As needed anti HTN meds in the hospital- can we stop the madness?

 

We often see in the hospital, BP is treated as needed. Often, as nephrologists we have suggested to NOT do this. Outpatient problem that exists for years cannot be corrected in 2 hours by hydralazine or beta blockers so that the "vitals" look good and " numbers" are good for rounds. A recent study published in Hypertension nicely showcases this via a retrospective propensity matched protocol. When compared to scheduled BP meds patients to Scheduled meds and PRN patients ( over 4000 each), risk of AKI, stroke and mortality was higher in the as needed group. In addition, length of stay was higher as well. 

This comes following another recent article in JAMA looking at a similar concept. Among 22,000+ patients studied in hospitals with non cardiac diagnosis, hypertension was treated as needed in several patients.  In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Treating with intensification of anti HTN meds without signs of end organ damage lead to worse outcomes.

Finally, another study in 2019 in JAMA found that among older adults hospitalized for noncardiac conditions, prescription of intensified anti-hypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

So basically, let's not try to treat a number but the patient and let's not make a chronic problem a priority in the admission that doesn't warrant too many changes. That may be doing some harm!

Nephrology and US News and World Report Rankings

 

Traditionally, all fields in medicine had some sort of ranking in US News and World Report. July 2021, Nephrology was removed and was changed to rankings based on " Renal Failure".  What does that even mean?

Traditionally, what consists the score is patient experience, structure, mortality and length of stay and nephrology used to include reputation related to both med and surgical procedures. We don't know what the "kidney failure" consists of when the new rankings were assigned. 

Even the old way of ranking was flawed- as many of us know that when you include surgical procedures- you are not involving other fields like vascular surgery, transplant surgery and perhaps Urology. That is " Kidney care" but not " Nephrology". And " Kidney failure" alone is not nephrology either.

ASN President and ASN timely released a rebuttal and I think this needs to be read by all. This is extremely important. 

https://www.asn-online.org/about/press/releases/ASN_PR_20210727_Hospital_Rankings_S.pdf

The " Kidney Failure" is not a good way to advertise nephrology to patients as most patients see US News World report.  Nephrology is a field that includes quality care in Prevention, Treatment and then Management of AKI. In addition, other hospital acquired disorders such as acid base, hyponatremia and so forth are part of Nephrology. Complex GN cases are not easy to define treatment and are also part of nephrology. Social components are also critical when we discharged ESKD patients and obtaining an outpatient dialysis spot in certain parts of the country is not easy for patients. Lot of key stakeholders are involved in this and length of stay can get affected. 

As pointed out in the rebuttal by ASN, during the initial surge of COVID19 in 2020, many states experienced AKI and dialysis shortages-- how did we all manage this as a community- we can't prevent the AKI in some cases- but how did we manage it.. that is extremely important. As a field in medicine, we really excelled and did our best!

In general, rankings are not good in certain fields that are more as a result of other fields like Nephrology. What I mean is - our AKI cases in general are NOT caused by us- they are either drug induced, sepsis induced, ct surgery induced, contrast induced, etc... So how can the field of Nephrology be responsible for this or the respective program in that hospital. It really is a more complex and more large system issue that needs more collaboration and dedication from other fields in medicine to PREVENT AKI and associated complications. Intrinsic renal causes such as GNs or TMA are a rare entity in a large scheme of things.

In another editorial, the authors say that it is about time we stop ranking hospitals based on their reputation mainly but look at the crucial layers of data within the state. The author suggests that look at the areas in which a hospital performs , measure each of them and give a score set- simple- remove the reputation component and keep it fair.

Perhaps the ranking systems needs consultants to guide them from both academic and community nephrology to help create a rank list -if we still even want to do that. I say we bow out and just focus on providing good care!

Kudos to ASN for saying what is on our mind

Concept Map: Methotrexate Renal Toxicity

 

Picture created using biorender.com
Pathology pic obtained from google: Arkana lab collection. 

ASN Kidney News All Education Issue 2021

 July 2021 is an entire issue of ASN Kidney News. See all visual abstracts related to the issue

Opinion: Impact factors and Renal Journals( Kidney Journals or Nephrology Journals)

When we observe, no nephrology journal that published original investigations had an impact factor of >10.0 till 2021. Cardiology, Oncology and Gen Med journals top the lists usually with high impact factor in the 90s, 70s, 60s but obviously in the two digits. It is good to see finally that two of our journals KI and JASN have entered the two digits, both flagship journals of ISN and ASN. 

What is an impact factor? (IF). It is an index calculated by Clarivate that reflects the yearly avg number of citations of articles published in the last 2 years in a given journal, as indexed by the web of science. In the academic world, this matters as journals with high IF values are often deemed as more important and carry more prestige. Several promotional meetings at med schools also take this metric as the most important on where the candidate's work is published. Lower IF journals or higher IF journals

Despite it's shortcomings, IF and the author's citation index( h-index), such judgements remain common practice suggesting a need for an alternative method. Some have proposed something called the relative citation ratio( RCR).  It is an improved method to quantify the influence of a research article by making novel use of its co-citation network—that is, the other papers that appear alongside it in reference lists—to field-normalize the number of times it has been cited, generating a RCR. Since choosing to cite is the long-standing way in which scholars acknowledge the relevance of each other’s work, RCR can provide valuable supplemental information, either to decision makers at funding agencies or to others who seek to understand the relative outcomes of different groups of research investments.

One should read this interesting tweet on this topic

We have a broken system in science. Currently, the main bulwark still protecting science from total collapse in the US is the NIH scientific review system.

I know this may sound extreme. But hear me out. 1/N

— Mara Mather (@MaraMather) June 29, 2021

Also, check out this amazing post by Curry on " Sick of Impact Factor" . He says that that real problem started when IF began to be applied to papers and people. He says and I quote, 

" I can’t trace the precise origin of the growth but it has become a cancer that can no longer be ignored. The malady seems to particularly afflict researchers in science, technology and medicine who, astonishingly for a group that prizes its intelligence, have acquired a dependency on a valuation system that is grounded in falsity. We spend our lives fretting about how high an impact factor we can attach to our published research because it has become such an important determinant in the award of the grants and promotions needed to advance a career. We submit to time-wasting and demoralizing rounds of manuscript rejection, retarding the progress of science in the chase for a false measure of prestige."

Some not so perfect options/alternatives for IF are on this website.  Here is the chemistry world's revolt against it. This one study showed that an Article Influence score (AIS) and Source Normalized Impact per Paper (SNIP) were the only bibliometric alternatives to demonstrate a positive correlation when compared to the IF (r = 0.94) and (r = 0.66) respectively.

Interesting discussion on twitter on the recent announcement of renal journal IFs. 

Nephrology specific impact factors: KI 10.6, Jasn 10.1, AJKD 8.8, CJasn 8.2, NDT 5.99, clinical kidney journal 4.5, KI Reports 4.1

— Manish M Sood MD MSc FRCPC (@Msood99M) June 30, 2021

So, what should renal journals do? Should we be leaders in medicine and change the tide or try a stick with the old ways and continue using the IF? 

Concept Map- Causes of Renal Amyloidosis

 

Created using biorender.com 

Immune checkpoint inhibitors and the Kidney infographic

 

Here is a comprehensive infographic by Tejas Desai on 4 studies from around the world with ICI and the Kidney. 

Topic Discussion: SGLT2i and the Kidney

 

Post Grand Rounds SLGT2i and the Kidney Tweetorial
- The Glucoretics - thanks @edgarvlermamd @ChristosArgyrop @jam_hirsch for some slides
Start...PART 1 https://t.co/rXn5AqYinO

— Kenar Jhaveri (@kdjhaveri) May 28, 2021

SLGT2i and the Kidney Tweetorial Part 2
Start: Time to #flozinate
When prescribing- mindful for bp management https://t.co/OD5WOYOYv0 @aishaikh pic.twitter.com/PDqCo1vJK2

— Kenar Jhaveri (@kdjhaveri) May 28, 2021

Two tweetorials I had recently done on the benefits of SGLT2 inhibitors

Here is a table summary of what exists on benefits of various things in Nephrology

SGLT2i  benefit	Summary or Major Reference
Diabetic Kidney Disease	https://onlinelibrary.wiley.com/doi/full/10.1002/clc.23508
IgA Nephropathy	https://www.kidney-international.org/article/S0085-2538(21)00396-3/fulltext
SIADH	https://jasn.asnjournals.org/content/31/3/615.abstract
Hypomagnesemia	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380494/
Kidney Stones Prevention	https://link.springer.com/article/10.1007/s00125-021-05424-4
Anemia of CKD	https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30300-4/fulltext
Prevent AKI	https://cjasn.asnjournals.org/content/16/1/70.abstract
Prevention of cisplatin AKI	https://journals.physiology.org/doi/full/10.1152/ajprenal.00512.2019

 

COVID19 vaccine induced glomerular diseases?- a literature update May 2021

The vaccine for COVID19 has been a lifesaver for many around the world. As expected, as you upregulate your immune system- you are going to get some flare ups of your immune system. Thus far, what are we noticing Minimal change disease, MN and IgA nephropathy. 

Several published cases of podocytopathies- mainly minimal change disease- either de-novo or relapse have been reported ( 4 cases thus far)

https://www.kidney-international.org/article/S0085-2538(21)00493-2/fulltext (Pfizer-BioNTech )

https://www.sciencedirect.com/science/article/pii/S0272638621005096 (Pfizer-BioNTech) 

https://www.ajkd.org/article/S0272-6386(21)00602-8/fulltext ( Pfizer-BioNTech )

https://www.kidney-international.org/article/S0085-2538(21)00478-6/fulltext (Pfizer-BioNTech)

IgA nephropathy flaring up has been reported ( 3 cases thus far)

https://www.kidney-international.org/article/S0085-2538(21)00465-8/fulltext ( Moderna)

https://www.kidney-international.org/article/S0085-2538(21)00286-6/fulltext (Moderna)

Relapse of Membranous Nephropathy  ( one case)

https://www.kidney-international.org/article/S0085-2538(21)00494-4/fulltext (Sinovac’s COVID-19 vaccine.)

Acute transplant rejection has been reported

https://www.kidney-international.org/article/S0085-2538(21)00466-X/fulltext ( Pfizer-BioNTech)

While we cannot be totally sure if this is vaccine related- timing maybe a factor. I am sure there will be many more to be added to this list.

Despite this, the vaccine saves lives! Remember severe COVID19 disease led to significant AKI and ATN and even several cases of glomerular diseases. Such vaccine associated immune responses should not deter one from getting vaccinated. Overall, even the flu vaccine and other vaccines have been associated with several glomerular diseases such as MCD and membranous nephropathy.  Given mass vaccinations happening around the world, there will be cases of vaccine induced GNs( but still very very rare)