February Renal Path Video - Wash U Nephrology Web Episodes!

For anyone wanting to unravel an unusual case and brush up on their renal pathology, check out the February episode of the Wash U Nephrology web series.

Point of Care Ultrasound for the Nephrologist at #SCM2017

Want to up your ultrasound game... Attend the point of care ultrasound for the nephrologist pre-course at the NKF Spring Clinical Meeting in Orlando, FL April 18 2017

click here to register

The nephrology 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.

Renal Grand Rounds: Correlate Clinically

I recently presented the case of a middle-aged patient with ESRD secondary to Goodpasture syndrome. She presented with AKI 3 months after a kidney transplant. Her creatinine had normalized to 0.9mg/dl post-transplant. However, over the next few months she had multiple hospitalizations for infections, perinephric fluid collections and three episodes of AKI. Her creatinine finally stabilized at 1.5mg/dl. Due to concerns that she was overly immunosuppressed, her mycophenolate was discontinued during her last admission and her prednisone was stopped per weaning protocol. She was continued on tacrolimus. At her post-discharge follow up, she was found to have recurrent AKI with Cr 2 mg/dl She had 1+ blood on UA, but no proteinuria. GBM antibody was negative. She was admitted for a transplant kidney biopsy.

The biopsy demonstrated diffuse linear staining of the glomerular basement membrane. There was no evidence of active glomerulitis or crescent formation. Mild mesangial expansion and moderate thickening of the GBM were noted with no signs of cell-mediated or antibody-mediated rejection.

This prompted the million dollar question: Is this diffuse GBM staining early recurrence of anti-GBM disease or something else?

The inciting event of anti-GBM disease is still unknown (correlations with smoking, cocaine use, solvent exposure, and infections), however the pathophysiology is fairly well established - an insult causes a conformational change of the type IV collagen network in the GBM resulting in exposure of the non-collagenous portion of the alpha-3 chain which elicits an immune response. Based on multiple uncontrolled studies, these patients can be transplanted 6-12 months after their GBM antibody titers become negative and they have similar transplant outcomes when compared to other causes of ESRD.

But how often does it recur after transplant? In 2013, Tang et al retrospectively analyzed 58,000 patients in Australia and New Zealand started on RRT and found 449 diagnosed with anti-GBM disease, 224 of whom were transplanted. Of those transplanted, 2.7% developed biopsy proven recurrence. So... it recurs, but rarely.

What about a false negative GBM antibody titer? Our patient's titer was negative, and the reported false negative rate for the ELISA and western blot is 2-3% making it unlikely. However, there have been case reports of anti-GBM disease with negative ELISA and weakly positive western blot suggesting low or transient antibody production. In addition, alternative immunoglobulins not picked up by the ELISA, such as IgG4, and alternative GBM antigens have been proposed based on case reports.

What else could produce diffuse GBM staining? In monoclonal immunoglobulin deposition disease the physicochemical properties of the monotypic light chains result in high affinity for the GBM and diffuse linear staining. In addition, in diabetic glomerulopathy, there is thought to be a loss of negative charge in the GBM which allows negatively charged species such as immunoglobulin and albumin to collect in and expand the GBM. Our patients SPEP and SFLC were normal, and the donor didn't have a known history of DM. 

In the end, we couldn't answer the million dollar question definitively, but we decided to treat with plasmapheresis, rituximab, and restarting prednisone and mycophenolate. Rituximab was used instead of cyclophosphamide due to previous complications during her initial treatment.  She's currently doing well with Cr stable at 1.5mg/dl

Posted by Patrick Reeves

(Picture is Dr. Ernest Goodpasture who first described this condition while studying victims of the Spanish Flu in 1919)

Renal Grand Rounds - What Lurks in the Gap

I recently presented the case of a middle-aged man with a history of a remote Roux-en-Y gastric bypass, chronic diarrhea, and colon cancer on chemotherapy who initially presented with progressive fatigue and weakness in the setting of increased diarrhea. Shortly after admission he developed agitation that progressed to encephalopathy with dysarthria. His baseline labs from a month prior to presentation were notable for a chronically low serum bicarbonate of 15-17 with no anion gap. When he presented he was hypokalemic to 2.5 and his bicarbonate had dropped to 11 with a new elevated anion gap of 25 and normal L-lactate. Metabolic acidosis was confirmed on VBG. Interestingly, his urine electrolytes demonstrated a positive urine anion gap of 26.

He was ultimately diagnosed with D-lactic acidosis based on his clinical presentation which was confirmed with a serum D-lactate of 6.28. For the week prior to admission, he had been drinking 1.5 L of Gatorade (224 g of sugar!) daily to replace diarrhea losses.

This was a classic presentation of D-lactic acidosis in which overgrowth of gram positive anaerobes in the setting of short bowel syndrome is combined with a large carbohydrate load resulting in bacterial fermentation and D-lactate production.  He even had the classic neurologic findings!  His chronic non-gap acidosis likely represented chronic diarrhea and D-lactate production, and his rising anion gap when he presented was consistent with increased D-lactate production.

In D-lactic acidosis, the findings of hypokalemia and a positive urine anion gap can provide a helpful clue. With elevated serum D-lactate levels, the fractional excretion of D-lactate approaches 100%, i.e. everything that's filtered is excreted. This is because the stereospecificity of the sodium-L-lactate cotransporter in the proximal tubule results in poor reabsorption of D-lactate relative to L-lactate. The negatively charged D-lactate essentially drags positively charged sodium and potassium into the urine causing hypokalemia as well as a positive urine anion gap (Na + K - Cl) due to the increased urine sodium and potassium.


This patient did well after his Gatorade was cut off and he was treated with antibiotics to address gram positive anaerobic overgrowth.

Posted by Patrick Reeves

(Image taken from here - an educational blog for ED residents)

Nephrology Business Leadership University

See below for details on a very interesting looking course for Renal Fellows:

We are excited to introduce a new innovative program available to Nephrology Fellows -   Nephrology Business Leadership University (NBLuniv.com)

NBLU is a unique week long program that brings together a diverse faculty of practicing Nephrologists, hospital and dialysis provider executives, and other healthcare professionals who will share their insights on leadership, the business of nephrology, and the evolving healthcare landscape.  Most sessions are held in a workshop format and are highly interactive and individualized.  

Fellows attending a NBLU rotation can expect to leave with:
1.Ability to evaluate potential employers for the ultimate fit
2.Enhanced leadership and business understanding to bring to potential employers
3.An understanding of the ever-changing payment / reimbursement landscape
4.The know-how to embark as a solo practitioner or as a high impact member of a group practice
5.Confidence approaching the interview process
6.Knowing you have the tools to start your career in the right direction

Topics Covered:
-Billing & Coding Workshop
-CV and Interview Tips
-ACOs, ESCOs Basics
-How to find the right job
-Growth Strategies for your practice
-Marketing 101
-Practice Management
-How to Review Employment Contracts
-Financial Planning
-Much Much More.......

NBLU will hold its second annual program from August 7th to August 11,2017 in Plano, Texas.
Since we would like to keep the sessions very interactive space is limited. 

Registration is free and can be done on the website NBLuniv.com

Travel support, hotel accommodations, and most meals are provided to all fellows that are attending.  There should be little to no out of pocket expenses to the fellow or their training program.

Program Organizers - University of California San Diego Division of Nephrology  & Dallas Renal Group (dallasrenalgroup.com)

TESTIMONIALS FROM FELLOWS ATTENDING LAST YEAR CAN BE VIEWED ON WEBSITE!  NBLUniv.com
Nephrology Business Leadership University

If you or your program director has any questions please feel free to contact me at cmiracle@ucsd.edu

Renal Grand Rounds - A Chilling Case of Hyperkalemia

A 62 year old man with ischemic cardiomyopathy (EF 35%) and CKD (baseline Cr ~3 mg/dl) had a witnessed out-of-hospital cardiac arrest.  EMS arrived within 3 minutes.  He received CPR and was shocked out of ventricular fibrillation (VF).  He was intubated and therapeutic hypothermia was initiated in the field. He was admitted to the CCU, where therapeutic hypothermia was continued for 24 hours.  He received aggressive KCl repletion for hypokalemia (see graph below) and supraventricular arrhythmias.  On the second hospital day the patient was rewarmed, developed severe DIC (INR 10), worsening shock requiring 3 pressors, and renal was consulted for hyperkalemia and oliguric AKI on CKD.

Clinical pearls: Hypokalemia is a frequent complication of hypothermia for two major reasons: 

1) cold diuresis, which is believed to result from peripheral vasoconstriction, increased venous return, and increased ANP; 

2) catecholamine-induced shift of KCl into cells.  

Interestingly, the latter seems to depend on the type of protocol used to induce hypothermia.  Core cooling increases norephinephrine but not epinephrine, and therefore does not cause a shift of K into cells.  In contrast, external cooling (which was used in this case, with the application of cooling pads) increases epinephrine disproportionately to norepinephrine.  The B₂ agonist actions of epinephrine cause a shift of K into cells.  It is therefore critically important to avoid KCl repletion during rewarming due to the risk of rebound hyperkalemia, particularly in oliguric patients such as this one who are unable to deal with the excess potassium load once it moves back out of the cells during rewarming.

Posted by David Leaf

Come to KIDNEYcon April 7-8 2017 for hands on learning

When- April 7-8, 2017
Where- Little Rock, Arkansas
Who should attend- Internal Medicine Residents, Pediatric Residents, Adult and Pediatric Fellows, Attending Nephrologists

**if you are an adult nephrology fellow and interested in coming please note that you should take the in-service exam  April 5 or 6. talk to your program director or coordinator

Travel Grants- Available to Adult and Pediatric Residents and Fellows (DUE DATE Feb 17th)

REGISTER HERE

Mission Statement

KIDNEYcon is an annual two day educational event with a mission of fostering enthusiasm for careers in nephrology among residents and fellows and to provide educational updates on relevant kidney topics. An additional focus is to develop collaborative research projects between academic and private nephrologists.

Director- John Arthur, MD, PhD
Professor and Chief of Nephrology
University of Arkansas for Medical Sciences

Co-Director- Shree Sharma, MD
Nephropathologist
Arkana Laboratories, LIttle Rock, AR

Education Director- Matthew A. Sparks, MD
Assistant Professor and Associate Program Director
Duke University

KIDNEYcon is an annual conference designed to provide updates in the latest advances in kidney care in a hands-on collaborative format. A key component of KIDNEYcon's mission is to build enthusiasm for the field of nephrology among residents and fellows. We also aim to facilitate collaborative research projects among participants of the conference. The conference is a platform for nephrologists and medicine trainees to interact with experts from across the nation and learn about and discuss recent advancements in the diagnosis and treatment of kidney disease. The conference consists of Friday workshops targeted primarily to medicine residents, nephrology fellows and early stage nephrologists and a Saturday scientific and clinical conference with broader applicability.

KIDNEYcon 2017 will feature four interactive hands-on workshops

1. The Kidney Biopsy Academy 
2. Vascular Ultrasound for Assessment of Volume Status Workshop 
3. Interventional Nephrology Workshop
4. Social Media in Nephrology Workshop 

The Saturday session will be an educational meeting with multiple interactive sessions featuring case-based studies and audience response technology, followed by Q & A sessions with the expert panel.

One of the first duties of the physician is to educate the masses — Sir William Osler

Please consider coming to the conference. I am really excited about this years conference and our goal is to break the mold of the traditional conference. You will leave KIDNEYcon with more confidence and knowledge.

Matt Sparks

Wash U Web Episode - Kidney Pathology 101, "Welcome to 2017 Edition"

Happy New Year to all RFN visitors!  This month's nephrology web episode coming from Washington University is a primer on kidney histology.  Most of us can recognize the silver stain from the trichrome, but how many times have we looked at the H and E stain and confused it with the PAS?  Unfortunately, I have been guilty of this myself during many biopsy conferences.

Check out the video below: