Thursday, August 30, 2018

2009 RFN Poster From Nate Hellman

Hector Madariaga pointed out that Nate blogged about a long forgotten poster from ASN Renal Week 2009. Long before it was even called Kidney Week. I pulled up the abstract program from 2009 and found it. I recall going to his poster as I was an avid follower of RFN and a friend of Nate. However, this was well before phones were ubiquitous and I have no direct photo evidence of attending. Reading the abstract is impressive. A few things to note about this abstract. First, Nate blogged in 308/365 days in an entire year! I don't believe this feat will ever be matched. Impressive! Second, the future section is very interesting and I believe Nate would be proud to see the website live on. Now in the 10th year of RFN let's all cheers to Nate and another 10 years of RFN.

Tuesday, August 28, 2018

August Nephrology Web Episode CPC available

The August installment of the Wash U Nephrology Web Episodes are back for more renal pathology in CPC style format.  The case was discussed on Glomcon a few months back, but for those that missed it, you can still learn a lot in this format.

Our discussant is 2nd year fellow Dr. Miraie Wardi, who also just returned from the annual Nephrology Business Leadership University (NBLU) meeting, and we also discuss her incredible experience there. 

Want to learn about Hemodialysis Access? Here's "Hemodialysis Access 101"!

Hemodialysis Access 101 (click to access the tool) is an online interactive teaching tool that focuses on teaching hemodialysis access from a nephrologist's perspective. It consists of 3 main sections:

  • Animated concept videos describe HD access creation, function, examination, and complications


  • Real patient videos with features that simulate a bedside teaching session with a focus on access examination

  • 5 simulated cases of access complications that are structured step-by-step from the point of patient presentation at the hemodialysis unit through physical examination, diagnostic tests, and intervention in a fun, thought provoking, and interactive manner


Check out this video that describes the tool in more detail.

"Hemodialysis Access 101", one of the winners of the 2018 ASN Innovation in Kidney Education Contest, was developed by Namrata Krishnan, MD (@NamrataKrishna3) and Gowthaman Gunabushanam, MD at the Yale School of Medicine/Veterans Affairs Medical Center in Connecticut.

Saturday, August 18, 2018

The Dual Role of the Nephrologist in Patient Care

Nephrologists face many daily challenges in their role managing chronic kidney disease (CKD). CKD is an expensive and debilitating condition that affects approximately 14% of Americans. Adding to this list of challenges is the fact that nephrologists often assume the role of primary care physician to patients with end-stage kidney disease (ESKD) who require chronic dialysis. In one study, 90% of surveyed nephrologists responded that they provide primary care to their patients receiving chronic dialysis. According to these same nephrologists, only 20% of these patients had another primary care physician. Nephrologists, in their role as primary care providers, offer general health care counseling, preventive care, referrals, immunizations, and care of minor acute illnesses that are unrelated to a patient’s kidney failure. However, this same survey concluded that nephrologists, while providing these essential services, often fail to conform to the standard guidelines of primary care provision. Furthermore, nephrologists do not address women’s health issues as much as primary physicians do. According to a Canadian study conducted in 2005, 80% of nephrologists and 85% of family physicians think that dialysis patients should receive primary care from primary care providers (PCPs) and not from nephrologists. In addition, the study showed that there was rampant miscommunication between members of these two fields, leading to “duplication or omission of services.” Indeed, it remains unclear whether there is evidence for benefit for increased access to nephrologists.

Where nephrologists are likely to excel is in the management of conditions that are comorbid with ESKD, including diabetes mellitus (which 90% of nephrologists surveyed said they manage), cardiac disease (75%) and gastrointestinal disease (69%). Nephrologists are better-equipped than primary care physicians to manage the wide-reaching effects of ESKD, which affects multiple bodily systems in unique ways. Because conditions like ESKD need to be considered in virtually every healthcare decision made by their doctor, the expertise of nephrologist is critical in medical decision making. For instance, in managing diabetes special care must be taken in the administration of anti-hyperglycemic agents as the pharmacokinetics and patient response may be drastically altered by the presence of ESKD.

As Bender and Holley note,
 “caring for patients with chronic kidney disease…requires the broad-based approach characteristic of primary care medical practice.” 
Simply by virtue of being experts in ESKD, nephrologists become better primary care physicians for these patients. On the other hand, there are significant issues with nephrologists acting as PCPs.

Should we include training in primary care in nephrology fellowship curricula to achieve parity in acting as PCPs? Unfortunately, this comes at a time where 40% nephrology fellowships are going unfilled and a shortage of nephrologists is predicted further hampering efforts due to time constraints in seeing patients. One glimmer of hope is Medicare has recently designated the dialysis unit as an originating center for telehealth services, but services provided still fall under the monthly capitated premium limiting reimbursements for time-pressed nephrologists. Finally, the question of whether more contact time with their nephrologists improves outcomes for patients with ESKD remains.

Open communication between individual nephrologists, PCPs, and the leaders of their respective academic fields is necessary if the American medical community is to optimize kidney care. Whether nephrologists should serve as PCPs for their patients with ESKD remains an open question. The benefits of knowledge of pearls and pitfalls of treating dialysis patients is intuitive, but significant hurdles remain including time limitations, reimbursement for services, adequacy of training, and lack of evidence base.

Noah Lieberman, University of Pennsylvania
Nathaniel Reisinger @Nephrothaniel

Wednesday, August 1, 2018

Alport Syndrome

I recently saw a patient in clinic with long-standing hematuria with numerous family members on her mother’s side with hematuria.  She now presented with proteinuria but stable renal function.  Collagen IVa disease was highly suspected and genetic sequencing identified a heterozygous carrier for a previously characterized pathogenic mutation in Col4a5.

In the process of taking care of this patient who was heterozygous for X-linked Alport’s syndrome, I wondered, “Who is Dr. Alport?”.
Dr. Arthur Cecil Alport was a physician originally from South Africa who attained his medical training in Edinburgh, Scotland. He had many different interests initially studying malaria abroad and then practicing medicine in London before becoming a Professor in Egypt where he fought for the care of poor patients.  He showed that with careful observation one can provide valuable insights into a specific disease. 
Dr. Alport was not the first to identify the entity of hereditary hemorrhagic nephritis.  Initially, William Howship Dickinson described a family with 11 out of 16 members with albuminuria in 1875.  Subsequent studies by Guthrie and Hurst identified families with hematuria and kidney disease of varying severity.  Dr. Alport saw a patient from the Guthrie/Hurst cohort which he further studied and published with the title, “Hereditary Familial Congenital Haemorrhagic Nephritis”, in the British Medical Journal in 1927 which led to the identification of the disease as Alport’s syndrome. 
In this paper, he found a number of female members of the family had hematuria but did not develop edema, heart failure, and kidney failure, a fate reserved for a selected few male members of the family.  He also noted numerous female members with profound deafness that at time was not associated with hematuria.  Though he acknowledged the hereditary nature of this disease, he also found hematuria and albuminuria were exacerbated by streptococcal infection which he had limited success in recreating in rabbits. 
The history of medicine often provides an interesting context for our current understanding of human disease.  By observing the association of deafness in families with hereditary hematuria, Dr. Alport brought to light a key identifier of the disease entity.  This identification ultimately led to the disease to be associated with his name though the renal phenotype of familial hematuria was discovered by prior investigators.
Posted by Ankit Patel, Nephrology Fellow, Joint BWH/MGH Fellowship Program