Wednesday, May 13, 2015

Goldfarb takes the ACP to the woodshed

David Goldfarb has written a sternly worded letter to the ACP in response to their clinical practice guideline, Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults. The guidelines took positions that seemed to make no sense when looked at as a whole. Due to insufficient evidence the guidelines recommend:

  • no need to determine stone composition prior to treating stones
  • no need to analyze blood chemistry before treating stones
  • no need to do 24-hour (or 48-hour) urine collections before treating stones
What makes those positions so absurd is that if increased fluid intake did not reduce stones the authors suggested a trial of allopurinol, thiazide diuretics or citrate (without guidance on how to dose, follow or how to choose among those therapies). These recommendations are based on research done on patients where the type of stone had been determined. Not following those enrollment criteria makes the conclusions irrelevant.

It is as if the ACP said not to measure blood pressure because there has never been a randomized controlled trial of patients where blood pressure was measured versus patients who do not measure blood pressure.

Goldfarb's letter added some other incredible details to the story I was unaware of including:
None of the authors of the paper have a single other co-authorship in PubMed relevant to kidney stones, other than the AHRQ review. I believe that none of the authors are nephrologists or urologists, none have a kidney stone clinic, none appear at, or present research at, kidney stone meetings, none have any experience regarding management of kidney stones
And this doozy, in response to a comment of the paper from the lead author:

As we point out in the guideline, we are aware that many physicians do select medications based on stone type, for example, allopurinol for uric acid stones, and we do not discourage that practice. 

Physicians who regularly treat stones or who played NephMadness (2014 edition) know that allopurinol is used to prevent calcium stones not uric acid stones which are best treated with alkalinization.

Read Goldfarb's letter. It is excellent.

Calcium Booklet

Minor updates.

PDF (7.6 mb)

Pages (8.7 mb)

I think this covers all the high points that residents need to know about calcium. Please send feedback of what is missing.

Saturday, May 2, 2015

One million

The blog turns 7 on May 30th. But tonight we flipped the odometer.
One million page views.

I bet we never see ten million. Established 2008

The push to one million. Blog post about Twitter (NephJC) and Twitter mention of an old post on MDRD and protein restriction. A PBFluids deep cut.

Friday, May 1, 2015

NephJC: one year in the can

The first NephJC chat was April 29th 2014, so the official birthday went unrecognized a couple of days ago. Such is the way of academic medicine.

Swapnil and I are delighted with the success of the endeavor which launched with humble beginnings on Medium aweek before the first chat with this manifesto:

Coincidental to the calendar turning over, NephJC is being recognized in two articles in the medical literature. The first is the first systematic review of microblogging journal clubs. It is an interesting and thought provoking article. NephJC takes a victory lap in Table 2:

NephJC is third in participants and total number of tweets and first in tweets and impressions per month. I found this paragraph particularly insightful:

Especially in light of Twitter's recent financial results.

The other entry in the medical literosphere was an article written by Swapnil and I as part of a special issue of International Psychiatry Review dedicated to social media and edited by the fabulous Margaret Chisolm. It was a unique opportunity to formalize our thoughts on NephJC and journal clubs in general.

It's been whirlwind first year and I'm looking to see what new boundaries NephJC can stretch in year two.

Sunday, April 26, 2015

Videos for patients and by patients

This is my go to video for helping patients make decisions on what modality to choose.

Last night I received the following Tweet:

I can't recommend the video enough. In this age where everything is sanitized and abstracted as much as possible this video is just authentic. It's as real as it gets. To me it brings to life all of the little things we ask dialysis patients to do, from waking up early, to restricting fluids, to spending 12 hours a week in a recliner hooked up to a machine with only one hand free. 

It is awesome. 

Everyone should watch it.

Canadian Society of Nephrology: Kidney Week's MiniMe

I was invited to speak at the Canadian Society of Nephrology last fall. Swapnil set up a talk on social media. My first international speaking gig. Very cool.

We have two associates out on Maternity leave and another key partner retired a couple of months ago, so practice is tight. No way I could take half a week like I do for Kidney Week. I left for my 1:30 talk at 8:30 that morning. Direct flight from the D to Montreal. As I'm walking through the airport I'm looking for nephrologist ads. During Kidney Week there will always be a big a pharma company advertising in the airport. I love seeing those ads and trying to imagine wha percentage of the general population have any idea what Samsca™ or Aranesp™ are. Montreal had none of these advertisements. I took a taxi to the Hotel Bonaventure.

Found my way to the conference center and registered for the conference. The conference had about 450 people in total, about one 30th the size of Kidney Week. It is like Kidney Week Mini Me. Same clothes, same attitude but smaller. In this case a lot more than just one eighth the size.

Kidney Week is a major international conferences. I heard more foreign languages in Philadelphia last Novemebr than I heard at CSN which was being held in Montreal. We often associate size with quality but thie would be totally unfair to CSN. The lectures were amazing. They absolutly stand toe to toe with the quality you get at Kidney Week. Of course, there are some Canadian specific lectures that didn't interest me, but the general nephrology content was excellent. Five lectures in particular were amazing:

1. Patient oriented symptoms of ESRD

2. Conservative care With Dr. Fliss Murtagh

3. Membranous nephropathy with Daniel Cattran

4. FSGS with Dr. Hladunewich

5. Screening cancer tests in dialysis patients. Dr. Zimmerman gave an excellent and practical talk.

Their were also a few debates. I was disappointed that I had to choose between GN and the hypertension debate. It sounds like it was outstanding:

Swapnil and I did our social media session.


The talk was broadcast live on Periscope. So 21st century.

The plan was a one-two punch, where Sawpnil presented why you should engage with social medi,a and I followed with a "how to" engage in social media. It went well. I had some trouble using Keynote on the iPhone app to advance the slides. I used Keynote on the iPhone to control Keynote on my computer. It worked perfectly during my (admittedly abbreviated) practice sessions and for about half my presentation before it crapped out. I need a more reliable solution, please tweet recommendations. The AV-guy was pretty good at picking up my signals to advance the slides but it wasn't natural and threw my rhythm off. I'm Sorry Canada, I could've done better. That was another difference from ASN. At CSN they had no trouble wiring in my MacBook Air to their AV set-up. Much slicker than the MUST USE POWERPOINT party line from ASN.

I'll post the slides when I get a chance, but first I need to add a slide crediting @Doctor_V and Howard Rheingold, who involuntarily donated ideas to my talk. And I want to pump up the Who to Follow section with a description of mining Symplur to find thought leaders. I also need a slide telling people about Twitter4Nephrons.

In the end, I had a great time at CSN and would definitely go again; maybe not next year in Halifax, but why don't we meet the year after in British Columbia?

Tuesday, April 21, 2015

The ASN is waking up to social media

The ASN has long had a Twitter account but it was infamous among the nephrologists of Twitter as being a oneway mode of communication. A fact that was lampooned on the ASN Bingo board. Getting a reply from @ASNKidney was a badge of honor.

While complaining about how the leadership at the ASN just doesn't get it was a great parlor game among the renal bloggers, things began to change. In the Fall of 2013, Sarah Faubel called me to ask if I thought we could do a social media symposium at Kidney Week 2014. This materialized as the Tweets, Likes, and Blogs: How to Use Social Media for Your Patients and Your Benefit session. See recaps here and here.

Even before the session other things were changing. In early November, the ASN sent out it's first Work Force Task Force Report. In the e-mail that announced it, they asked people to discuss the report on Twitter with the hashtag #NephWorkForce.

It was the first time I had seen a hashtag come from ASN. The community was ready to talk and we had a great discussion about some of the issues, but strangely there was no participation by the ASN leadership. MGKatz said it best:

But ASN was not foolish, just cautious. They were testing the waters. When the second Work Force Report was published they had Mark Parker available for a formal tweet chat and he was gracious enough to answer questions from me to knock together a table setting blog post. Again there was spirited discussion, and ASN was actively participating.

In mid February-Dr. Faubel drove one of the NephJC on NephroCheck. She suggested the article, wrote up the introduction and was one of the primary tweeters during the chat. Dr. Faubel is the chair of the ASN AKI Advisory Group. Jay Koyner, another member of that group also joined the chat.

ASN then organized a pre-World Kidney Day chat with leaders from the NKF and ISN. Deidra Crews was the representative from ASN for that chat. This chat was amazing with incredible participation from industry, government and all three major real professional organizations. The ASN no longer looked like a reluctant partner but was driving the conversation:
Tomorrow the ASN will continue this trend by hosting a chat about the upcoming ASN Hill Day, where ASN goes to the nation's capitol to talk to our elected leaders about how the government can help kidney patients. The ASN is sending three representatives to chat about the event:
  1. Crystal Gadegbeku @Crystal4Kidneys Section Chief, Temple Health Nephrology, kidney researcher, ASN public policy board member.
  2. Michelle Josephson @Michelle53598125 Transplant Nephrologist and chair of the ASN Transplant Advisory Group
  3. Richard Knight @knightra Transplant patient, vice president of the Association of American Kidney Patients
This should be an interesting chat about something that I have only thin knowledge. Please join the chat at 9PM EDT, hashtag #ACT4Kidneys

We have been calling for ASN to join the social media revolution, now that they've awoken we need to do our part to make this partnership meaningful and productive.

Saturday, March 14, 2015

International Pi Day and taking a Pie to the Face for Kidney Disease

So Pi Day is just about over but during the day we did a three stooges around the Topf household. After taking the pie to the kisser I wrote a check to the National Kidney Foundation of Michigan for $31.41.

I'd like to challenge Matt Sparks, Kenar Jhaveri and Edgar Lerma to take pie and write a check.

Pi Day Kidney Challenge from joel topf on Vimeo.

Resources to help you publicize #NephMadness

I did a quick 10 minute presentation at morning report for the residents to get them excited for NephMadness.

You can download the presentation here:

Keynote file


NephMadness: What's up with that? from joel topf on Vimeo.

Only eight more days. Get those entries in!

Sunday, March 8, 2015

#NephMadness is back

Last Sunday we launched NephMadness
for the third time. This began as a last minute Hail Mary by the crew at AJKDblog to commemorate World Kidney Day in 2013. The response was so overwhelming that despite initially thinking this would be a one-and-done we decided to come back and improve the idea.

We have steadily improved the execution of NephMadness.

Last year we introduced a system to allow online bracket submissions. We found a company that provides white labelled online tournament brackets. This gave us streamlined registration and allowed for automatic scoring. Participation sky rocketed. Last year we also brought in content experts to act as our selection committee to make sure we had the best field possible.

This year, we have a number of further improvements. The primary complaint last year was seemingly arbitrary way the winners of each match up were determined, basically it was a system we called "Matt and Joel decide." Not surprisingly people were not enamored with this system and this year we have deputized a blue ribbon panel of nephrology experts to make the decisions.

We are also getting better at producing the brackets themselves and filling out the field. We now have written on 192 concepts since we started NephMadness. We have seen that the best match-ups pit related concepts up against each other and we have really increased the use of that technique in this year's brackets. In addition we have themed the entire tournament as nephrology's interaction with other specialties.
Download a PDF of the brackets
We have also changed the schedule. The first two years we tried to track the schedule of March Madness as closely as possible. This meant we opened the brackets on Selection Sunday and closed them a week later. This year we opened the brackets on March 1 and accept submissions for 3 weeks, until March 22. This will, hopefully, increase participation.

Another area of improvement is in the Tourneytopia rollover descriptions. Last year we just copied the scouting reports from AJKDblog and pasted them in to the roll overs. They had a bunch of links and were really long. This resulted in really long descriptions that were difficult to read in the rollovers. This year we have a short 2-3 sentence description for the rollovers written solely for that purpose. Oh and a picture.
Go to Tourneytopia to submit your brackets for NephMadness
Last year we had a confusing collection of three sites, Tourneytopia, and AJKDblog. This year we jettisoned and completely redesigned AJKDblog to be a much more effective container for NephMadness. The editorial staff at AJKD really did an outstanding job with the redesign.

This year the journal, AJKD, is really behind the contest. The Feb and March issues of AJKD had pack ins to promote the contest.

A photo posted by @jtopf on

And the journal website has two high profile ads for NephMadness.

The last change is we are partnering with MedScape, a long time partner with the NKF and AJKD to promote NephMadness. Medscape is republishing all the content from the scouting reports and e-mailing their audience.
At St John Hospital and Medical Center we are having all of our fellows and faculty complete their own brackets and then we will have a consensus conference and build a collective entry to see if we can do better as a pit crew or as lone cowboys (and cowgirls).

Tuesday, February 24, 2015

Twitter Chat Tonight, Tuesday Feb 24 about World Kidney Day

I have been involved in Nephrology social media for years now, and it has been rewarding seeing the global community of nephrologists connect and develop a voice over that time.

While social media in general and Twitter in particular was once thought of as a time waster, it is now recognized as critical communication channel that allows back and forth communication as well as side to side communication.
First order communication: traditional top down

Second order communication: back and forth

Third order communication: back and forth and side to side
The side to side communication is what builds the community and is what twitter excels at. Imagine how boring the NephJC chats wold be if the only communication you saw was from the NephJC host? The whole point of the chat is to leverage the diversity of expertise in the crowd. 

Tonight will be a first in social media. Representatives from the International Society of Nephrology, The American Society of Nephrology and the National Kidney Foundation will be convening to discuss the upcoming World Kidney Day. It should be a great discussion. Please join us in (dare I say?) this historic moment. The discussion starts at 9PM EST and the hashtag is:


More information, including who the representatives are, is available on Medium.

Saturday, February 14, 2015

Must know facts about albumin! Number seven will blow you away!

Albumin is made in hepatocytes at a rate of 200 mg/kg/day - Created with Haiku Deck, presentation software that inspires

Improving albumin levels among hemodialysis patients
  1. Albumin is made in hepatocytes at a rate of 200 mg/kg/day 
    1. or 14 g in 70 kg person
  2. Total body albumin is 4-5 g/kg
  3. 40-45% of albumin is in the intravascular space
  4. Normal albumin concentration in the interstitial space is 
    1. 0.7 in fat and 
    2. 1.3 in skeletal muscle
  5. Albumin has a half life of 2 to 3 weeks
  6. The drop in albumin with inflammation is due to: 
    1. reduced synthesis and 
    2. increased fractional catabolic rate (FCR)
  7. Intradialytic weight gain of 2.8 liters (4% in a 70 kg man) will dilute the albumin down 0.8 g/dL 

Improving albumin levels among hemodialysis patients (PubMed)
Measurement of interstitial albumin in human skeletal muscle and adipose tissue by open-flow micro perfusion (PubMed)
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