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:

#WorldKidneyDay

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 




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

Monday, February 9, 2015

Potassium Wars, The Grand Rounds Presentation.

Last week I delivered my grand rounds to both St John Hospital and Providence Hospital. This grand rounds on Kayexalate and the new therapies to increase colonic potassium clearance. Take a look. I hope you enjoy. I have more to say about this talk, and hopefully I will do a directors commentary of the presentation. I have 99 problems but have no for that time now.

Potassium Wars, The Native Keynote file (431 mb) Alternative link.zip (307 mb)
Potassium Wars, The PDF of the Keynote (184 mb)
Potassium Wars, The Movie, It's almost like being there (1.05 gb)

Or stream it:

K wars, The Movie from joel topf on Vimeo.

Saturday, January 24, 2015

ASN Quiz and Questionnaire 2014: Acid-Base and Electrolyte Disorders

CJASN just published two answers to the Electrolyte quiz from ASN Kidney Week, unfortunately they have the answers right next to the questions, so you can't take the test honestly, Here are the questions, without the answers. Get the article here.


Case 1: Mitchell H. Rosner (Discussant)
A 60 year-old man with a history of a heart transplant and stage 4 CKD was diagnosed with a gout flare 6 days ago and was prescribed prednisone, 30 mg daily; allopuri- nol, 100 mg daily; and colchicine, 0.6 mg three times daily, for the first 2 days and then colchicine, 0.6 mg twice daily thereafter. Before the gout attack, the patient had been feel- ing well and his baseline creatinine was 2.9 mg/dl with an eGFR of 29 ml/min per 1.73 m2. Other medications in- cluded mycophenolate mofetil, cyclosporine, pravastatin, carvedilol, calcitriol, and furosemide.
After 48 hours of taking the allopurinol, colchicine, and prednisone, the patient developed nausea, intermit- tent vomiting, and profuse diarrhea. This continued in- termittently over the next 2 days. However, during the past 2 days, he has developed worsening lethargy; muscle aches; and continued nausea, diarrhea, and abdominal pain. His family brings him to the emergency depart- ment (ED).
In the ED, he was found to be confused, tachycardic, and hypotensive, with a BP of 76/42 mmHg and pulse of 120
beats/min. He then sustained respiratory arrest and was successfully intubated; he was also started on vasopressin, norepinephrine, and intravenous fluids to support his BP. Laboratory results at the time of admission are shown in Table 1.

Question 1a
The acid-base abnormality in this patient is:
     A. Aniongapandnon–aniongapacidosis
     B. Respiratoryacidosisandaniongapacidosis
     C. Respiratoryalkalosisandaniongapacidosis
     D. Respiratory acidosis and anion gap and non–anion gap acidosis
     E. Respiratory alkalosis and anion gap and non–anion gap acidosis 

Question 1b
Which of the following drug interactions were likely responsible for the patients presentation?
     A. Allopurinol,pravastatin,andmycophenolatemofetil 
     B. Allopurinol,pravastatin,andcyclosporine
     C. Colchicine,allopurinol,andmycophenolatemofetil
     D. Colchicine,pravastatin,andcyclosporine 
     E. Colchicine,prednisone,andpravastatin 


Case 2: Mitchell H. Rosner (Discussant)
A 37-year-old woman with a 3-year history of severe sinus disease and headaches is referred to you after several laboratory abnormalities were found. Her medical history is significant for two episodes of nephrolithiasis (no stone analysis was per- formed). On questioning she notes that pain and redness develop in her hands in cold weather. She takes no medications except for occasional antibiotics for her sinus problems. Her BP is 108/50 mmHg and her physical examination is unremarkable except for some fullness over her parotid glands. Her laboratory studies are shown in Table 2. On further questioning, she reports no drug abuse.

Question 2a

Which one of the following laboratory tests would you order next?
     A. Serumandurineproteinelectrophoresis 
     B. Plasmareninandaldosteronelevels
     C. 24-hoururinecortisol
     D. Stool screen for laxative abuse
     E. Anti-SSA,Anti-SSBserologies 

Aggressive intravenous potassium chloride and oral potas- sium citrate supplementation are administered. Laboratory tests repeated 1 week later reveal the following: potassium, 3.5 mEq/L; bicarbonate, 15 mEq/L; and anion gap, 6. The patient is seen by a neurologist for her chronic headaches, and topiramate, 200 mg daily, is started.

Question 2b
Which of the following changes would be expected if lab- oratory work was repeated several weeks after initiation of topiramate?
    A. Potassium,2mEq/L; bicarbonate, 5mEq/L; aniongap,8 
    B. Potassium,4mEq/L; bicarbonate, 20mEq/L; aniongap,8
    C. Potassium, 4 mEq/L; bicarbonate, 5 mEq/L; anion gap, 15 
    D. Potassium, 2 mEq/L; bicarbonate, 5 mEq/L; anion gap, 15
    E. Nochangeinelectrolytesfrompriorvalues 

Tuesday, January 13, 2015

What am I going to do with all of these draft posts?

I have been blogging at PBFluids since 2008 and have 737 posts. What has been slowly growing is the number of unpublished drafts. Mostly this is clever ideas not fully realized like this evocative title:


There are others that if published would be career suicide like my completely overly honest reviews of the ASN Board review with letter grades for each of the speakers. The GPA was 3.7 but there were some clunkers in the mix:


The number of drafts is as of now 70 posts. I am going to try to salvage some of these posts and put them on the blog.

The first is a post titled "Epic ASN Post" This is from Kidney Week 2011. The post was written 12/1/11.

Landed in Philly and went to the AirBnB room I found. Seventy-five bucks a night and only a mile from the conference center. Awesome!

FourSquare, remember when that was a thing? 
Milagros

Derek


Kenar

Monday, January 12, 2015

ASN #NephWorkForce TwitterChat on Tuesday January 13 at 9pm EST

Mark Parker, the chair of the ASN Workforce Committee, will be on Twitter next Tuesday to discuss the latest report. This report is the second done by Ed Salsberg and his colleagues at GWU. This report is all about the fellow experience in getting a job.

The report is available here.

Dr. Parker answered some questions to stoke the fires of discussion, that interview can be seen on Medium.

ASN Nephrology Workforce Report

The first workforce report stimulated some discussion on Twitter, that discussion is saved here:



A summary of the discussion about the second report so far is available here:

My summary of the report:


  • The survey was distributed to 1,530 ASN Nephrology fellow and trainee members in June and July of 2014.
  • 441 responded. Response rate of 28.8%.
  • There are 930 fellows in ACGME accredited programs and they received 333 responses from this sub-group. 
  • What is up with the 600 trainees not in ACGME spots? DO programs?
Interesting gender differences:
How about this eye opening stat:
USMGs had a median debt of $100,000 to $149,999. IMGs were significantly different with a median debt of $0 and 65% having no debt.

Career plans

Nephrology breaking barriers, has higher starting salaries for women compared to men:
Female respondents had a slightly higher median anticipated base income than male respondents, who had a median anticipated base income of $150,000 to $174,999.
Job hunting troubles were much more common among IMGs with only 22% finding a satisfactory job compared to 56% of USMGs. Visa problems and unappealing locations were leading problems in job hunting. 71% reported no or very few jobs within 50 miles of their training location.

Happily 72% of respondents indicated they would recommend nephrology to medical students and internal medicine residents.

It's an interesting report, take a look and...
Please join Dr. Parker to talk about #NephWorkForce Tuesday, January 13 at 9pm

Saturday, December 27, 2014

Why we needed Kayexalate in the first place

In February I'm giving grand rounds on the Potassium Wars (what, you didn't realize we are in the opening stages of the potassium wars?). I was looking at the original research on Kayexalate from 1961 and came across this ad. Check out the doses of spironolactone they were slinging:


400 mg of spironolactone, daily and this is in a world without loop diuretics!

Tuesday, December 23, 2014

Purple Urine, now that's not something you see everyday

From the NEJM 2007.


Purple discoloration can occur in alkaline urine as a result of the degradation of indoxyl sulfate (indican), a metabolite of dietary tryptophan, into indigo (which is blue) and indirubin (which is red) by bacteria such as Providencia stuartii, Klebsiella pneumoniae, P. aeruginosa, Escherichia coli, and enterococcus species. The clinical course is benign, and the urine typically clears with resolution of the bacteriuria and acidification of the urine. 


H/T Life in the Fast Lane

The first Nephrology Social Media Internship

A few pioneers at the intersection of social media and nephrology have banded together to create an internship in social media. The founding members of the loosely coordinated Nephrology Social Media Collective (logo pending, but it should be pretty cool) are:

  • Myself
  • Swapnil Hiremath, co-founder and brain child of NephJC
  • Matt Sparks, savior of Renal Fellow Network and co-creator of NephMadness
  • Kenar Jhaveri, blogger at NephronPower and editor of AJKDblog
  • Paul Phelan, contributor to NephJC, Renal Fellow Network and AJKDblog
  • Jordan Weinstein, creator of UKidney
  • Edgar Lerma, creator of #NephPearls hashtag and serial author
The idea behind the internship is to give guidance to doctors or students who want to become experts in social media. There are a number of different techniques and strategies in social media and we will provide the intern an opportunity to work with these techniques first hand. Projects that will be open to the interns include:
  • NephMadness
  • NephJC
  • AJKDblog
  • Renal Fellow Network
  • Research
  • UKidney
  • DreamRCT
Technologies that the intern will be exposed to include:

  • Podcasts
  • Google hangouts
  • Tweet chats
  • Storify for curation
  • Mail Chimp newsletters
  • Twitter analytics
  • Google analytics
  • multiple blogging engines including:
    • Blogger
    • WordPress
    • Medium
    • SquareSpace
But more important than the technology, is that the interns will have access to our collective wisdom and have access to an instant personal learning network to allow them to pursue their personal social media goals. This is the first time we have done this and we are still working out the exact curricula, but if you are in nephrology, residency or medical school and want to learn how to leverage the power of social media consider applying for the position.


Just another day at the PBFluids world headquarters

Waiting for me in my inbox today:
Hello Dr. Topf, 
My name is Julia XXXXX, and on behalf of Keryx Biopharmaceuticals, I’d like to introduce Keryx as a resource for you as you develop content for your blog, Precious Bodily Fluids, given your commitment to advancing understanding of renal diseases. I’d like to periodically share updates from the company to keep you informed regarding its lead therapeutic product and commitment to patients on dialysis.

In fact, Keryx just announced it has begun shipping AURYXIA™ (ferric citrate) tablets to wholesalers in the U.S. Auryxia is approved for the control of serum phosphorus levels in patients with chronic kidney disease (CKD) on dialysis. Auryxia is the first and only absorbable-iron-based phosphate binder that is clinically proven to effectively control phosphate levels within the KDOQI guidelines range of 3.5 mg/dL to 5.5 mg/dL. The U.S. Food and Drug Administration approved Auryxia in September 2014. In addition, Keryx has created the “Keryx Patient Plus” program to assist with patient accessibility to Auryxia. 
For more information, please visit http://www.auryxia.com/. The full press release is below and includes additional information. 
If you are amendable, we will continue to reach out to share updates from Keryx and AURYXIA in the coming year that we hope will be useful for your readers and followers. 
Please feel free to reach out with any questions. 
Best, 
Julia
My reply
Julia,

Thanks for reaching out. I’m glad there is a new phosphate binder available for dialysis patients. I was wondering if you have any data that shows Auryxia reduces any patient oriented outcomes (e.g. hospitalization, mortality, fractures, morbidity)? And if not, is Karyx planning on doing such a study? And if not, why not?

Joel
Fingers crossed but with a skeptic's scowl

Thursday, December 18, 2014

Topf gets taken to Dr. Zen's Design Woodshed

I try to design nice posters and one that I was particularly proud of was 2013's Assessment of the Nephrology Blogosphere that I presented at Kidney Week. 

PDF | Powerpoint


A few months ago I submitted it for a design critique at Dr. Zen's Better Posters. Well this tweet surfaced today:


The review isn't pretty:
The colours in the table are not explained anywhere. I am guessing “green”means statistically significant, and “orange” means... a decline in posts over time? Maybe that could be mentioned in the main text at the left. 
The table is big and dense. Again, I wonder if it could be simplified, either graphically (first step: remove the vertical gridline!) or even removed. If I’m reading it right, some of the information in the table is repeated in the graphs to the right of the table. 
The last line of the table - “Totals” - appears to be incorrect. It looks like most of those entries are means, not totals. 
Also, the text mentions 30 blogs, but only 22 are plotted.
I only plotted the 22 with the longest duration of publication. What was the point of graphing KidneyTalk's 6 posts over 2 months? (4 years after the last post, she still owns the URL) 

I also disagree with his critique of the QRcode and bit.ly link. I think QR codes mostly suck and for most people snapping a pic of a URL is quicker and more reliable. I also think every person should have a little home page for their poster where it can be downloaded and supplementary information made available. See the homepage to this year's NephMadness poster.



Overall this was great feedback and I swear my next poster will be better.

Wednesday, December 17, 2014

Over-indexing on medications

I have a patient with CKD stage four, diabetes and hypertension. In fact, I have a hundred patients with CKD stage four, diabetes and hypertension. However, this patient had uncontrolled blood pressures. Here is the nomogram from her home blood pressures:
She was taking once daily furosemide and we changed it to torsemide, for better pharmacokinetics. She returned a month later and her blood pressure was fixed, systolics equally distributed between the 120s and 130s. So a win for Torsemide, or maybe not...

She was excited because she had been reworking her diet and was no longer drinking pop. She was eating more home-cooked meals and really focusing on eating more vegetables and fruits. She was also being more conscious of her sodium intake.

When I walked into the room I was focused on the medication change, because that was my intervention. But the more I spoke with her, the more I began to lean to the lifestyle interventions. She was adopting spontaneous DASH diet:
  • More fruits and vegetables
  • Decreased processed and restaurant food
  • Decreased fructose intake
  • Improved compliance
She denied non-compliance on her previous visit, but her new focus on her health should certainly increase her medication compliance. All of this was in play. 

In the end, medicine is a giant, uncontrolled experiment and correlation does not equal causation. Just because you changed medicine doesn't mean that is was what fixed the blood pressure.
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