Monday, August 31, 2009
Friday, August 28, 2009
Wednesday, August 26, 2009
- We had just finished clinic in the DCAM and were walking back to the nephrology section. We often would go to his office to discuss something but this time he invited me into a lab. He turned on a Bunsen burner and made two shots of Turkish Coffee. Spending those moments drinking fresh coffee in the lab was the single coolest teacher-student moment of my life.
- My wife and I had twins while we were in Hyde Park. Only two professors came over for the Bris on my birthday, Adrian Katz and Pat Murray.
- Adrian and Miriam invited my wife and I over to his house for Passover. We brought our 6 month old twins. I remember being terrified of what they would break. The Katz's were wonderful hosts and it was like going to the Wizard of Oz for dinner.
- I remember his office. It was a beautiful large office with great built in bookcases lining one wall. The cases were full and every second or third book had a small yellow sticker. For months I had been meeting him in there. I had noticed the dots but assumed it was just a personal filing system. One day he asked me if I knew what those dots meant. I shrugged. He explained that a dot represented a book or chapter he had written. It was a mind boggling accomplishment, you were literally faced with a wall of academic achievment. I have written textbook chapters. For me it is about as easy as coughing up a lung. Amazing.
- We were talking about intradialytic hypotension. How could we dialyze this patient without resorting to CVVH and a transfer to the ICU. I mentioned cold dialysate and he said that it is effective but patients don't like it. My eyes widened like saucers and I said:
"I didn't know that patients could feel the cooler temperature."University of Chicago has a nice obituary.
Adrian replied, "You could fill an ark with what you don't know." And then started laughing uproariously. When he finally regained composure, he had tears in his eyes. He explained that he had once had a mentor who had used that same joke on one of Adrian's peers. It was such a happy memory for him that he couldn't contain it.
Amgen Inc. (Nasdaq:AMGN), the world's largest biotechnology company, today announced that the company has initiated a landmark trial to evaluate the impact of treating anemia on cardiovascular outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes. TREAT (Trial to Reduce cardiovascular Events with Aranesp(R) (darbepoetin alfa) Therapy) is one of the largest clinical trials in the company's 25-year history. The TREAT study design as well as additional Sensipar(R) data was presented at the American Society of Nephrology (ASN) annual meeting in St. Louis.
"Current research suggests that anemia is an augmenter of cardiovascular risk in individuals with CKD and type 2 diabetes," said TREAT lead investigator Marc Pfeffer, M.D., Ph.D., chief of medicine at Brigham and Women's Hospital and a professor at Harvard Medical School. "TREAT will be the definitive study to determine if treating anemia with Aranesp does, in fact, lower the risk of death and non-fatal cardiovascular events in individuals with CKD and type 2 diabetes."
TREAT is an international 4,000 patient, multicenter, randomized, double-blind, placebo-controlled trial. The primary endpoint of TREAT is a composite index of time to mortality or non-fatal cardiovascular event, including myocardial infarction, myocardial ischemia, stroke and heart failure.
BACKGROUND: Patients with chronic kidney disease (CKD) have a high burden of mortality and cardiovascular morbidity. Additional strategies to modulate cardiovascular risk in this population are needed. Data suggest that anemia is a potent and potentially modifiable risk factor for cardiovascular disease in patients with CKD, but these data remain unsubstantiated by any randomized controlled trial (RCT). Furthermore, the clinical practice guidelines for anemia management in patients with CKD are based on limited data. The need for new RCTs to address critical knowledge deficits, particularly with regard to the impact of anemia therapy on cardiovascular disease and survival, is recognized within the guidelines and independent comprehensive reviews of the existing published trial data.
STUDY DESIGN: The Trial to Reduce Cardiovascular Events with Aranesp (darbepoetin alfa) Therapy (TREAT) is a 4000-patient, multicenter, double-blind RCT, designed to determine the impact of anemia therapy with darbepoetin alfa on mortality and nonfatal cardiovascular events in patients with CKD and type 2 diabetes mellitus. Subjects will be randomized in a 1:1 manner to either darbepoetin alfa therapy to a target hemoglobin (Hb) of 13 g/dL or control, consisting of placebo for Hb > or =9 g/dL or darbepoetin alfa for Hb <9> or =9 g/dL. TREAT is event-driven and has a composite primary end point comprising time to mortality and nonfatal cardiovascular events, including myocardial infarction, myocardial ischemia, stroke, and heart failure. TREAT will provide data that are critical to evolution of the management of cardiovascular risk in this high-risk population.
Tuesday, August 25, 2009
Around this time the potassium came back at 9.4 mmol/L. The patient was then given 4 units of insulin. The low dose is typical of our ED as they tend to be skittish about giving 10 units of insulin to ESRD patients due to concern over symptomatic hypoglycemia. They chased the insulin with an amp of D50 and sixty grams of Kayexalate. The glucose was 84 mg/dL prior to the insulin and D50.
Monday, August 24, 2009
I teach this concept as determining what the bicarbonae would be in the absence of or prior to the anion gap.
The concept comes from the idea that for every mEq of bicarbonate that is consumed by the strong acid (other anion) the anion gap should rise by one. So if the bicarb is 16, a delta of 8, we would expect an anion gap of 20, a normal anion gap of 12 plus the delta bicarbonate of 8. This is a ∆AG/∆Bicarb of one.
[Some authors] suggested that mixed disturbances should be considered if the ratio is less than 0.8 or greater than 1.2. Paulson, applying this rule to a group of normal control subjects and patients with simple metabolic acidosis, noted that the formula erroneously categorized 56% [specificity of 44%] of this group as mixed disturbances. Use of the 95% confidence interval of ±8 mEq/L increased the specificity to 97% but with a poor sensitivity of only 27%.
Thursday, August 20, 2009
I'm really happy how the lecture turned out. Not my best but pretty strong for a first crack at a new topic.
I structured the topic by looking at patients with low, normal and high anion gaps to go along with the high osmolar gap and started with a case of a high osmolar gap paired with a negative anion gap. I have only seen one negative anion gap and that was a case of hyperkalemia and hypoalbuminemia. This case comes from the Canadian Medical Association Journal. The low anion gap is from the unmeasured cation, lithium. The patient had a lithium level of 14.5 mmol/L.
Tuesday, August 11, 2009
Thursday, August 6, 2009
In contrast, the rates of death from all cardiovas-cular diseases combined were 30 to 40 percent lower among men (relative risk, 0.7; 95 percent confidence interval, 0.7 to 0.8) and women (relative risk, 0.6; 95 percent confidence interval, 0.6 to 0.7) reporting at least one drink daily than among nondrinkers. The largest reduction, in both absolute and relative terms, occurred in mortality from coronary heart disease among drinkers who, at enrollment, had reported heart disease, stroke, or some other indication of preexisting risk of cardiovascular disease.