Thursday, November 21, 2013

UKidney's library of high impact articles

Ukidney has just posted a new page on their website. It is a library of high impact nephrology research articles. Other sites have attempted to do this but this one is particularly well done. The lead-in describes it as a growing library of "key high-impact articles." They are a little vague on the goal here but I hope they keep the list of articles small and tight. The lazy thing to do would be to include every seemingly important paper with little curation. The most value is added by maintaining editorial vigor and declaring a limited set of articles as the most important. I'd even put a number a number on it. Keep it limited to the 50 most important articles in nephrology. I like 50 because that is a number that a motivated fellow could read in a week.

A good decision in generating the list of articles was not adding the classic articles of nephrology. I was hard pressed to find an article older than 15 years. It would be easy to add Bartter and Shwartz's original description of SIADH or Thurau's brilliant essay on acute renal success but those are lessons taught in text books. We read the medical literature to find what is new and the contributors at UKidney wisely limited their list to newer data. A second, separate project might be to find the 50 most important studies in nephrology, even if they don't affect modern nephrology much, but that should not contaminate this mission.

It will take more oversight and real editorial rigor to keep the library manageable, but that is a valuable mission and separates this project from a dropbox folder of every PDF a fellowship has covers in journal club.
One area that could be improved would be the addition of a 2-3 sentence description of why the contributors feel this article deserves a place in the library. Think of it as the plaque next to the picture in Cooperstown. That kind of meta-data can be so important in putting articles in scientific perspective and it would also give the organizers a venue to justify why each article is important.

To paraphrase Alan Kay, UKidney's article collection is the first one good enough to criticize.
The site is organized by 9 icons showing the different sections.

I am going to go through it section by section and describe what changes I would make. My decisions are only that, my decisions. There is no right or wrong here, I am just giving my angle.

The first section is anemia. This section has four articles, all of them negative trips of epo: Normalization of hematocrit, CHOIR, CREATE and TREAT. These clearly are the most important articles in the fall of ESAs we have witnessed in the past decade, but they are not all equal. Given the relative size of the trials, this list could be limited to the Beserab trial in hemodialysis and TREAT in CKD.

Also the lack of iron could be corrected by inclusion of DRIVE.

Bone and mineral metabolism 

This section reads like a Genzyme (Sorry, I mean Sanofi) reading list. They included the original article on calcium x phos product and two separate articles on binders and coronary calcification. As appealing and intuitive as coronary calcification is, it is an intermediate end-point that is not validated to correlate with patient outcomes. This view on binders seems unbalanced especially given the conspicuous absence of the negative mortality trial of sevelamer (DCOR). Additionally all of the other dimensions of Calcium, phosphorous and PTH are ignored. Where is EVOLVE and Teng's retrospective trial of dialysis survival with and without active vitamin D therapy. Also where is Wolfe's FGF-23 and dialysis mortality study? This section needs a lot more attention. Remove the retrospective and old in order to widen the scope of the section.


The Diabetes page is nearly perfect. One quibbles, I would add the long term follow-up of the DCCT trial because that introduced the concept of metabolic memory and changed the original study from one that affected a questionable intermediate endpoint, microalbuminuria, and replaced it with doubling of serum creatinine.

Fluid and Electrolytes

The fluid and electrolyte page, a subject near and dear to my heart (in case you hadn't noticed), needs work and I mean a lot of work. Right now it has a case report about a disease you will never see, syndrome of inappropriate diuresis, and a collection of review papers. All of the review papers are excellent but it is hard to consider any review article a high impact article. High impact articles for this section to consider include:

The next section is general nephrology and UKidney wisely created sub-sections to break up the 37 articles in this section. They should add a cystic disease section and a CKD section.


Nailed it.

Acute Kidney Injury

The AKI section leads off with a couple of review articles. See above. Then it has a review and meta analysis of NGAL. This can't be high impact because the test is readily available and no one knows what to do with the data anyways. This article seems out of place in this list. The the ATN trial takes it rightful place on the list. Strangely, right after that is a meta-analysis that recommends the high dose that was disproven in the ATN trial. I say flush Panu's article. Bringing up the rear is a meta-analysis showing that iHD and CVVH can both be used in ARF. Fine.

Things that are missing from the AKI section is the big meta analysis on renal dose dopamine has a place here. I would also include some of the data from CABG that show increased mortality from minimal increases in creatinine. Also the recently completed CORONARY study along with some of the previous work linking AKI to CKD should be included.

AJKD Core curriculum

No complaints. Clever addition.

Critical Care Nephrology

This looks like a retread from AKI. Only one additional article, a Cochrane Review of IHD versus CVVH. They should collapse these two headings into one.


I must admit I am not as up to date on the literature in this sub-field as I should be. But overall it looks like they have too many articles on MMF for lupus (3 of the 8 articles). They have nothing on membranous or FSGS. This looks like a half-baked section. I will give them a pass as they work on filling the library.


The next major section is hemodialysis. There are a lot of articles on AKI in this section. Though we treat AKI with dialysis, I think this section should be left to chronic dialysis and include PD with HD. 

In terms of missing studies. I would add the Aggrenox study on access patency. They should include some of Agarwal's work on blood pressure in dialysis patients, they should include the IDEAL study, one of the most important dialysis studies in the last decade. Another important study was Tamura's study on the deterioration of functional status with dialysis.


The hypertension section seems light to me. It is filled with a number of trials of different drugs. It is missing ALLHAT and AASK but more importantly it is missing aspects of hypertension beyond what drug and what blood pressure target. They should include some Symplicity data, and at least one trial on the importance of ambulatory / home blood pressure monitoring. They should include the Cochrane Review of Pharmacotherapy for mild hypertension and the DASH diet RCT.

The Peritoneal dialysis

The Peritoneal dialysis section is tiny. It makes me think that the PD and HD sections should be combined and form a new section called chronic dialysis. Two additionals would be PD for acute renal failure sepsis (don't do it) and an article on PD First.


I am not as familiar with this literature as I should be and I honestly don't know what should be on the list. Though I think that the CJASN study on recurrence of primary disease after transplant should be included.

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