Pearls From a Successful Nephrologist

Blog Post

Hello #medtwitter; we have one of the #nephtwitter legends here with us! He is our very own Dr. Lerma; with almost 8000 followers on twitter. You might know him from his famous #nephpearls or his amazing nephrology secrets book that he co-authored with Dr. Sparks and Dr. Topf.

How do you describe yourself in one sentence?

Dr. Lerma: I am a lifelong learner who believes that no matter what stage in life we are in, there are always new things to learn and explore.

Where did you do your nephrology fellowship?

Dr. Lerma: I did my Fellowship Training at Northwestern University between 2000-2002 under the tutelage of Drs Dan Batlle, Robert Rosa, William A. Schlueter, Murray Levin, David M. Roxe, Serafino Garella, Peter Ivanovich and Cybele Ghossein.

What makes nephrology interesting to you?

Dr. Lerma: Even when I was just student, I was always fascinated by mechanisms and how things work or not; so in medical school, I was really enthralled in learning more physiology and pathology; being able to understand the mechanisms of various conditions, and formulate therapeutic strategies based on that knowledge was very appealing to me.

You are currently on private practice based in Chicago; what are the most important key factors to become successful in private world? (in 5 words)

Dr. Lerma: Below are 5 things that I think are important when you’re practicing medicine whether you’re in private practice or academics.

Patience: You have to be patient in navigating today’s medical system, e.g., EMR, etc. You have to take time to talk with your patients and their families and not have them feel that you’re hurrying them up. Explain what they need to understand and answer all their questions.

Hard work: Everybody else around us is working hard. In order to set yourself above the rest, you have to keep doing it, and be consistent at it.

Respect: In medicine, you are working with people from all walks of life, from all socioeconomic and educational levels, whether they are your patients, staff, colleagues, or higher ups. Some people may not agree with your decisions and assessments; hear what they have to say. Give them the respect that is due to them and they will offer you the same.

Honesty: I cannot help but emphasize that the old adage “honesty is the best policy” is very important. Be trustworthy and you will earn utmost respect.

Politics: There is politics in everything. Try to steer away from it.

When you show that you’re patient, you consistently work hard, and you’re trustworthy, you will earn the respect of ‘almost’ everybody and you won’t have to change your beliefs and values on account of somebody else’s proclivities.

How many hours a day do you spend on twitter?

Dr. Lerma: I can’t really put a number to it. I think my hours on Twitter vary. Anyone who follows me on Twitter would attest that I tweet more when I’m in a conference or meeting, e.g.,  #KidneyWk #NKFClinicals or when I’m in a chat, e.g., #NephJC #AskASN #HealthXPH. I also tend to tweet more in the wee hours of the morning. There are times when I just read other tweets.

What’s your secret of being this popular on twitter with thousands of followers?

Dr. Lerma: I don’t really consider myself as popular. I do not consider myself in the same rank as #NephTwitter giants such as @kidney_boy @Nephro_Sparks @hswapnil to name a few. I will say though that #Nephpearls is probably what resonates with most Nephrology enthusiasts and that’s why they tend to follow me. I am also very cautious in tweeting about certain topics, e.g., politics, religion, etc. If someone would ask a question regarding a Nephrology topic, I always try to answer to the best of my knowledge, or I would try to find the answer and include a reference. There are occasions wherein, I just don’t know the answer, and I would suggest posting either on ASN Communities or using the hashtag #AskRenal.

How do you balance your personal life and your busy day schedule?

Dr. Lerma: Work Life balance is particularly challenging at the start. I do not think that there is a single algorithm for that. I am blessed to have a very understanding and supportive wife and 2 daughters. When I initially started practicing, it was very difficult to have such a balanced life. I had difficulty saying ‘no’ to projects and commitments (publications, leadership positions, etc.) outside work. As a young novice, you tend to accept all opportunities to the point that you’re multi-tasking over multi-tasking; this can be detrimental not only to your health but also to the project(s). When you do this, the result can be a sub-par product. However, as I grew older and had more experience, I’ve learned to become more efficient by taking on only what I can handle.

Which one is harder? Residency or nephrology fellowship? Fellowship or new job?

Dr. Lemra: Each step in your career, from being a medical student to residency to fellowship to ultimately becoming an attending, has its own sets of challenges and tribulations. I think that support from your family and colleagues is of paramount importance. One thing is for sure. As you get up on the ladder of your career, the amount of responsibilities increases significantly. More importantly, with time, and with more experience, you are able to handle situations with more ease.

What makes you happy during the day? What is the most precious thing that you have achieved in your life?

Dr. Lerma: In an existential way, I think this is a difficult question. In a way, I would answer this question differently if you asked me 20 years ago as compared to 10 years ago, and now. Well, I will say that, my family makes me happy. Being able to spend time with them and seeing my daughters grow up and carve their own paths makes me happy. Everything I do in my career, day in or day out, now, really revolves around them. The academic successes and financial rewards I have received, are all trimmings under the tree that are now in the back seat.

Do you think if interest in nephrology will increase in the next two years? 5 years?

Dr. Lerma: The results of NRMP’s Medical Specialties Matching Program for appointment year (AY) 2018 seem to be similar as compared to AY 2017. There was a 42% increase in the number of US graduates matching into Nephrology programs while a 16 % decline was seen with IMGs. I do not know exactly how Nephrology as a specialty will be in the next 2 years or 5 years.

While there are multiple factors (lifestyle, reimbursement issues, complexity of patients, hospitalist movement) that are contributory to this decline in interest in Nephrology as a career choice, personally, I think that mentorship is a key component that is crucial in making the specialty more attractive. There are also programs that are geared towards encouraging our younger colleagues to join the Nephrology work force, e.g., ASN Kidney Stars Program, Origins of Renal Physiology: Mount Desert Island Biological Lab (MDBIL), etc.

I am uncertain if the recently signed Executive Order will translate into making Nephrology more appealing as a career for the younger generation.

What kind of activities are you involved in for education purposes on social media?

Dr. Lerma: I am involved with various Nephrology centered social media activities, e.g., #Nephmadness (Joel Topf, Matthew Sparks, Anna Burgner, Timothy Yau) #NephJC (Nephrology Journal Club founded by Swapnil Hiremath and Joel Topf) #NSMC (Nephrology Social Media Collective). I am also involved with the AJKD Blog, and the Interventional Nephrology Series (Aisha Shaikh, Buck Bucktowarsing, Crystal Farrington) of Renal Fellow Network (Editors: Samira Farouk, Sam Kant). I also try to help those Internal Medicine residents interested in Nephrology who rotate with me by giving them opportunities to write for ‘Disease A Month,’ and AJKD Blog.

What is the best thing about nephrology online community? What’s the worst thing about it?

Dr. Lerma: The best thing about it is the ‘collegial atmosphere.’ Everybody is supporting everybody. You won’t be afraid to ask a question for fear of being embarrassed or dejected. And anyone interested in participating is welcome to do so.

There are a lot of opportunities, from blogs to chats, etc. and that can be good or bad. To a beginner, it can be overwhelming.

As you go through your career as a future nephrologist, enjoy the ride … find your niche… and once you find it, focus on it. But don’t ever forget your family. They are the most important part of this ride… they will be with you always whether you’re in the ups or downs.

What is your main message to the Nephrology fellows in general? 

Take it 1 day at a time. There will be successes and there will be failures. Enjoy the successes but don’t take too long in doing so. Learn from your failures because you can change it to a success.

What is your advice to new Nephrology fellows?

No. “We are what we are because we have been what we have been …” – Sigmund Freud

Last comment…?

Dr. Lerma: In your career (just as in life), there will be challenges and there will be disappointments; always try to find the silver lining to help you get through these.

“When God closes a door, He opens a window.” (Malachi 3:10)

During these challenging times, think back to when you were in the beginning of your career. Why did you go into medicine? Why did you go into Nephrology? The answer(s) will hopefully give you the inspiration to continue to persevere and turn adversity into opportunity.

Then there will also be successes … always be humble and thankful.

“Gratitude is not only the greatest of virtues but the parent of all others.” (Cicero)

Thank you very much for taking the time to answer our questions. You are amazing and your contribution to #nephtwitter is really appreciated. We have learned a lot from you!

Thank you!

Yasar Caliskan @yasar_caliskan

Sayna Norouzi @saynanorouzi

#NephMadness 2019 – Baylor College of Medicine

Blog Post, NSMC 2019

The Section of Nephrology in the Department of Medicine at Baylor College of Medicine hosted a #NephMadness 2019 kickoff party this year.  The event was a valuable window into trends, updates, and points of contention within the field of nephrology. Participants were preassigned a topic or region of the bracket, spoke 2-3 minutes about each topic and made a case for which topic they believe should win in front of an audience. #NephMadness brought faculty, fellows, residents and students together in a setting that is both fun and educational. Here are their perspectives:

Medical Student:

I was excited to attend. Last year, I put all of my faith behind the Animal House Region only to discover that few people share my interest in how the noble camel manages to store enough water to survive life in the desert. After that disappointing defeat, I was hopeful that this party would give me inside information about the fellows’ and attendings’ thoughts on each of the regions. It was entertaining to see which topics received unanimous support and which topics split the crowd straight down the middle. The lighthearted drama of the debate paired with the festive decorations for each region made for a great afternoon. I learned a lot but most importantly I have high hopes for my bracket this year and am excited to see the final results!

Jennifer Kaplan, MSIV @KingdomPlantayy

Internal Medicine Resident:

Many residents only experience nephrology on the inpatient consult service, which, although valuable, limits our perception of kidney disease to the acute setting. Fortunately, #NephMadness runs the gamut of topics, from hospitalist medicine, to vasculitis, to transplant, to C3-i and more. It is an excellent demonstration of the diversity and breadth of the field. Moreover, the #NephMadness party at BCM creates a sense of community and inclusivity within the program. Medical students, residents, fellows, and faculty are all invited to present regions of the #NephMadness bracket in both small- and large-group settings (while enjoying pizza and popcorn). As someone interested in a career in nephrology, this event is a way to interact with the fellows and to get face-time with the nephrology faculty.

Jefferson Triozzi, MD @triozzijl

Nephrology Fellow:

#NephMadness is a fun opportunity to learn about nephrology topics in bite-sized, non-textbook language which make it approachable and relaxing! As a first-year fellow, because I have multiple discussions about choice of IV fluids and inpatient hypertension management on a daily basis; I decided to dive deep into learning the Hospitalist Region. I co-piloted my presentation with a resident named Jefferson–see his thoughts above! He summarized perioperative medicine and I discussed the IV fluids bracket. Together we designed and shared a handout for our winning pick. This handout was received well and, as a bonus, helped sway the audience in our favor. I was pleasantly surprised to see the number of medical students and residents present. Thanks to the power of social media, the turnout for #NephMadness (previously only nephrology fellows and a couple attendings) has grown.

Sayna Norouzi, MD @Saynanorouzi

Attending:

This year, I had the honor of hosting the Baylor #NephMadness bracket filling party. The room followed each fellow’s presentation along with the official #NephMadness PowerPoint presentation before voting. Being in the front of the audience tallying the votes, I could see how excited and energized the room was as we progressed through our bracket. This energy was only partly attributed to the bracket filling; it was mostly due to the number of sugary treats brought to represent the brackets! Thanks to the support of the Section of Nephrology, we were able to throw a successful party this year! #NephMadness is a marvelous way for everyone along the medical professional food chain to engage in a little friendly competition whilst learning together in a relaxed/entertaining environment.

Natasha N. Dave, MD @natashaNDave

Dr. Dave is wearing a Nephrun T-shirt and Dr. Norouzi had a #NephMadness cap!

Cereal (Lucky charms) = C3 section
Bottle pops = Dry on dialysis
Sour flush = Wet on dialysis
Black bullet Mario Kart sour treat = Substance toxicity
Popcorn = Bile casts section
Dumb dumb lollipops = Old school
Twizzlers = Hyperaldosterone section
Skittles = Opiates, NSAIDs
Ring pops = Lactated ringers
Starbursts = Tramadol, GABAnergics
Star Wars (May the force be with you) Coloring Books = Terlipressin, Norepinephrine
Normal saline and Lactated ringers to represent their respective sections were tried by a brave few after the festivities
Red, white and blue sparkly mini hats = US HTN guidelines
Blue beaded bracelet = Light chains
Mini microscopes = ANCA vasculitis
Maintaining the basketball theme, we also passed out miniature basketballs/trophies to everyone as well!

Our Benefactors

Blog Post, NSMC 2019

I love video games. Growing up the the 90s meant the magic of Mario, Donkey Kong and Zelda. Now social media has replaced Super Nintendo and whilst a large portion of my twitter feed is dedicated to nephrology there is an equally large portion dedicated to gaming and the culture which has grown up around this.

There is now an established culture of streaming in video games via services such as Twitch in which people play a video game for an online audience who watch and interact through the chat and media presence of the streamer. It’s big enough now for some people to make it their full-time job. One of the better things that can occur with streaming is charity streams, in which big name streamers play video games for a charitable cause in order to raise money. It’s surprising how much good can be done through this type of philanthropic endeavor. People such as Dr Lupo raised over $1million for St Jude’s Children’s Research Hospital through charity streaming in 2018, or Arin Hanson from the Game Grumps who raised $55,000 in a single siting for Healing Horse Therapy Centre.

But I digress. Recently, a chap by the name of HBomberGuy did a charity stream of Donkey Kong 64 in order to raise money and awareness of the rights of trans people,  after Graham Linehan was accused of making disparaging comments via his social media account towards them. Video gaming has its own cultural sphere on social media and one of the curious things about social media is its unpredictability as to what exactly will capture the hearts and minds of the internet as a whole. Well this event certainly did. Via word of mouth over social media platforms and the appearance of several video-gaming celebrities, United States based politicians like Alexandria Oscasio-Cortez and Chelsea Manning, the stream blew up and helped raise over $340,000 for Mermaids, a United Kingdom based charity supporting trans rights. It’s by far one of the most wholesome and kindest stories I’ve heard in some time, and one could not help but feel inspired by it.

So musing on the fantastic work that HBomberGuy recently did with his stream to raise awareness for trans rights, I had to ask myself, would it be possible to do a similar thing for nephrology? Could I play video games in a similar vein (after all, I do love them and want to advocate for my patients and spread awareness of kidney disease at the same time) for a good cause and will the community rally behind me and provide donations to those organisations which need it most? Unfortunately, the answer realistically is, probably not.

Firstly, I would never presume that I would have influence, anywhere near that of these big streamers, who make such things their careers. And unfortunately without that kind of clout such a project is probably going to have little momentum getting off the ground. Secondly, such things are fluid and evolve naturally through the same grapevine that social media and the internet works on. Something just captures peoples’ imaginations for whatever reason and it becomes an event – you can’t plan for that. It just happens. And lastly is a point brought up by Laura Dale, a trans woman who co-hosts a video games podcast (which I listen to each week) who pointed out that part of the reason this had the success it did is because it was a cis person doing it, and not someone from within the trans community. It is easier for people to rally behind a cause when it isn’t a member from the minority group that is championing it.

And this point is the last reason why it might be difficult for such an event specifically for kidney disease to take hold if I was running it. While I am fortunate not to have chronic kidney disease, my natural role as a clinician is to advocate for my patients. In this way I am not separate from this group, thus directly counteracting this crucial component.

Advocacy for kidney patients and video games! Is there a way to marry these two ideas together? Or is there any other way in which we can capture the imagination of the general public (in short, go viral!) in order to raise money to help those with kidney disease?

Could we as a group approach a larger streamer and ask for their assistance in a charity stream for kidney disease? Would it garner enough support? I honestly cannot answer these questions as I sit here and softly tap away at my keyboard. But perhaps by drawing attention to my musings our community as a whole might be able to achieve more things for our patients.

P.S. The title of this blog post is also a direct nod to a level from a video game. Props to anyone who knows which one I am referencing.

‘Size and Flow Matter’ – Memoir of an AV fistula

Blog Post, NSMC 2019

My name is Fistulus Magnus. I came to this world a decade ago, by the hands of a very skilled surgeon, who anastomosed my host’s brachial artery to his cephalic vein. My host’s name is Mr. Hohf. I take a lot of pride in having served Mr. Hohf diligently over the years. He unfortunately suffers from end-stage kidney disease (ESKD) that resulted from diabetes and is currently undergoing in-center hemodialysis three times a week.

You must be wondering where I got my name. Well, it was bestowed upon me by the other fistulas at the dialysis unit. While some never quite served their hosts with the appropriate blood flow on dialysis, others were just not mature enough for the job (no pun intended). I, on the other hand, was raging through every single dialysis session without issues. All the other fistulas looked up to me. My size spoke for itself. I was the Arnold Schwarzenegger of all fistulas. Big, tortuous, pulsatile and most importantly, easy to poke. Dialysis nurses loved me, but Mr. Hohf, not so much. He would constantly try to keep me away from prying eyes under his long sleeves but I took no offence. Deep down under, I knew I was the reason he was still alive. After all, as the good nephrologist always says, ‘Your fistula is your lifeline’. I carried on and did my duty.

Example of a dilated and tortuous AV fistula.
https://bjaed.org/article/S2058-5349(17)30161-0/pdf

I was worried for Mr. Hohf though. He has required recurrent hospital admissions for ‘volume overload’ and ‘hypoxic respiratory failure’ over the past year (No, I did not go to medical school, but years of being around medical people teaches you medical terms). We were now at our fourth admission in eight months. His most recent echocardiogram showed grade 2 diastolic dysfunction, pulmonary hypertension with peak pulmonary artery (PA) pressure of 60 mmHg, dilated inferior vena cava and a high cardiac output of about 8 L/min. Although, his dialysis treatments were optimized to ensure euvolemia, but his respiratory status remained tenuous. A left heart catheterization showed non obstructive coronary artery disease, with high left ventricular end diastolic pressure of 22 mmHg. CT scan chest with pulmonary embolism (PE) protocol was negative. Infections were ruled out. He had no chronic obstructive pulmonary disease (COPD) or asthma. It was presumed that Mr. Hohf was non-compliant with dietary restrictions and his dialysis unit miscalculated his dry weight. The heart failure was attributed to non-ischemic cardiomyopathy. While in the hospital, his dialysis sessions were complicated by  intra-dialytic hypotension and development of cramps. Discharge to home then ensued. Shortly after, we were back with the same issues, despite adhering to fluid and salt restriction and outpatient dialysis.

‘I have good exercise capacity but I just cannot handle this fistula’

One fine morning during our fifth admission, a team of nephrologists laid eyes on me. Mr. Hohf was on high flow oxygen therapy, with accessory muscles working as hard as they could. The medical team was paying attention to me and I was keen to show them my excellent skills on dialysis. One of the nephrologists reached out to my anastomotic site and occluded the blood flow to the point of augmenting the pulse at my inflow. The other physician measured Mr. Hohf’s blood pressure and pulse, while I was being compressed against the shaft of the humerus. They noticed a 20 mmHg increase in blood pressure and drop in heart rate by  20 beats per minute. “The Nicoladoni Brenham sign!” one of them exclaimed, with a glow in his eyes reminiscent of kids on Easter.

The next day, a duplex study was done that revealed a flow of almost 4L/min through my outflow tract. This was more than 30% of Mr. Hohf’s cardiac output! ‘Duh! I wouldn’t expect anything less. I am Fistulus Magnus after all’, I told myself. Unfortunately, reality started to unfold. We were taken for a repeat echocardiogram where the same maneuver was performed followed by measurement of the cardiac output. Indeed there was a 30% drop in cardiac output on occlusion of my anastomotic site. I was ‘hemodynamically significant’ they said. I was the cause of Mr. Hohf’s recurrent admissions and pulmonary hypertension. I was the reason why Mr. Hohf’s heart was failing.

The hemodynamic changes following AV fistula creation. Sometimes, blood flow increases to undesirable limits. https://journal.chestnet.org/article/S0012-3692(17)32290-0/pdf

All these years, I fulfilled my duties believing strongly that I was doing the best for my host; growing bigger and bigger and allowing higher blood flows. It turns out I was shunting too much blood back to the heart and the myocytes were having a hard time coping with the workload. I was like a dam with flood gates wide open, resulting in a downstream reservoir that could barely cope with the gigantic rush of water. Owing to my size, tortuosity and blood flow, I was causing more harm than good. A diagnosis of ‘high output cardiac failure due to arteriovenous (AV) fistula’ was assigned to us.

So what next? The nephrologists recommended that I undergo banding to reduce my size and blood flow. It was a reality check, but I warded off all apprehension and proceeded with the procedure.

The surgery was performed successfully and we were both sent home. I felt very frail and flimsy, but dialysis seemed to run well regardless. Most importantly, Mr. Hohf had not had an admission in over six months and he had a better control over his breathing and volume status. A follow up echocardiogram showed that his pulmonary hypertension had improved with peak PA pressure of 40 mmHg and cardiac output of 5.0 L/min.

In the end I realized that things worked out for the best, and  saved Mr. Hohf many hospital admissions, mental stress and procedures. My colleagues at dialysis tell me this is a rare condition, but it may very well be more common than we think.  Physicians should keep a higher index of suspicion for conditions like this. There is a newbie across the hallway who is sizing up to be like my previous self. I will make sure to give him a well informed word of advice: ‘Size…and flow matter.’

#NephPath – The Tubulointerstitium

Blog Post, NSMC 2019

NephPath 101 – Understanding the tubulointerstitium. – by NSMC2019 intern and nephro-pathologist Vighnesh Walavalkar.

Check out the original post on Renal Fellow Network

Excerpt –

The tubulointerstitium of the kidney is broadly divided into the cortex and the medulla. These are extremely important components of the kidney, which can show a broad spectrum of changes ranging from subtle to significant, in both acute and chronic kidney injury. Therefore, in order to recognize the pathologic changes in these areas, one must first be familiar with its normal architecture

In this post, we will cover the main histologic features of the normal tubulointerstitium as seen on diagnostic kidney biopsies. For a more in-depth review please refer to my favorite references for kidney pathology: Heptinstall’s Pathology of the Kidney, Silva’s Diagnostic Renal Pathology and Renal Pathophysiology, The Essentials.

DNAJB9: Demystifying Fibrillary Glomerulonephritis

Blog Post, NSMC 2019

Fibrillary glomerulonephritis (GN) is a rare disease which accounts for about 1% of all kidney biopsies. The very first description of the disease was published by Rosenmann and Eliakim in 1977. They described a patient with nephrotic syndrome due to deposition of what they describe as “an amyloid-like material in the glomeruli,” but upon ultrastructural analysis, this material “appeared shorter than amyloid fibrils”

Post by NSMC2019 Intern and Nephrology Fellow – Lovy Gaur

Link to original post on Renal Fellow Network