My First 9 Visual Abstracts

Blog Post

#NephMadness gave me the opportunity to learn and practice how to create visual abstracts. The #VisualAbstract is an effective and efficient way to disseminate research, and they are also fun to make! Here are some of my first attempts below (click to enlarge, made in Powerpoint):

 

Samira Farouk, MD

Chief Nephrology Fellow, Icahn School of Medicine at Mt. Sinai

NSMC Intern 2018

NephMadness Choose Wisely Campaign (#NCWC)

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What to do?  So many good choices, so many ways this can go.  Will your bracket survive past your colleagues and friends or will you have to hear them go on and on how they  pity you or just tell you that you suck.  When the conversation at the next conference turns to NephMadness you don’t want to be the person saying, “Hey I have an early day got to go back to my room”.  Heck this madness is so crazy popular people have literally been kidnapped to prevent entry into the tournament!  

You think to yourself how do I get an edge on the competition.  You google best bets NCAA tournament, there are over 2 million hits.  Oh you meant google best bets NephMadness, first think that shows up is NephMadness for Dummies.  You almost throw your phone/tablet/computer against the wall to show it whose the boss, but wait you remember you will have to buy a new device and who knows if that device will be any smarter.

Then you head to twitter and you see salvation!  You come upon the NephMadness Choose Wisely Campaign #NCWC?  How did this happen? What is this?  Well you see Nephrology Social Media Collaborative (NSMC) Intern Mohamed Elrggal was in a deep sleep when the Knight of NephMadness Past came to him.  He immediately awoke and googled the below image as he needed to know who this Salt Whisperer was.

Image result for gandalf choose wisely

Mohamed thought to himself what does this mean? Suddenly an idea came upon him, what if he led a team to retrospectively analyze the history of the Blue Ribbon Panel, from publications to tweets to choice of coffee and input this data into a simulation model.  He could run the simulation a few thousand times and then be able to accurately predict the winning Teams in NephMadness.  He immediately communicated this idea to his Nephrology Social Media Collaborative (NSMC) co-interns and the team was assembled.  Mohamed’s brainchild became knowns as the Nephrology Choose Wisely Campaign#NCWC.

The first entry was done by the man Mohamed himself.  This was followed in rapid succession by more entries and to totally annihilate the competition check out the wonderful Visual Abstracts!

Image result for rapid fire from destroyer

Below are a list of hyperlinks, first link is to that region’s NCWC entry and then below is the hyperlink to that #specific region (click #NCWC for the whole collection in one spot):

Strong work by @ssfarouk on putting together the infographic summarizing the twitter polls below:

So now you start to feel like you might just win and start to plan a Championship Parade but WAIT WAIT WAIT!  Simply winning is not enough, you feel the need to embarrass your colleagues and walk around like a Boss at the office, to show those other fellowships “Yea we’re bad, What! What!”. Well to honor the idea of FOAMed (Free Open Access Medical education) and to keep your head spinning with content we rolled out the good stuff:

Still don’t know whom to pick, well if all else fails here are some free picks for you. Want free picks in Spanish, no te preocupes we got you covered.

Asking where can I look to find everything mentioned in this blogpost and more coverage of NephMadness click below:

#NephMadness

Shout out to all the contributors to this year’s NephMadness and all the wonderful posts and innovative educational tools used.  A special thanks to our NSMC faculty and the NSMC interns!

And let’s wrap this up with aShooting Starr Moment!

Image result for shooting star

Now let’s win this thing and go cut down some nets!

#nephmadness #nephforward #NSMC

See the source image

#NephMadness Choosing Wisely Campaign: Trial Outcomes Region #TrialsRegion

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Welcome to the #TrialsRegion; the region with the greatest potential for generating debate about clinical practice (in my humble opinion). Our ability to distil out the relevant information from the outcomes of trials is paramount in improving the delivery of care to patients with kidney disease. Particularly given the rising prevalence of CKD, there is a clear imperative to develop additional therapies through high-quality trials. Much focus has been placed upon the quality and quantity of RCTs within Nephrology; the overall consensus is that we are lagging behind other specialities. Selection of the correct surrogate marker is fundamental in determining the relevance and wider applicability of trial outcomes.
The first matchup in this region pits the old familiar reliable against the young pretender.Doub

Doubling of creatinine has been used as an endpoint in randomised clinical trials for decades. Long-term changes in serum creatinine are thought to reflect a structural renal function decline and predicts development of ESRD. Doubling of creatinine should reflect a sustained reduction in GFR and represent an important step in progression to ESRD.
Although well established, this venerable contender is far from flawless. Using the CKD-EPI creatinine equation a doubling of serum creatinine level approximately corresponds to a 57% decline in eGFR based on serum creatinine level which is a relatively late outcome in CKD. The variable acute and chronic effects of many drugs on renal function suggest caution should be used when interpreting clinical drug trials using doubling of serum creatinine as outcome.

Enter the challenger 40% reduction in eGFR. There is great interest in considering alternative endpoints to shorten trial duration and reduce sample size. 40% is obvious less than 57%, meaning you hit your clinical endpoint at an earlier stage. This has significant implications for the design and likely successful outcomes of CKD trails. Unfortunately, CKD does not decline in a step-wise manner which is a significant limitation of this approach.  Steady loss of function over time is a relatively late manifestation that reflects physiological factors in remnant nephrons.  The applicability of 40% decline in eGFR is not uniform across all clinical settings, particularly if the treatment effect is not uniform across those who progress rapidly and those who do not progress. The use of different equations for determining eGFR must also be considerGraph.pnged. The NKF-FDA concluded that 40% eGFR decline is broadly acceptable as a kidney end point across a wide baseline of eGFR range, however a minimum follow up of 2-3 years is recommended. The trade-off is between improving power (more events) while increasing type 1 error (i.e. false positives).

It is important to bear in mind that both contenders are based on a biomarker; they do not provide information regarding patient health status. Creatinine itself has limits as a biomarker; changes in serum creatinine can be attributed not only to renal structural changes but may also be reflective of muscle mass, dietary changes, changes in renal tubular secretion of creatinine (particularly in patients with proteinuria and hypoalbuminaemia), and haemodynamic effects (particularly relevant given how many of our “go to” medications in CKD exert their clinical effects).

The chatter so far seems to be leaning towards 40% eGFR decline:

Scouting report @methodsmanmd

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Mark’s Bracketology for Trial Outcomes @drpaddymark

Bracket1.png40% eGFR Decrease and Other New Kids on the Block @Badves

New Kid.png

Combing through previous tweets by @NephRodby:

Nephy.pngNeph 22.png

Unfortunately, I was unable to uncover any clues about how the rest of the BRP would be inclined to vote based on their Twitter accounts and PubMed searches; perhaps because these aren’t the easiest of search terms to track.

Prediction—40% reduction in eGFR purely from the point of view of causing a minor upset of an established behemoth and generating discussion. Topf22.png

 

Protein.png

The second match-up in this region is genuinely intriguing—two diametrically opposed surrogate measures.

Proteinuria

Beyond any doubt, proteinuria is predictive of an increased risk of progressive renal function loss over time. This association is found in various pathophysiological conditions, includiPROte.pngng diabetic nephropathy, hypertensive nephropathy, and various primary renal diseases. Difficulties arise with regards to 1. Standardised collection methods (spot vs 24 hr collection) 2. Whether it can be used as a surrogate marker—secondary analysis of the RENAAL study found that reduction of proteinuria was a strong predictor of outcome however there are several studies with conflicting outcomes.

Patient reported outcomes

“The good physician treats the disease. The great physician treats the patient who has the disease” William Osler

PROMS

Given its chronicity and symptom burden, the subjective patient experience is key in understanding the impact of CKD. The success of treatments has been historically assessed by doctors using laboratory measures; incorporation of patient perspective into routine clinical practice has been slow to be incorporated. This is because such measures are thought to be intangible and therefore difficult to replicate across clinical trials.

  • Patient Reported Outcome Measures (PROMs)—any metric assessing health, illness or health care benefits from the patient’s perspective; in general they take the form of a questionnaire. PROMs have the potential to highlight relevant symptoms and changes in symptoms, promote patient engagement in their treatment. They include the Kidney Disease Quality of Life Short Form and the Dialysis Symptom Index.
  • Patient-reported experience measures (PREMs) capture information about the healthcare experience as perceived by the patient. They can refer to a variety of issues ranging from cleanliness of facilities to waiting times and how HCPs deliver information.

Of the two, proteinuria has certainly generated the most discussion to date

 

Oates 2.png

Protein 2

Proteinpost.png

 

Swqap post

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The rest of the BRP

Given the extensive patient advocacy work by @FionaCLoud I would imagine she would lean towards PROs.

During her time as ASN President @EleanorLederer has spoken about patient engagement and its role in clinical decision making.

Lederer.png

@DrDeidraCrews was involved in a study examining patient related outcomes and has done extensive work on social determinants of health.

Reid.png

Scouting report @methodsmanmd

Scouting

Mark’s Bracketology for Trial Outcomes @drpaddymark

Mark 2.png

My prediction: Although proteinuria remains the more controversial of the two, Patient Related Outcomes by a narrow margin (5 to 4).

Final winner: 40% reduction in GFR. This could be the dark horse of the competition.

NephMadness Choosing Wisely Campaign (#NCWC): Pathogenic DSAs vs The Untransplantables (#TransplantRegion)

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The fight to come out of the Transplant Region is like a sibling rivalry.  Truly all four competitors relate to each other under the umbrella (aka family) of access to transplantfor various patient populations.  Get ready because you know in sibling battles there is no “illegal” weapon.  It is time to get down and dirty.  We are going to discuss Pathogenic Donor Specific Antibodies (DSA’s) versus The Untransplantables.  Please check out my NSMC co-intern Dr. Samira Farouk’s amazing game preview of Kidney Donor Risk versus VirallyInfected Kidneys.

Let us first take a look at Team Pathogenic DSA’s.  They have been scouted before with excellent reviews and concerns.  If one word describes this team as Dr. Dorry Segev mentioned in his overview of the Transplant Region it is “Enigma”. The detection of Pathogenic DSA’s allows for more appropriate matching between donors and recipients and avoiding acute antibody mediated rejection (ABMR). However, how do you know how significant the DSA is?   This brings us to the team leader Antibody Strength or his streetball name “Da MFI” (Mean Fluorescence Intensity).  A team’s leader can reflect both a team’s strength and weaknesses all at once.  “Da MFI” shows good game with great defensive MONITORING on the court, but has limitations such as getting caught out of position or not finishing at the basket.

Ideally the HLA antibodies bind proportionately to a standard amount of target antigen and high antibody levels will develop.  But what if using single antigen bead assays that give us the “Da MFI” the following happens?

1. There is a lower antigen density and despite high levels of antibodies produced there is a falsely low MFI

2.There are high antibody levels and complement activation leading to soluble C1q that blocks HLA antibody binding to the selected antigen, resulting in a falsely low MFI

3. Two different antigen beads have different HLA antigens but the same epitopes diluting the serum antibody resulting in a lower MFI

4. The patient had a sensitizing event leading to production of DSA after antibody testing

5. If you take the same samples with the same beads and do the same test over a course of a week you could end up with varying MFI’s

So Yes we can detect Pathogenic DSA’s but we definitively do not always know what it clinically means.

In 1968 the World Health Organization established criteria for screening practices and it was said that yes in theory was a good practice but there will be “snags”.

So yes there is a lot of science and fascination with Team Pathogenic DSA’s but I have to agree with Dr. Segev, the Team are a group of freshman with their “snags” that will grow together and change with new teammates over time, this is likely not the year but a title run might not be that far in the future

Also Pubmed articles by the Blue Ribbon Panel mentioning “Antibody”: 0

Our opposing team are the Untransplantables One easy rule in picking the winner in NephMadness is where is the most ready prime time player aka look for a relevant intervention with a significant transparent effect on diagnosis, treatment, or patient outcomes.  Well the Untransplantables were once a ragtag group that heard the words, “too sensitized”, “can’t go against nature”, “no student would ever EXCHANGE over to this team”, and “can’t land a hot shot recruit”, maybe not anymore.  They have a superstar in my opinion that would make the all tournament team, overcoming HLA incompatibility in transplantation.  The superstar has two primary offensive weapons, the paired kidney donor exchange (PKDE) and desensitization.  Let us focus on PKDE.  The National Kidney Registry (NKR) is a national registry in the USA of listing living kidney donors and recipients in need of a kidney transplant.  The NKR was founded in 2007 and as of early 2018 has resulted in 2598 transplants(https://www.kidneyregistry.org/index.php).  This goes beyond a patient being untransplantable with a potential donor, it also allows for a better match in terms of other factors such as age.  PKDE can be used in concert with desensitization via an  algorithmic approach.

See the source image

But do not forget there are a few other players that have given new hope to patients.  One of them is ABO incompatibility transplantation which is becoming more mainstream in particular with specific type B blood recipients receiving organs from donors with A2/A2B blood type.

Simply put, the Team Pathogenic DSA’s has plenty of team Defense and Monitoring.  However it is questionable how much this will lead them to a win.  On the other hand we have The Untransplantables whom have a great defense (since technically DSA monitoring is used in these patients) but can score in both natural and unnatural ways.

Plus if you ask who is the most prime time ready player that has made an impact measured by number of transplants, then it becomes an even easier decision.

Yep HLA typing and checking for DSA is a pillar of transplantation, but think about it if I find an issue using my DEFENSIVE MONITORING but then how do I SCORE off it?  Use one of the methods mentioned with the Untransplantables like desensitization or PKDE.

Plus if you think health care providers and patients aka our Blue Ribbon Panel want to overcome barriers not just hear they exist which way do you think they will sway?

Pick: The Untransplantables    

Tweet: Highlights from #NephMadness #WomensHealthRegion: Reproductive Planning in CKD

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