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:
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
#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
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
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.
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.
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.
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.’
#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
Check out this fun crossword about transplantation. Let us know if you get all correct in the comments below.
Hint: For all the answers visit the #Transplantation region of #Nephmadness
The first matchup in the #TransplantRegion leaves us with two tantalizing options: “Kidney Donor Risk” and “Virally Infected Kidneys”. How does one possibly choose between the bold risk one takes when choosing to save a life and the now possible but previously unimaginable transplantation of kidneys infected with Human Immunodeficiency Virus (HIV) the curable Hepatitis C (HCV)?
Let’s take a quick look at team #KidneyDonorRisk. Why should we care about kidney donor risk? Well, even the first kidney donor in 1954 ultimately progressed to end stage renal disease (ESRD)…
Since 1954, we have developed new tools to better quantify a potential kidney donor’s ESKD risk, like this calculator – which can be used to calculate any donor’s pre-donation 15 year and life time ESKD risk. In addition, 2-time APOL1 champion may easily carry this team to the saturated 16. Would you advise kidney donation to a patient with 2 APOL1 risk alleles, given that 2 out of 19 patients developed ESKD after a median follow up of one year in one small study? If you’re still not convinced, take another look at @KristaLentine’s support of this team as the winner of not only this matchup, but also of the entire #TransplantRegion. She emphasizes the importance of the understanding of donor risk and transparency of communicating this risk.
If #KidneyDonorRisk isn’t your thing, maybe you’re a believer in the #VirallyInfectedKidneys.
And why wouldn’t you be? The THINKER trial showed us that HCV + kidneys can now be transplanted into HCV – recipients, with successful treatment of HCV post transplantation. A limited kidney donor pool may ultimately be significantly expanded, if HCV+ kidneys are no longer discarded. Similarly, the HOPE (HIV Organ Policy Equity) Act has resulted in the transplantation of HIV+ organs and promising overall and graft survival rates.
Now what? You’ve read @paulphel‘s comprehensive scouting report and seen enough visual abstracts, but all that really matters is the Blue Ribbon Panel. I predict team #KidneyDonorRisk to win this matchup, and here are the 5 of 9 Blue Ribbon Panelists that I’m most confident will help advance it to the next round:
- @FionaCLoud: She’s a kidney transplant recipient and fierce advocate. It seems likely that she’ll keep #KidneyDonorRisk in her bracket.
- @DrDeidraCrews: She researches the impact of racial disparities on chronic kidney disease, and has published on the disparities in access to kidney transplantation.
- @Mike_J_Choi: He’s an author on a 2013 NEJM study describing APOL1 risk variants, race, and progression of CKD. I don’t expect him to forget about APOL1 so quickly.
- Tazeen Jafar – She has studied predictors of low eGFR after kidney donation, in a Southeast population from Singapore.
- @medicalaxioms – He probably cares about the #KidneyDonorRisk. The tweet below says it all:
Ready to make your pick? Submit your bracket here.
Samira Farouk, NSMC Intern 2018 @ssfarouk
From ‘Prematurity’ to ‘Menopause’, life completes a full cycle in the Women’s Health region of Nephmadness 2018. Let it be the glomerular disease (preeclampsia) or dialysis & transplant (reproductive planning) or endocrine disturbances, this region has something for everyone, including our pediatric colleagues. The fact that all of the players in this region are of vital importance makes the choice even more difficult.
For me, all are champions in their own way, but let’s try to peep into minds of #Blueribbonpanel (BRP) who will have the final word in crowning the champion. The fact that we have 6 wonderful ladies (out of 9 members) on the BRP is a testimony to the fact that this region is going to make it big.
Reproductive planning Vs Menopause in CKD
None of the BRP members have leaked any clues about how they might vote on the Twitter just yet. Therefore, we decided to do a deep dive and search the #WorldkidneyDay chat. This gives us some important clues. Fiona Loud (@FionaCLoud), Policy Director at Kidney Care UK, who is a kidney transplant recipient herself, has talked about Pregnancy in CKD.
She has actively advocated for the patient’s perspective related to pregnancy in CKD during the World Kidney Day chat (#WKDChat).
So it will be not a surprise if she votes for ‘Reproductive Planning’. Also, Eleanor Lederer (@EleanorLederer) had actively participated in the #askASN Chat and discussed reproductive issues in CKD
And she surely advocates pregnancy in glomerular diseases.
Quotes by Roger Rodby (@NephRodby) on reproductive planning are so famous that he was quoted in a presentation in India.
After reading his paper on “Disease-specific patient reported outcome tools for SLE” we are confident that he will favor reproductive planning. A Twitter and PubMed search for Deidra Crews (@DrDeidraCrews) didn’t reveal any clue directly related to these regions, however she has done some commendable work in the field of disparities in Chronic kidney disease and transplant which makes me believe that she will support reproductive planning in CKD as well.
Thus 4/9 votes for reproductive planning.
None of the PubMed/Twitter accounts of other BRP members had any other clues however, this post by Mark Reid (@medicalaxioms) might be the best clue we can get and is “right” to the point.
Menopause in CKD is an equally important topic addressing harmful effects on cardiovascular risk, bone health and on patients’ quality of life. But we expect ‘reproductive planning’ to be much more popular amongst the BRP. Also, Selection committee member Michelle Hladunewich (@mhladunewich) will try to persuade the BRP in the favour of Reproductive Planning as is evident in her important review on pregnancy in CKD and recently in ESKD.
A battle for the larger Global Impact: Preeclampsia Vs Prematurity
Two of the BRP members Fiona Loud and Mark Reid have a shared their experience with Preeclampsia in these tweets.
Eleanor Lederer has elegantly explained urinary findings is preeclampsia in this paper and she has also addressed this issue on twitter.
This makes it again 4/9 votes for preeclampsia.
The only BRP member who may lean towards ‘Prematurity’ is Sarah Faubel (@doc_faubel) by the virtue of her work AKI in neonates. Bryan Carmody (@jbcarmody) has made an excellent argument in favor of prematurity in AJKD blog mentioning the long-term kidney outcomes, but unfortunately, he is not on the Blue Ribbon Panel.
Preeclampsia seems to be very popular amongst those who have already filled their brackets.
And that’s my poll for the Women’s Health Region
Bottomline – Women’s health region is here to win. Choose your pick wisely.
Follow #NCWC for daily region updates.
Read the full AJKD blog (and check out the full scouting report for the #Women’s healthregion here).
Submit your NephMadness brackets here.
Do let us know about your choices in the comments.
As the submission deadline for picks for #NephMadness 2018 approaches, many of us are wondering how the Blue Ribbon Panel will make its decisions on which teams should advance to the next round. Here we take a look at the Animal House Region (#AnimalRegion) to see who looks like an under-dog and who may come out top dog (animal puns are an added benefit of this region!)
The Battle of Osmolality Regulation: Pee Shark versus Salt-Switching Salmon
It’s tough to get a read from selection committee member Dr. Mark Zeidel and Dr. Timothy Yau’s (@Maximal_Change) great scouting report of this region. This opening battle serving as a clash of the competing osmololar balance mechanisms. Based on popular opinion alone, the shark appears to be somewhat of a fan favorite, judging by the interest garnered by a tweet thread appears in August 2017 about the Greenland shark. While not entirely composed of urine, sharks maintain extremely high urea levels to act as “osmoregulatory ballasts” allowing these predators to maintain osmolality in the range of 1,000mOsm/kg with 30% composed of urea. In addition to their fascinating physiology, sharks also possess fine control of osmoregulation through their rectal glands, with Na/K/2Cl concentrations 50x that of the TAL in humans. Additionally, this discovery has allowed for advances in our understanding of the TAL and diuretic physiology – findings with direct and important consequences for humans.
However, Team Salmon also puts together a convincing team, with a versatility not often matched in this year’s field. As a teleost fish, salmon adapt from freshwater to saltwater and back again to freshwater, a swing of environmental osmolality of 1,000 mOsm/kg without significant changes in serum osmolality. This is due to a combination of osmosensor mediated diffusion and upregulation of transporters in the gills, as well as specialized cells in the GI tract. If adaptability is the key to a team’s success, Salmon may be the sleeper in this region.
Camel versus Toad: Water, water everywhere or nowhere?
This matchup is the battle of adaption to environmental extremes, and it’s tough to get a read from the selection committee scouting report. This dipsogenic dromedary is the exception rather than the rule with regard to osmolality. Returning to the scouting report, Dr. Zeidel focuses on the physiology of this adaptive response:
Despite these adaptive responses, as camels dehydrate over their 2 weeks without water, their Na rises from 154 to 191 mEq/L, with corresponding serum osmolality rising from 304 to 406 mOsm/kg. When given access to water, they re-hydrate rapidly; they lower their serum Na and osmolality to baseline levels within hours. And again, despite this massive shift, their mentation and neural function remains intact. Remarkably, these large swings in serum osmolality do not alter the camel’s neurological functioning.
Camels appear to be drawing strong support on Twitter, with memes in support of this team almost equaling that of Team Shark above. One weakness of the Camel team is the lack (so far at least!) of physiologic understanding of how camels tolerate such dramatic dehydration/rehydration – although some supporters of this team may argue that this makes the feet even more impressive!
Team Toad’s argument is for the power of the amphibian’s bladder, with the ability to reabsorb water from the bladder as needed depending on evaporative skin losses. First discovered in the 1950s, this physiologically advanced animal (along with others) was responsible for the discovery of aquaporins and essential in our understanding of free water homeostasis. Findings of this advanced physiology in toads and frogs has had direct implications for our understanding of water handling in the human distal tubule. Additionally, the discovery of aquaporins was considered so fundamental that Peter Are won a Nobel Prize for this finding, further strenghting the importance of this team.
Can we gather any information about how the Blue Ribbon Panel will vote? A search of their twitter activity doesn’t reveal any strong preferences, retweets or suggestions of animal preference – in fact all members of the Blue Ribbon Panel have been silent on this region. A quick review of PubMed offers a few clues into how the panelists may vote. Sarah Faubel (@Doc_Faubel), for example, is interested in animal models of AKI, suggesting that she may pick a team from this region to go deep in this year’s tournament. Additionally, Eleanor Lederer (@EleanorLederer) studies regulation of sodium phosphate transporter in proximal renal tubule cells, suggesting that she may be on Team Shark.
As we head into #NephMadness 2018, many of us are wondering how the Blue Ribbon Panel will make its decisions on which teams they select to advance to the next round. Here we take a look at the Pediatric Nephrology Region (#PedsRegion on Twitter) to see if there is any lean towards one team being victorious over another in each match-up.
Genes in CAKUT vs. Environment in CAKUT:
Congenital anomalies of the kidneys and urinary tract (CAKUT) are the most common cause of CKD in children. Kidney organogenesis is a precise, multi-step process that begins around 3 weeks gestation with formation of the pronephros and continues through the 36th week of gestation as the final kidneys undergo nephrogenesis. Because of the complexity of kidney development, multiple genetic and environmental insults can influence organogenesis and lead to abnormal formation of kidney and/or urinary tract structures. This #NephMadness rivalry is a battle of “nature vs. nurture” to see which team reigns supreme.
It’s tough to get a read from selection committee member Michelle Rheault’s (@rheault_m) scouting report on this match-up. She touches upon the 50+ genes that have been discovered thus far that are implicated in various congenital anomalies, ranging from renal agenesis to primary vesicoureteral reflux, and how next-generation sequencing could identify a potential cause for CAKUT in 5-10% of cases. Given her research interest in Alport syndrome, a disorder with a clear genetic basis, and her recent comments on Twitter, it may suggest she is trying to sway the Blue Ribbon Panel towards choosing the “Genes in CAKUT” team:
Then again, in the scouting report she emphasizes the burden of maternal diabetes and obesity in pregnancy and the risks of prematurity, which affect millions of babies born each year. This suggests a possible lean towards environment due to its greater impact on kidney health at a population level.
On a global scale, over 15 million preterm births occur each year. Prematurity leads to the arrest of nephron development and renal hypoplasia although some nephron development may continue after birth. Unfortunately, while premature infants are trying to form a few last nephrons after birth, they are exposed to nephrotoxic medications in the course of their care that may further disrupt this process.
Has the Blue Ribbon Panel leaked any secrets about their thoughts on genes vs. environment in CAKUT? It’s hard to tell as no one on the panel has talked about this match-up on Twitter yet.
A quick PubMed search may offer other clues into how the panelists may vote. Deidra Crews (@DrDeidraCrews), for example, is interested in socioeconomic factors that lead to racial disparities in chronic kidney disease for African Americans. Recognizing the role that environment plays in the risk of kidney disease in this population, it is possible she may vote for “Environment in CAKUT.” Looking at Tazeen Jafar’s research interests in ethnic disparities in the treatment of kidney disease in South Asian countries, this may signal another vote for “environment” as well.
On the genetics side, Michael Choi (@Mike_J_Choi) has a research interest in APOL1 risk alleles. Fiona Loud (@FionaCLoud), the Policy Director at Kidney Care UK, is a renal transplant recipient herself and has tuberous sclerosis, a genetic disorder of tumor growth associated with renal manifestations including angiomyolipomas, cysts, and renal cell carcinoma. This may signal two votes from these panelists for “Genes in CAKUT.”
So where does this leave us? Two Blue Ribbon Panel members with possible votes for “Environment in CAKUT” and two potential votes for “Genes in CAKUT,” but it’s anybody’s game.
GN Diagnosis vs. HTN Diagnosis:
Glomerular diseases comprise the second most common cause of pediatric chronic kidney disease, just behind CAKUT. However, they are arguably the most challenging cases we see in our practice and come with plenty of co-morbidities and complications. Many of us have had that experience of a patient with steroid-resistant nephrotic syndrome that has gone through our limited arsenal of immunosuppression down the path to ESKD, or that challenging lupus nephritis patient with multiple lupus flares while on oral steroids and MMF. Hypertension, on the other hand, is also a tough team to beat. There is a known association of high BP in childhood with adult hypertension, yet many children go undiagnosed. Furthermore, obtaining accurate BP readings in children can be a challenge (older studies have shown that infants who cry raise their BP by 30-50 mmHg on average!) and BP targets are different based on the child’s age, gender, and stature.
Going back again to the selection committee member for the #PedsRegion, Michelle Rheault’s research interest in Alport syndrome may suggest she could be setting up the Blue Ribbon Panel to vote for “GN Diagnosis.” However, again looking at kidney disease from a population-level standpoint, she makes the following argument about the burden of pediatric HTN and the consequences of us not identifying it early:
Unfortunately, children with high blood pressure grow up to be adults with high blood pressure. In the Childhood Determinants of Adult Health study, children with blood pressure >90th percentile had a 35% increased risk of elevated blood pressure or hypertension in adulthood. Children with hypertension also demonstrate increased intermediate markers of cardiovascular disease including increased LV mass, carotid intimal media thickness, and pulse wave velocity. By putting in a little effort early to diagnose and treat childhood hypertension, a lifetime of cardiovascular disease risk can be minimized. From a potential health system impact standpoint, this team has a clear leg up on the competition.
This, in addition to the hype surrounding the newly released AAP Pediatric Hypertension guidelines, make it seem like “HTN Diagnosis” has a home court advantage.
But what does the Blue Ribbon Panel have to say? A quick Twitter search has not revealed any clear bias from panelists towards one particular team. When looking at PubMed, Michael Choi’s research interests in APOL1 and glomerular disease as a whole suggests a vote for “GN Diagnosis.” Tazeen Jafar’s research on BP control in rural South Asian communities and involvement in the Control of Blood Pressure and Risk Attentuation (COBRA) trial suggests a lean towards “HTN Diagnosis” with her vote.
Like the CAKUT bracket, “GN Diagnosis” vs. “HTN Diagnosis” remains a toss-up. Glomerular diseases, though relatively uncommon in the whole pediatric population, is a more common cause of CKD and ESKD in children than in adults and fraught with management challenges. However, given the long-term risks of not identifying elevated BP in childhood and the rising prevalence of HTN in this age group, particularly due to the obesity epidemic, I would lean towards “HTN Diagnosis” as claiming victory but not by a big margin.
Follow #NCWC for daily region updates.
Read the full AJKD blog (and check out the full scouting report for the #PedsRegion here).
Submit your NephMadness brackets here.