Nephrology in a Resource Limited Setting, Gaza Edition

Uncategorized

by Nimra Sarfaraz

What did I expect from the healthcare system going into the Gaza strip, seemingly one of the most inaccessible and dangerous places on earth ?

It’s embarrassing to say that media portrayals played a role in my notions. I was expecting to see a lack of physicians in a weak system with destruction all around. What I saw was simultaneously heartbreaking and comforting. I went with a team from MedGlobal, a non profit aimed at providing sustainable health care services to refugees, the most vulnerable in crisis areas and in low resource settings. Through MedGlobal, a diverse team from a professional, ethnic and religious backgrounds formed. Our team consisted of specialists in pulmonary critical care, Ob/Gyn, pediatrics, colorectal surgery, surgical oncology, anesthesia, pediatrics, nephrology, heme/onc and neurology. The team had clinicians from both the UK and the US with members identifying as Hindu, Jewish, Muslim, Catholic, Christian and agnostic; our unity around a common goal was beautiful to be immersed in. Our goal was to provide patient care, teaching and donating direly needed medical supplies, all of us were there on our own time and paid our own expenses.

On our first day there, we met with officials from the Ministry of Health and heard from leaders in the oldest and biggest hospital, Al-Shifa . What I will always remember more so than the jarring statistics was the sense of pleading to be heard, heard by the global community about what is happening. There’s a mingled guilt and helplessness in situations like this and I always come away wondering what sheer dumb luck has led me to such a position of comfort and privilege to sit across from individuals ever capable and exemplifying resilience. Later in the day the clinicians dispersed to meet with their Palestinian counterparts in one of two of the main hospitals we were working at, Al-Shifa Hospital or Nasser Hospital with the purpose of understanding each specialty’s work flow and assessing needs for future missions. I was paired and rounded with Dr. Riad, a bright nephrologist who had studied and trained in Egypt. We rounded on patients together and saw cases that ranged from run of the mill AKI to more complex cases such as steroid resistant childhood nephrotic syndrome that was now worsening, prompting a change in therapy. We visited the dialysis unit where many patients greeted Dr. Riad more as a friend. At the end of the day, when the group reconvened over dinner, all our experiences were similar – the lack wasn’t of human capital or education, the handicap was in a stifling lack of resources and mobility. Half of basic necessary drugs are at zero stock level, meaning there are not enough essential medications to effectively run a hospital to last through the next month. Astounding. The average amount of electricity per day is 7 hours. Dr. Aarti Garg, who did laparoscopic colon surgery on this trip, witnessed firsthand electricity flickering mid operation: luckily, big hospitals have generators but what of regular people?

What was I able to contribute as a nephrologist ?

Honestly the nephrologists there are capable and bright. They are deft at managing complex cases and have access to medications such as tacrolimus, mycophenolate and steroids. Uptodate is a highly cherished resource. Some of the more expensive medications, such as rituximab, are impossible to access because of the blockade. If a patient needs these medications, they need to be transferred out of the Strip. Transfer to more advanced centers is an onerous process, as on average 43 people are given permission to leave per day. Thinking comparatively to Las Vegas, a city of about the same size, to imagine only 43 people allowed to leave Las Vegas per day is mind boggling. People can’t leave to study, to visit family or to get more advanced and necessary medical care. Kidney biopsies that are done are sent across the border to neighboring countries to be analyzed. There is no doubt room for improvement, though it would be remiss to comment without also noting that these limitations will be difficult to overcome unless the prevailing root circumstances change. One notable example was the number of patients in the dialysis unit and the space each patient was allotted. The dialysis unit was full to the brim with one patient able to reach over and touch their neighbor, privacy and space, you see, is a luxury in a densely populated area with limited resources. Medications such as erythropoietin and calcitriol were not available; many patients asked us if we were able to provide these medications on a regular basis. 

I have gravitated towards point-of-care ultrasound particularly because of ease of use, rapid diagnostic ability and practicality of use, especially in low resource settings. I’ve previously taken a course with MedGlobal and have been using the Butterfly ultrasound probe on a regular basis. The Intensivists at my home institution have guided and taught me along the way as well. I was tasked with teaching a Point-of-Care Ultrasound workshop to the Internal Medicine and Intensive Care physicians at Nasser and Al-Shifa Hospitals; around 35 med students and attendings attended between two hospital systems. The workshop was well received and we did bedside ultrasound on patients in the Intensive Care Unit there. This part of my time there was likely the most beneficial of contributions to the most amount of people as the clinicians there are going to be using what they’ve learned on an ongoing basis. 

I encourage anyone with even a fleeting curiosity to delve for themselves into the complexities of the situation and with intentional conscience not forget the humanity of people, approach learning about this situation with empathy. Often times the most common narrative is not reflective of reality.

#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