Tag Archives: Nephrology

Can Doctors and Nurses help Dialysis patients recover?

In the case of dialysis dependent acute kidney injury patients this is a question which Dr Dinna Cruz  and colleagues (University of California San Diego) are asking and seeking opinions from both nephrologists and non-nephrologist doctors and nurses involved in care of dialysis patients.  It was a question which arose out of discussions at this year’s Continuous Renal Replacement Therapies conference (CRRT 2014). Personally, I think it is a brilliant starting point for research to go out and seek the opinion of those “at the coal face” actually treating patients. If that includes you, please take a moment to complete the survey. If it includes someone you know, please pass this request to participate on.  Here is Dr Cruz’s request:

Currently there is much interest regarding the recovery aspect of AKI. A specific area of interest is how to enhance recovery in patients who remain dialysis-dependent at the time of discharge. It is hypothesized that patients with potential for renal recovery may require a different care plan than the “usual” ESRD patient.

Therefore we are asking your opinion regarding the post-discharge care of such patients, using this short survey. It will take only a few minutes of your time, and represents a starting point for developing potential strategies for these patients. We think it is very important to have the input of specialists from different healthcare settings and countries to give a more balanced view.

Kindly complete the survey appropriate for your specialty, then please share both these links with other colleagues so we get more responses from around the world

For nephrologists:

https://www.surveymonkey.com/s/postdischAKIcare_neph

For non-nephrologists, including acute and chronic dialysis nurses:

https://www.surveymonkey.com/s/postdischAKIcare

Thank you very much for your help!

Source: Anna Frodesiak-Wikimedia Commons

Source: Anna Frodesiak-Wikimedia Commons

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Cheesecake files: Of bathtubs and kidneys

Sitting in the bathtub you notice that there is a slow leak around the plug.  You adjust the taps to maintain a flow of water that exactly counteracts the loss due to the leak; the water level stays constant.  This is called a steady state and the same thing happens with out kidneys and the molecule used to assess their function.  Our bodies generate creatinine at a constant rate which finds its way into the blood.  Under normal circumstances our kidneys excrete that creatinine into the urine at the same constant

rate.  The creatinine concentration in the blood, therefore, stays constant.  When our kidneys get injured (as they very often do in hospitalised patients) this is like plugging the leak.  Just as the water level in the bathtub would rise slowly – undetectable at first – so too does the creatinine concentration rise slowly.  It normally takes a couple of days to be noticed.  Most of my work has been about trying to detect this injury to the kidney early.  However, if the kidneys start to recover then excess creatinine is only slowly cleared from the blood by the kidney – a process that similarly can take a day or two before it is detected.  Just as not knowing if the kidneys have been harmed makes treatment and drug dosing difficult for the nephrologists and intensivists, so too is not knowing if they have recovered.  My latest publication (aka a cheesecake file) that has appeared in press presents a simple tool for the physicians to try and determine if kidney function has recovered after having been compromised.

This particular piece of work began when a St Louis Nephrologists (a kidney doc), Dr John Mellas, contacted me to say that although a manuscript of his had been rejected by reviewers, he thought there was merit and could I help him (he found me through a search of the literature).  I confessed to being one of the reviewers who had rejected the manuscript!  Fortunately, John was forgiving.  His problem was that he was called in to the intensive care unit to look at a patient with high blood creatinine concentration.  Should he put the patient on dialysis or should he wait?  If he knew if the kidney was already recovering, then he would be less likely to put on dialysis. We talked about the issue for a while and eventually settled on a possible tool which we could test by looking at the behaviour of creatinine over time in abut 500 patients in the ICU.  The tool is quite simple.  It is the ratio of the creatinine that is excreted to the creatinine that is generated.  If more creatinine is being generated than excreted then probably the kidney function is still below normal, however, if more is excreted than generated then probably the kidney is recovering.  The difficulty is that there is no way to measure in an individual what the creatinine generation is.  We ended up using equations based on age, sex, and weight to estimate creatinine generation.  This is a bit like using an equation which takes into account pipe diameter, mains water pressure, and how many turns of the screw the tap has had to determine the rate of water flow.  Creatinine excretion, though, can be easily measured by recording total urine production over several hours (we suggest 4h) and multiplying this by the concentration of creatinine in the urine.

We discovered that by using the ratio between estimated creatinine generation and creatinine excretion we were able to tell in most patients if the kidney was recovering or not.  My hope is that physicians will test this out for themselves.  The good thing is that it requires only minimal additional measurements (and costs) beyond what are already made in ICUs, yet may save many from expensive and invasive dialysis.

Pickering, J. W., & Mellas, J. (2014). A Simple Method to Detect Recovery of Glomerular Filtration Rate following Acute Kidney Injury. BioMed Research International, 2014. doi:10.1155/2014/542069

 

A day to celebrate

If it weren’t for your kidneys where would you be?

You’d be in the hospital or infirmary,

If you didn’t have two functioning kidneys.

(with apologies to John Clarke aka Fred Dagg)

Happy World Kidney Day everyone.

This blog started off life as $100 Dialysis because I believe that if we can make a computer for $100 then surely we can do the same for dialysis!  Dialysis is a life saver, yet its cost kills as so many can not afford the treatment.

There’s some good news in the dialysis world.

Schematics of the zeolite nanonfibres and how they may look in practice

Schematics of the zeolite nanonfibres and how they may look in practice

Just last week the MANA – International Centre for Materials NanoArchitectionics announced  they have developed a method to remove waste from the blood using an easy-to-produce nanofibre mesh.  Importantly, they claim it is cheap to produce.  Details were published in Biomaterials Science (free access).  Despite the photograph, there have been no human studies yet, but I expect that won’t be too long in the future.

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

In the meantime, the FDA gave approval last month for human trials of a wearable dialysis device produced by Blood Purification Technologies Inc (the WAK).

New Zealand, and Dunedin and Christchurch in particular, lead the way in Home Dialysis.  One Dunedin tradesman has even taken Home Dialysis a step further and turned it into portable dialysis by dialysing in his work van during his lunch hour. Of course, those needing a holiday may go on the road in specially equipped camper vans (http://www.kidneys.co.nz/Kidney-Disease/Holiday-Dialysis/).

Cause for celebration in the New Zealand kidney community was the gong (Office of the New Zealand Order of Merit) given to Adrian Buttimore who for 40 years managed Christchurch’s dialysis service.

These are just a few pieces of good news as doctors and scientists work around the world to improve the lives of dialysis patients.

_________________

Hot off the Press… I couldn’t resist adding this…. Pee, the answer to the world’s energy problems. http://www.bbc.com/future/story/20140312-is-pee-power-really-possible

 

Open letter for a professional association regarding impact factors

Dr John Pickering
Department of Medicine
University of Otago Christchurch
Christchurch
New Zealand
Dr Peter Kerr
Editor
Nephrology
Journal of the Asia Pacific Society of Nephrology

3 July 2013

Re:  Open letter regarding the Nephrology journal’s use of impact factors

Dear Dr Kerr

As an occasional referee for Nephrology and member of the ANZSN affiliated with the APSN I write concerning Nephrology’s use of the Thomson Reuter’s Impact Factor and the journal rankings based on them.  Specifically I urge that Nephrology remove the Impact Factor and ranking from the journal web site.  This is because the continued use of Impact Factors reflects poorly on the integrity of the journal and the APSN.  My reasons are:

(i)            Regularly when refereeing I have to ask authors to present medians and interquartile ranges rather then means and standard deviations when the distribution of the variable they are measuring is not normally distributed.  The Impact Factor is the mean of a very highly skewed distribution and, as such, it is a nonsense statistical metric.

(ii)          Rankings on the basis of the mean of a skewed distribution are similarly a nonsense metric.

(iii)         Impact Factors are open to manipulation.  See:

Nature 2013: http://blogs.nature.com/news/2013/06/new-record-66-journals-banned-for-boosting-impact-factor-with-self-citations.html

Science Feb 2012: http://www.sciencemag.org/content/335/6068/542.summary

(iv)         Professional associations have begun to recognise the inherent flaws in how research is assessed.  In particularly a world-wide movement initiated by the American Association of Cell Biology, namely the San Francisco Declaration on Research Assessment (DORA), has identified some much needed standards to maintain integrity for scientists and associated professional associations.  See http://am.ascb.org/dora/and http://www.sciencemag.org/content/340/6134/787.long

Regards,

John

cc. Dr Yasuhiko Tomino, President Asia Pacific Society of Nephrology (APSN)
Dr Rowan Walker, President Australia New Zealand Society of Nephrology (ANZSN)
Any interested party may read this letter through https://100dialysis.wordpress.com or http://sciblogs.co.nz/kidney-punch/