Community Minded

Community Minded summaries are written by ASN Community Leaders and are published weekly in the ASN In The Loop newsletter.  The summaries highlight a recent popular, controversial or other outstanding discussion in the ASN Communities.  If you are interested in writing for Community Minded, please contact Susan Willner, swillner@asn-online.org

Is there a role for low protein diets for CKD?
The Modification of Diet in Renal Disease (MDRD) results were published in 1994 as a “negative” trial but some questions still remain. Was the MDRD properly powered? Was the GFR slope outcome measure flawed? This thread reevaluates the role of protein restriction not only for slowing progression of renal disease, but also for delaying the need for dialysis through decreased uremic toxins, especially with a “plant based” diet. Did we “throw out the baby with the bath water”?


Home HD without a partner?
There are financial incentives for any home dialysis therapy. Peritoneal dialysis does not require a partner, but traditionally hemodialysis performed alone was simply considered way too risky. However, machine technology and patient monitoring have improved. What is the FDA’s stance on this? Are the conservative practices in the US the same as the rest of the world? This thread may open your eyes and open up options for your patients!  

Nephrotic syndrome in a patient with one normal sized and one small kidney
A 60-y/o man presents with edema and is found to have 9 g/d of proteinuria and a creatinine of 1.7 mg/dl. His BP was 200/100. His kidney ultrasound shows asymmetric kidneys, 11.1 and 8.5 cm in length. Several questions arise. With the HTN do you work him up for renal artery stenosis? Should he be considered having a solitary kidney from a renal biopsy risk standpoint? The proteinuria improves with BP control and some opinions are to do a serologic workup alone and just watch the patient while others think that renal artery visualization and then possible a renal biopsy are indicated. What do you think?
Summary provided by Roger Rodby, MD, MS

A 55 year old woman with Unexplained Hypokalemia: A rare disease or something she is doing to herself?
A 55-y/o woman presents with potassium levels that run 2.5 meq/l despite taking 60 meq of K a day. Her blood pressure is normal. Her renin and aldo are both very low. This lively discussion focuses on the work-up of hypokalemia and just how difficult it can be if you cannot rely on a history. Urine chemistries can help but not if you cannot be sure what the patient may or may not be taking. This case has a solution but don’t just skip to the end, follow the thread and see what you think first. 
Summary provided by Roger Rodby, MD, MS

A tough case of IgA nephropathy
A 48 y/o woman presents with HTN and a creatinine that increased from 0.9 to 2.6 mg/dl in only 7 months. A renal biopsy demonstrates IgA nephropathy with 40% of glomeruli sclerotic, 20% segmental sclerosis, 11% crescents and 6% segmental necrosis. KDIGO requires 50% crescents and rapid renal failure to consider cyclophosphamide. This patient’s IgAN has clearly been very destructive thus far. Do you follow KDIGO and give only steroids or treat more aggressively like a vasculitis? And is there a role for rituximab or plaquinil?  What would you do?
Summary provided by Roger Rodby, MD, MS


Peritoneal Dialysis in a scuba diving instructor?

A patient with CKD is approaching ESRD and is considering PD. The patient is a scuba diving instructor and thus many questions arise. What are the risks of an exit site infection in salt water v fresh water? Should special care be taken to the exit site? Should he wear a wet or dry suit? Should he drain before diving? And finally, a very interesting concern that arose in the discussion is the risk of central volume overload from the movement of fluid from the interstitial space to the intravascular space because of the increased atmospheric pressure, risking potentially disastrous pulmonary edema while underwater!
Summary provided by Roger Rodby, MD, MS


A 63 year old Woman with Hyponatremia and Polyuria
A 63-y/o woman with schizophrenia presents with seizures and a PNa of 111 meq/l. She receives 3% saline but then develops polyuria and overcorrects requiring D5W and DDAVP. Subsequent history describes a patient with polydipsia. Her Uosm was 162 mosm/kg. The discussion focuses around the topic of psychogenic polydipsia and the exact role that the degree of urinary dilution and the amount solute intake plays in the ability to excrete excessive water intake. Using oral urea to increase solute load is discussed at length, with some nice calculations showing the expected effect it will have on the BUN. Can you follow the math in this discussion?
Summary provided by Roger Rodby, MD, MS


Do Buttonholes cause more or less infections?
Buttonhole associated infections have been a topic of growing concern over the past few years.  With the utility of this technique to facilitate self-cannulation, particularly among home hemodialysis patients, discussing the pros and cons of buttonholes is especially relevant in the midst of efforts to promote home therapies.  While infection due to technique deviation has been a concern, there are other concerns including bacterial colonization of buttonhole tracts and practicality of using buttonholes for in-center dialysis.  Read this interesting thread to learn more.
Summary provided by Leslie Wong, MD, MBA, FASN


A patient with advanced CKD and a monoclonal gammopathy, do you biopsy?
A 46-y/o man presents with severe HTN, a serum creatinine of 11, a benign urine but with a urine protein/creatinine ratio of 5 g/g. Serologies unremarkable but he has a monoclonal IgG-lambda in his blood. He is also found to have new onset CHF. Is this all just malignant HTN or could he have a monoclonal gammopathy of renal significance or even amyloid?  Kidney size is 7.4 and 8.6 cm. There are very different opinions on the need for a renal biopsy as well as the safety given the patient’s HTN and CKD. What would you do?
Summary provided by Roger Rodby, MD, MS


Is the time right for CRRT, and who should provide it?
A 42-y/o man is emergently cannulated for VV ECMO for ARDS and develops oliguria. His labs after several hours reveal a BUN of 32 mg/dL and creatinine of 0.9 mg/dL. On a flow of ~ 5 L/min and 100% oxygen his pH is 7.35 and lactate is 1.8. He has made only 20 ml/hr of urine output over 5 hours. There is minimal improvement with a diuretic challenge and the patient is already 3 liters positive in fluid balance. Is it time to start him on CRRT? Should it be started now by the intensivist or can it wait until tomorrow when the nephrologist arrives. What is the evidence for starting RRT early and should this be a procedure provided exclusively by nephrologists? Read the discussion and let us know what you would have done.  

Summary provided by Rajit Basu, MD, MS


How do you treat AKI in resource-poor settings?
Medical resources are almost unlimited in developed countries. Certainly, something as “simple” as dialysis is easy to provide for patients with AKI. But what about countries where resources can be extremely limited? What options do you have? This discussion explores the options that may be available, with an attempt “to think outside the box” when it comes to these difficult clinical and socioeconomic scenarios. 

Hyponatremia in a 76 y/o man on Vasopressin for Sepsis
A 76-year-old man required vasopressin for sepsis and developed severe hyponatremia over a 3 day period. The vasopressin was discontinued, and he had an immediate water diuresis. Vasopressin has both V1 (vascular pressor) and V2 (renal ADH) activity but ADH activity with hyponatremia (as was present in this case) is very rarely seen when it is used as a pressor in the ICU setting. Read this very interesting thread for some explanation of this interesting physiology.  
Summary provided by Roger Rodby, MD, MS

Is moderately increased albuminuria in DM benign?
RASS inhibition providing renoprotection is a main component in the management of hypertensive proteinuric diabetic kidney disease. What do you do if you have a diabetic patient with low grade proteinuria but a normal BP since the seminal studies on this topic involved patients with an elevated blood pressure? How far can you extrapolate a study?  Let us know your thoughts.
Summary provided by Roger Rodby, MD, MS

HTN in a 20 Year Old with a Positive Family History for HTN
A 20-year-old has hypertension for 1 year. His father age was also found to have HTN at age 30.The patient has a normal [HCO3] and a normal [K]. Work-up thus far has shown normal renal artery Doppler studies, normal urinalysis, creatinine, renin, aldosterone and AM cortisol levels. Workup for pheochromocytoma is negative. Given the family history of HTN in his father at a such a young age as well, does the patient deserve genetic studies for an inheritable form of HTN? Not everyone agrees on the answer to that question in this Discussion
Summary provided by Roger Rodby, MD, MS

D-RTA and NSAIDS
NSAIDs and distal renal tubular acidosis? How can that be? NSAIDs are over the counter, they are inexpensive, and their use is very very common. But if they caused an RTA, how could that not be common knowledge. Well apparently, there is a link to their (oddly only ibuprofen) use, but mostly in much higher than typically prescribed doses and usually in conjunction with codeine. Is this just some odd toxicology trivia, or is this something we really should be aware of? You decide after you read this thread.
Summary provided by Roger Rodby, MD, MS

Does Internal Jugular Vein Thrombosis Need Anticoagulation?
A 62-year-old ESRD patient receives HD through a R internal jugular vein non-tunneled catheter. A bacteremia mandates the catheter removal. She receives antibiotics and the infection clears. Her AV fistula is not mature, and she needs a tunneled HD catheter. Upon placing the catheter under ultrasound, a clot is incidentally found in the IJ vein. The primary medical service wants to start heparin and warfarin. What is the role of anticoagulation for catheter related clots in the neck and arms? Do you have to anticoagulate, remove the catheter? The ASN Communities gets the experts’ opinions on this one.
Summary provided by Roger Rodby, MD, MS

IgA vasculitis
An 80-year-old develops a skin rash, abdominal pain with rectal bleeding, hematuria and AKI. A skin biopsy showed leukocytoclastic vasculitis, but immunofluorescent staining was not performed. ANCA testing is negative. He is treated with steroids alone and the rash, abdominal pain and renal function all improve. He refuses a renal biopsy. How do we go forward in treating this apparent case of HSP? The majority of the data on treating HSP comes from the pediatric literature, but HSP in adults has a worse prognosis than HSP in children. Should this change our diagnostic and therapeutic approach to adults with this presentation? What do you do when guidelines are vague? Read this discussion for some opinions on this matter.

Summary provided by Roger Rodby, MD, MS


Membranous Glomerulonephritis
The ability to test for antibodies to PLA2R in blood and on the kidney has been one of the major advancements in the diagnosis and treatment of Glomerular Diseases of the last decade if not longer. Should “primary MGN” be defined by these antibodies and if so, what does it mean if the serum tests negative but the tissue positive. And what is the role of antibodies to thrombospondin (THSD7A)? How do the results of these antibody tests influence treatment decisions? These issues and more are tackled.
Summary provided by Roger Rodby, MD, MS

Alpha-ketoanalogues to Slow Progression of CKD 4-5?
It has been almost 25 years since the Modification of Diet in Renal Disease (MDRD) results were published in the NEJM. While the MDRD was a negative trial, protein restriction may still be of value in slowing the progression of kidney disease. This is the basis for this Communities thread. The background behind the MDRD is discussed, as well as what went “wrong”. Was it truly a negative trial or did it succumb to some bad luck based on outcome measures and recruitment population?  This study will never be repeated, so we need to make the best of what we have. The practicalities of protein restriction and ketoanalogue supplementation are discussed as well. 
Summary provided by Roger Rodby, MD, MS

Lithium, Bipolar Disorder & Hypercalcemia
A patient on long-term lithium (Li) for bipolar disorder develops hypercalcemia (11 mg/dl). The PTH is mildly elevated and this is most likely related to Li use. While other drugs have been used to replace Li in patients with psychiatric disorders in which one of the many renal complications of Li occurs, this patient is very resistant to trying an alternative. What is the mechanism of Li induced hypercalcemia? What work-up is required and just how concerning is this Ca level in the context of its etiology?  Does it even need “treatment”? ASN Communities offers expert opinions in this interesting thread.  How would you approach this patient?
Summary provided by Roger Rodby, MD, MS


Contraception in CKD
What is the role of contraception discussions for women with CKD? What are the risks of pregnancy in CKD, and are some of these risks disease dependent that may dictate just what form of contraception may be preferred? How much does CKD affect fertility and should they be aware of that so that they do not delay trying to get pregnant as their CKD may progress and affect fertility even further. These topics are often an overlooked. What is your practice
Summary provided by Roger Rodby, MD, MS

Sodium Bicarbonate in Respiratory Acidosis
What should you do with a patient with a moderately severe mixed metabolic and respiratory acidosis that needs dialysis? What are the acid base concerns related to the treatment? What is the physiology behind these concerns? This discussion gets to the basics of buffer function as well as CO2 production and excretion. It is never a bad time to review basic physiological principles. If they were easy everyone could be a nephrologist!
Summary provided by Roger Rodby, MD, MS


AA Amyloidosis with Crescents in Rheumatoid Arthritis Patient
Adding insult to injury, AA amyloidosis is a devastating complication that may appear after years of a similarly devasting chronic inflammatory illness. Add crescentic GN to this mix and you really have yourself a real diagnostic and therapeutic quandary. Are these two independent glomerular processes? Either way, what are the options for treating AA amyloid in RA whether the crescents are related or not? The pros opine in this illuminating discussion.  How do you treat your patients with these conditions?
Summary provided by Roger Rodby, MD, MS


RRT for Patient with Cerebral Aneurysm
A 63-year-old female presents with an intracranial hemorrhage (with subdural and intraventricular extension and a saccular aneurysm) is found to have renal failure from previously undiagnosed polycystic kidney disease and requires renal replacement therapy (RRT). Concerns about RRT induced acute blood pressure changes or disequilibrium syndrome bring up the discussion of what is the safest method of RRT to minimize the risk of cerebral hypoperfusion or cerebral edema: CRRT, gentle hemodialysis, or even peritoneal dialysis. The pros and cons of each of these options are discussed in this interesting thread.
Summary provided by Roger Rodby, MD, MS

Organ Donor Pool
With the expanding list of patients requiring kidney transplants, there is acknowledgement by the medical community that we have yet to identify the most optimal way of allocating/utilizing many of our donor organs.  The discard rate is unacceptably high.  In 2013, OPTN/UNOS revised existing policies for Public Health Service’s increased risk (PHS-IR) donors and nucleic acid testing (NAT) helped identify which PHS-IR donors were at highest risk for transmission of hepatitis B, C and HIV.  Underutilization of these organs continues.  Use of high KDPI kidney­­s and better distribution of available kidneys remain two areas in need of improvement.  Identifying ways to more effectively utilize and distribute these resources remains a goal of the transplant community.  Read the thread to learn more and comment about these ideas.  
Summary provided by Mark Lerman, MD


Post Parathyroidectomy Hospital Stay
A simple question is posed: “Do patients get discharged on the same day or stay for several days after the surgery?  What is your protocol?  How long do patients usually stay as an inpatient?” This is an important question because many patients develop “Hungry Bone Syndrome (HBS) following parathyroidectomy for severe secondary or tertiary hyperparathyroidism. It is important to appreciate that HBS can be a dangerous but accepted immediate or delayed outcome of parathyroidectomy. Risk factors, natural history, and treatment options for HBS, and proposes strategies that may even be used to prevent this disorder are discussed in length. Opinions span the globe from West Virginia to Singapore.
Summary provided by Roger Rodby, MD, MS


Dialysis Decisions in Pregnancy Pre-ESRD
We recently had two dialysis-in-pregnancy posts: “Pregnant Transplant Patient with Poor Renal Function” and “Pregnant Patient With CKD 4”. Clear guidelines exist on managing the rare ESRD pregnant patient, but there is less known about how to manage pre-ESRD CKD and pregnancy. In the former, renal replacement therapy (RRT) is increased to target a weekly KT/V as high as 6-8 and a BUN as low as <20 mg/dl. But when do you start RRT on a non-ESRD CKD pregnant patient, and given that for any level of BUN and creatinine, that patient should healthier than an anuric patient on dialysis, should the BUN target be different? These important questions are pondered in these posts.
Summary provided by Roger Rodby, MD, MS


Natural History of AKI
Acute kidney injury – how good are nephrologists in predicting AKI recovery, and how long is it going to take until the recovery process is complete? Does it continue to improve in some cases over a year or more? Is delayed recovery from AKI now being increasingly recognized? Many outpatient dialysis facilities are now excepting patients with acute kidney injury that are dialysis dependent. Is delayed recovery in these patients being missed? What is the impact of different drug regimens?  Do you know the baseline kidney function prior to AKI? What additional research is needed? Join the conversation to learn how your peers answered these questions and to tell us how you would answer them.
Summary provided by Mark Lerman, MD, FASN

Hypertensive Donors
An otherwise healthy 34-year-old man wants to donate a kidney. He has HTN for 2 years only, and is controlled (127/87 as measured using ABPM) with only perindopril 4 mg/day. His BMI is 23 kg/m2, he has no proteinuria and his creatinine is 0.95. He has no target organ damage. Should he be considered for donation? What are the risks of mild HTN on a solitary kidney going forward knowing he should have many years of life ahead of him. Can “do no harm” go too far? The experts do not agree with each other on this ethical and medical dilemma. What is your opinion
Summary provided by Roger Rodby, MD, MS

ARBs and Lung Cancer
RAAS inhibitor use (ACEi and ARBs) is fairly ubiquitous in cardiology, nephrology and general medicine. Over the last year we have seen FDA warnings on three different generic ARBs finding trace amounts of various carcinogens in them. We hear about one, and change our patient to a different ARB, only to find that it later is also reported to contain a carcinogen! And around the same time a report comes out linking ACEi use to lung cancer. What do we make of these issues? Is this prudent information we should act on or “Chicken Little”? You will need to form your own opinion and approach as the Discussants struggle with this dilemma.  What approach(es) have you taken?
Summary provided by Roger Rodby, MD, MS

What Degree of Hemodynamic Instability Will Preclude Even CRRT
The question posed “What degree of hemodynamic instability will preclude even CRRT”? Realizing that CRRT was developed precisely for patients too unstable for intermittent hemodialysis, some patients still seem too hemodynamically tenuous to tolerate any form of RRT.  What are the considerations that give us concern about isovolemic CRRT in these most unstable patients? Are these concerns warranted? Is there a point of futility? What is the role of PD in AKI and what are the special considerations that may make it less or more desirable means of RRT in this setting? Hopefully this discussion will illuminate your management or at least stimulate thought about this ICU AKI unstable patient population. 
Summary provided by Roger Rodby, MD, MS

Advising Junior Faculty on How to Publish
Junior faculty who are not involved in research are often challenged to get their work published.   It’s not just that they are unknown but they don’t know how to approach the process.  To which journal should they submit their case reports, reviews, or quality improvement projects?  How should they start and on what topic? How can they learn from rejection letters? What skills must be mastered to become an effective scientific writer?  The discussion participants, all from different stages in their careers and all of whom have published, have offered some terrific feedback that anybody looking to publish should read.  It’s not too late to join the conversation in the Career Advancement Community and add your recommendations and feedback.
Summary provided by Kambiz Kalantari, MD, MS

Foamy Urine
We are all taught that “foamy urine” is classic for nephrotic syndrome. But just how specific is foamy urine for predicting proteinuria? Is proteinuria alone enough or do you need accompanying lipiduria? And how does proteinuria cause foamy urine in the first place? Is foamy urine different than urine with bubbles? This Discussion delves into this interesting and perhaps whimsical topic. Read it if for no other reason than to learn some trivia on what makes beer foam.
Summary provided by Roger Rodby MD, FACP, FASN

Supporting the Mission
Studies have indicated that how we deliver nephrology education may improve interest in nephrology as a future career for trainees.  Kidney educators are reviewing and evaluating new and unique methods for teaching and sharing of information.   Do different tools lend themselves to different specialties or disease conditions like Acid Base and Electrolyte issues?  What is the role of social media in training?  Do Concept Maps work? Are small group learning sessions effective?  Should educators consider the development of a nephrology toolbox that would contain unique tips and techniques?  Are Flipped Classrooms the answer?  Read the thread to learn more about these and other ideas. What innovative ideas have you implemented, or would you recommend?

Summary provided by Anna Burgner, MD 

Puzzling Hyponatremia
A 72 year old man with a history of a pituitary tumor presents with seizures and a serum Na of 125 meq/l. He appeared hypovolemic and his UNa was <20 meq/l. He was given normal saline, and his PNa increased to 130 meq/l, but his UNa remained <20 and he developed edema. He was subsequently found to have hypopituitary hypocortisolism. He was given hydrocortisone alone and his PNa eventually normalized. The discussion focused on how hypocortisolism can cause hyponatremia and it being a SIADH like syndrome, realizing the difficulties in this diagnosis when the patient initially developed edema as he was clearly in a Na and Water retaining state, something that would rule out SIADH. The discussants expressed their own ideas on whether or not the hyponatremia seen in hypoadrenalism qualifies as a form of SIADH, or has its own pathophysiology. Is this just a matter of semantics? Read the thread and form your own opinion.
Summary provided by Roger Rodby MD, FACP, FASN

Uncontrolled Blood Pressure in HD Patient
A 45 year old male on hemodialysis has uncontrolled blood pressure despite seven blood pressure medications to the point that he requires frequent admissions to the intensive care unit. Medication compliance is not the issue since he takes these medications when admitted but usually ends up requiring an IV nicardipine drip to control his blood pressure. What is the cause of “resistant” hypertension in this patient and the many just like him? Is there a role for bilateral nephectomy or vascular radio frequency ablation? Is this simply a volume issue and if so what is the best approach to get him to a lower dry weight? Is there a role for online hematocrit monitors, IVC diameter measurements, fluid status by bioempedance measurements, BNP levels and low sodium dialysates. This discussion is strengthened by being full of opinions and experiences from nephrologists that have been practicing for many decades.  
Summary provided by Roger Rodby MD, FACP, FASN

Calciphylaxis in PD Patient
A 68 year old female with ESRD on peritoneal dialysis (PD) develops calciphylaxis (calcemic uremic arteriopathy CUA). She is poorly compliant with any attempts at medical treatment for her CUA. The treating doctors want to give her sodium thiosulfate (STS). But while STS is typically given intravenously after hemodialysis (HD) to patients before they leave the HD unit, STS administration is a patient receiving PD is logistically very different. Should the patient be temporarily converted to HD specifically for STS treatment? Can STS be given intra-peritoneally and if so how often and at what dose? Can it be given orally? Very different opinions and experiences are expressed in this international discussion.  
Summary provided by Roger Rodby MD, FACP, FASN

Proteinuria/Nephrotic Syndrome in Pregnancy
A 30 year old woman develops progressive proteinuria in the third trimester of an otherwise uncomplicated pregnancy. Her blood pressure and renal function are normal and she has no edema. Many questions arise. Should a biopsy be done? Should she be delivered early? What blood tests should be done? Are diuretics safe? Is an empiric trial of steroids indicated? Should she be anticoagulated? Could this be preeclampsia? How should we define hypertension in pregnancy since so much weighs on this finding. Will we someday be measuring sFlt and PIGF ratios to help us with that diagnosis and will we have targeted therapies to make that ratio more favorable for a successful term pregnancy? Many questions are proposed and many differing opinions abound in this lively discussion. 
Summary provided by Roger Rodby MD, FACP, FASN

Tubulointerstitial Nephritis in a Young Patient

A 19 year old woman presents with hypertension and CKD. Her urinalysis is entirely normal and her kidneys are slightly echogenic. A renal biopsy has only 3 glomeruli, 2 of which are globally sclerosed, and there is extensive acute and chronic interstitial inflammation. What has caused this severe renal disease in such a young woman? Can hypertension alone explain these findings? What other work-up should be considered? Should genetic testing be done for autosomal dominant interstitial nephritis or nephronophthisis? Should she receive an empiric trial of steroids? Is there a role for another biopsy? Read the thread to see what the discussants decide. 
Summary provided by Roger Rodby MD, FACP, FASN