Ten Things Every Primary Care Physician Should Know

An article from a few years ago that might provoke some discussion. Some of the recommendations are a little out of date (I don't think I would target a Hb of 12 anymore in patients with CKD) but overall it seems like good advice.

The Top 10 Things Nephrologists Wish Every Primary Physician Knew

1. A "normal" serum creatinine level may not be normal.
2. Know the medications that spuriously raise the serum creatinine.
3. Patients with decreased GFR or proteinuria should be evaluated to determine the cause; positive urine dipstick results for protein should be followed up with a spot urine protein/creatinine ratio.
4.  In patients with early-stage CKD, periodic evaluation and intervention are appropriate to slow the progression of renal disease and avoid complications.
5. Do not automatically discontinue an ACEi or ARB solely because of a small increase in serum creatinine or potassium.
6. Anemia in patients with CKD should be treated with ESAs but should not be over-treated.
7. Phosphate-containing bowel preparation should be used with caution
8. Patients with CKD should avoid magnesium or aluminum-containing oral preparation. Concomitant use of citrate-containing preparations and aluminum-containing oral preparation is hazardous because it can lead to acute aluminum toxicity
9. Although most patients with hypertension should not be screened for secondary hypertension, certain clinical clues may suggest the presence of an underlying cause that, when addressed, may resolve or improve the patient's hypertension
10. In patients with recurrent stone disease, an in depth metabolic evaluation is needed to identify and treat modifiable risk factors, thereby preventing further episodes and/or promoting stone dissolution

I don't see much to disagree with on this list - I might not put the knowledge that bactrim and cimetidine increase creatinine so high on the list. I particularly like number 10 - most patients with recurrent stone disease are unaware that more than 95% of stone recurrences can be prevented with proper medical therapy.

With regard to number 8, although we don't really use aluminum-containing phosphate binders any more, it is still contained in some over-the-counter antacids. Citrate markedly increases the absorption of aluminum from the bowel and in patients with CKD, this has been associated with severe toxicity and death in one case series.

Are there any other things that we should add to this list?

Origins of Renal Physiology

Every year we like to publicize the MDIBL origins of renal physiology course. This is a great opportunity for renal fellows and the fact that it is free apart from transportation costs is a huge bonus. This is a message from the course director:

NATIONAL COURSE FOR RENAL FELLOWS: ORIGINS OF RENAL PHYSIOLOGY

THE ASN-Affiliated and NIH sponsored NATIONAL COURSE FOR RENAL FELLOWS: ORIGINS OF RENAL PHYSIOLOGY course welcomes applications from renal fellows.  The one week course (8/31/13 - 9/7/13) provides an intensive hands on laboratory experience which teaches classical physiology coupled to modern cell and systems biology.  The perspectives the course develops are ideally suited both to renal fellows who seek a career in investigation, as well as renal fellows who plan on a career as clinicians or clinician educators.

The course has received absolutely outstanding reviews from all of its trainees, over the past 7 years.  With generous NIH support, the course is offered tuition free, and room and board at the seaside Mount Desert Island Laboratories are also free.  The only cost is transportation to and from Boston; course organizers will help get all trainees between Boston and Maine.

To apply, go to the course website at:  http://www.mdibl.org/courses/Origins_of_Renal_Physiology_Renal_Fellows/114/

We look forward to seeing you there!

All the best,

Mark L. Zeidel, M.D.
Course Director

New Opportunity for Future Nephrologists

The ASN has out together this video announcing a new initiative to attract trainees to nephrology early in their careers. This would involve sponsoring medical students to attend the week-long origins of renal physiology course in Bar Harbor, a free membership of the ASN with access to travel grants for the annual meeting and pairing the student with a nephrology mentor.

I think that this is a great idea and suggest that if you are an interested student, or know some potential recruits, pass this video on to them.

Keeping up with the Neighbours

These days, the proliferation of medical journals makes it difficult to keep up with all the changes in our field. There are a number of means that people employ to manage their reading. I personally use google reader and follow all the major renal journals. Another resource that I find useful is Nephrology Now which aggregates some of the more important papers recently published in the field.

One suggestion from Nephrology Now last week was an ipad/iphone application called "Read". This application allows you to follow selected journals but will also pull out articles of interest from journals that you are not necessarily following if they align with your interests. It also allows you to directly search pubmed from within the app, save searches and, if it is freely available, download the pdf of the paper that you are interested in. Best of all, this is free.

I would appreciate any further suggestions from readers regarding ways to stay current.

Lupus Foundation of America Grant

The Lupus Foundation of America is proud to announce its new Career Development Award RFA. The purpose is to facilitate the professional development of nephrology, dermatology, and rheumatology fellows, in the U.S. and Canada, interested in lupus research towards a career as an independent clinician-scientist at an academic, medical, or research institution, with a research program having considerable focus on the investigation of basic, clinical, translational, behavioral, or epidemiological lupus research.  

To be eligible, applicants must hold an M.D. (or equivalent) from an accredited institution, be a U.S. citizen or legal resident of the U.S. or Canada at the time of application submission, be a first or second year Fellow in an adult or pediatric fellowship program in rheumatology, nephrology, or dermatology accredited by either the American Council on Graduate Medical Education (in the U.S.) or Royal College of Physicians and Surgeons (in Canada).

There is no Letter of Intent. The application deadline is March 29, 2013 and the earliest funding notification is May 10, 2013. The award is for $70,000 (with the possibility of a 1-year renewal) and can be used for salary and/or research, but certain restrictions apply. In addition, awardees of specific grant mechanisms are ineligible. Please see the RFA for complete details.

You can find the Career Development Award RFA at http://www.lupus.org/rfa.

Conference Review: Home Dialysis University

It doesn't take much to get me to take a trip to San Diego so when the opportunity came up to attend this year's Home Dialysis University conference I booked my flight.  Having lived in San Diego for many years prior to moving to the Bay Area I took the opportunity to both check out this great conference and stay and visit with old friends.

The conference (formerly known as Peritoneal Dialysis University) now has significant content going over home hemodialysis therapies with much of this being delivered by Brent Miller who was one of the FHN daily investigators and part of the ongoing FREEDOM study.

The conference registration and up to $350 in hotel and travel are covered for fellows by a grant from the International Society of Peritoneal Dialysis.  The conference and accommodations were at the Westgate Hotel in the Gaslamp district.  Great location and high marks for tasty breakfast, lunch and frequent snacks (all at no additional cost!)

Conference size was small, under 20 people so lots of opportunity to interact with the faculty and other attendees. Also a short conference, one full day and two half days.

John Burkart from Wake Forest gives a great lecture on how PD and HD work in terms of small and other solute clearance and reviews the uses and limitations of Kt/V.  He also gives a very practical lecture on the financial considerations related to home dialysis.  Anjali Saxena (one of my attendings who is the PD director down at the Stanford affiliated Santa Clara Valley Medical Center) covers PD access issues, the challenges that face the long-term PD patient and the infrastructure requirements for starting your own home unit.  Joanne Bargman from Toronto does some great case based discussions surrounding commonly encountered PD issues.

One of the highlights is the hands-on demonstration session were home dialysis RNs actually do a walk through with a PD cycler and a NxStage machine. Very informative.

An area where many fellows unfortunately have limited exposure is the nuances of the dialysis prescription writing for the NxStage system.  Brent Miller gives a really nice talk going over the details of this.  Lots of nice compare and contrast examples to conventional HD to put things in a more familiar context.

At least as of this writing, they haven't announced when the 2013 fellows conferences are going to be held so stay tuned to their website for dates.  In past years they've had sessions in several locations on several different dates so hopefully you'll find something that will fit your schedule.

I again tried my best to keep up a solid twitter feed of interesting points for RFN which you can find here with all the tweets indexed under #HomeDialysisU.

Career Choice for Nephrology Fellows

This month's eJournal Club article is not a traditional, clinical or basic research article but instead one which looks into the state of nephrology training in the US. There has been a significant decline in the number of residents applying for nephrology fellowships over the last 10 years and this has naturally caused some concern for the powers that be. More than half of nephrology trainees are now foreign medical graduates (including yours truly) and a committee has been set up by the ASN to explore means of increasing interest in nephrology careers among trainees and medical students. This article reports the results of a survey of nephrology fellows that was completed over the last 2 years.

The article highlights the importance of early mentoring in the decision to pursue a nephrology career. The second most important factor was interest in nephrology as a subject. I sometimes feel that the way that nephrology is presented to students means that they feel that it is too complicated and difficult and it puts them off. It is important for us to highlight the diversity of opportunities that are available in nephrology.

One good thing to mention is that most fellows who were surveyed were happy with their career choice. Only 7.5% of people for whom nephrology was their first choice regretted their decision. The number was higher for those for whom it was a second choice. Hopefully, the results of this survey will be utilized to try and identify areas to focus on to increase interest in nephrology again. We have a great specialty and we should let people know!

The discussion continues at CJASN.