New NephSAP Download Available

As I previously wrote....

I love NephSAP as much as the next nephrologist. I think the ASN does a great job and the booklets are phenomenal. That said, I can't make it through more than 5 minutes of the audio versions of NephSAP's. I feel they are absolutely brutal to listen all the way through.

I much prefer and recommend the print version.. unless you suffer from debilitating insomnia and are all out of Ambien.

Nevertheless, the latest installment is available: Volume 8, Number 6 - Transplantation

Enjoy

FDA Warns About Byetta Induced Renal Failure

FDA has notified healthcare professionals of revisions to the prescribing information for Byetta (exenatide) to include information on post-marketing reports of altered kidney function, including acute renal failure and insufficiency. 

From April 2005 through October 2008, FDA received 78 cases of altered kidney function (62 cases of acute renal failure and 16 cases of renal insufficiency), in patients using Byetta. The report states that, "Some cases occurred in patients with pre-existing kidney disease or in patients with one or more risk factors for developing kidney problems". However, as we know everyone who would be on Byetta has diabetes and thus inherently has at least one risk factor for CKD.

The labeling changes include:

• Information regarding post-market reports of acute renal failure and insufficiency, highlighting that Byetta should not be used in patients with severe renal impairment (creatinine clearance <30 ml/min) or end-stage renal disease.
• Recommendations to healthcare professionals that caution should be applied when initiating or increasing doses of Byetta from 5 mcg to 10 mcg in patients with moderate renal impairment (creatinine clearance 30 to 50 ml/min).
• Recommendations that healthcare professionals monitor patients carefully for the development of kidney dysfunction, and evaluate the continued need for Byetta if kidney dysfunction is suspected while using the product.
• Information about kidney dysfunction in the patient Medication Guide to help patients understand the benefits and potential risks associated with Byetta.

Cross off another diabetes medication for patients with advanced CKD....

High Fructose Linked to Hypertension

More from Renal Week in San Diego....

Lead investigator Diana I. Jalal, MD, assistant professor of renal medicine at the University of Colorado Health Sciences Center in Aurora and her colleagues used the NHANES data to evaluate median fructose intake from food high in added sugar, including bakery products, dairy desserts, chocolate and other candy, dried fruits, honeys, jams, jellies, syrups, and sugar-sweetened soft drinks (these soft drink account for 33-40% of fructose consumption in the USA as per Dr Jalal).

An analysis of data from more than 4500 NHANES participants  showed that consuming 74 grams or more of fructose per day  (equivalent to about 2.5 cans of 12-ounce sugary soda) correlated significantly with hypertension. Those with the high intake of fructose had a 28% increased risk for blood pressure of 135/85 mm Hg or higher, a 36% increased risk for blood pressure of 140/90 mm Hg or higher, and an 87% increased risk for blood pressure of 160/100 mm Hg or higher.

The relation was seen only between systolic blood pressure and fructose intake, Dr. Jalal said. There was no correlation between fructose consumption and diastolic blood pressure. Again, this is an observational report and further studies are indicated. Nevertheless, whether a strong link to hypertension is proven or not,  I think it is safe to recommend a diet of low fructose intake to everyone.

Low Vitamin D and CKD link?

Another report coming out of ASN's Renal Week details the possible link between low levels of Vitamin D in African Americans to their higher incidence of ESRD.

Michal L. Melamed, MD, MHS, associate professor of medicine and epidemiology at Albert Einstein College of Medicine in the Bronx, New York, and her coauthors analyzed data from 13,328 participants in the National Health and Nutrition Examination Survey (NHANES) III Follow-Up Study, in which 25(OH)D levels were measured from 1988 through 1994, and then participants were followed for up to 12 years. Serum 25(OH)D deficiency was defined as anything below 15 ng/mL.

After adjustment for clinical, demographic, and socioeconomic factors, the incidence of ESRD was 2.6 times greater in people whose serum 25(OH)D was less than 15 ng/mL than in those with higher levels. When the investigators adjusted for clinical covariates other than 25(OH)D, the risk of developing ESRD was 2.83 times higher among the black than among the white participants. Adjusting for ESRD reduced the risk by 58%, leading the authors to conclude that low serum 25(OH)D levels might account for a significant proportion of the ESRD risk experienced by the black participants.

Before putting everyone on 400- 1000 IU Vitamin D to prevent ESRD, we must understand this is an observational study and must be interpreted as such. Whether there is an association or a cause - effect relationship is as of yet, unknown.

Lasix Linked to Secondary Hyperparathyroidism

Another interesting paper coming out of ASN this week seems to propose a link between the loop diuretic (Lasix) and secondary hyperparathyroidism. Tamara Isakova, MD, a research fellow at Massachusetts General Hospital in Boston, and her colleagues believe the calciuresis caused by Lasix may stimulate PTH. Accordingly, thiazide type diuretics do not exhibit such a relationship.

The researchers conducted a cross-sectional study of 3,612 subjects. Median PTH levels were almost twice as high in patients taking loop diuretics than in controls (81 vs. 44 pg/mL). After adjusting for age, race, BMI, BP, diabetes, and estimated glomerular filtration rate, subjects on loop diuretics had a 2.4 times increased risk of secondary hyperparathyroidism (PTH of 65 pg/mL or higher).

It must be said that these papers coming out of ASN are not published in peer reviewed journals and scrutinized to the same degree..  but, nevertheless it is an interesting hypothesis.

Hurray For the Young Nephrologists

I think (and hope) I can still be called a young nephrologist although, it is somewhat subjective and the clock is ticking. If not, I take exception to this erroneous study. Anyway, a nice paper was just presented at the ASN meeting in San Diego claiming younger nephrologists tend to send there patients for renal transplantation preemptively more frequently than the more senior nephrologists.

As reported in Renal Business Today : "The investigators found that doctors closer to completion of medical school were significantly more likely to refer their CKD patients in time for preemptive transplantation. It is conceivable that the reason for this finding is that younger physicians are more likely to have learned about the benefits of preemptive kidney transplantation during their education. Hence they might be more prone to refer CKD early in their disease process, the authors concluded".

Bodybuilding with Anabolic Steroids Causes Kidney Disease

According to a paper being presented at the American Society of Nephrology’s 42nd Annual Meeting and Scientific Exposition in San Diego bodybuilding supplemented by anabolic steroid usage can lead to kidney damage.

The researchers seem to believe that extreme increases in muscle mass require the kidneys to increase their filtration rate, placing harmful levels of stress on these organs. It may also be likely that anabolic steroids have direct toxic effects on the kidneys. “Athletes who use anabolic steroids and the doctors caring for them need to be aware of the potentially serious risks to the kidney,” said Leal Herlitz, MD, of Columbia University Medical Center.

Dr Herlitz and her colleagues recently conducted the first study describing injury to the kidneys following long-term abuse of anabolic steroids. The investigators studied a group of 10 bodybuilders who used steroids for many years and developed protein leakage into the urine and severe reductions in kidney function. Kidney tests revealed that nine of the ten bodybuilders developed a condition called focal segmental glomerulosclerosis, a type of scarring within the kidneys.

Although there has been a general feeling anabolic steroid use to increase muscle mass and strength has many deleterious effects, the link to kidney disease has been quite flimsy. This study seems to have strengthen the argument.

Urea Kinetics Website Launch

Introducing a new website: UreaKinetics.org
Taken from the website: "The purpose of ureakinetics.org is, first of all, to provide a home for Solute-Solver and related programs linked to urea kinetics and adequacy of hemodialysis. The site was begun and is maintained by Dr. John Daugirdas, a nephrologist from Chicago. Anyone is welcome to comment in the Forum section, about either Solute-Solver or other questions relating to hemodialysis adequacy."

Petition For Every Other Day Dialysis

To:  Congressional Kidney Caucus
 
We, the undersigned, ask the Congressional Kidney Caucus to advocate for the Centers for Medicare and Medicaid Services (CMS) to increase the number of routinely reimbursed hemodialysis treatments from three per week (156/year) to every other day (183/year).

We are people on dialysis, care partners, health professionals, family, and friends. Dialysis is not the end of life, but can and should be a new beginning. We believe that so-called “adequate dialysis” (three short treatments per week) merely allows people who need dialysis to hang onto life unproductively--in essence, many are prevented from living the life they were meant to live. This need not be the case! Research has proven that more treatments mean healthier lives, fewer hospitalizations, longer survival, increased productivity, and less overall cost to the healthcare system for people on dialysis.

The U.S has the worst dialysis outcomes of any industrialized nation. Supporting every other day treatments will allow those managing their illness with conventional hemodialysis to avoid the ‘long weekend’ with no treatment—which many studies have shown triples the risk of sudden death from a heart attack. Even this won’t allow the U.S. to catch up; that won’t happen until longer and more frequent treatments are made more widely available. But it’s a start! Please give this vital change your support!

Sincerely,
The Undersigned

Click here to sign the petition. I am #2162.  

Decline in Functional Status Seen in Nursing Home Patients After Dialysis

Nursing home residents with requiring renal replacement therapy with hemodialysis suffered "substantial and sustained" declines in functional status after the initiation of therapy, according to a New England Journal of Medicine study.

The authors of the study point out that because there was no control group, they could not conclude that dialysis caused the observed functional decline. This was a retrospective look at 3702 nursing home residents starting hemodialysis between 1998 and 2000 who had at least one measurement of functional status prior to the initiation of dialysis.

The editorialists write: "Prior to the initiation of dialysis, elderly patients must be informed about its modest benefit in their age group and the possibility of conservative therapy that does not involve dialysis." So, although dialysis will prolong life in this patient population it does not seem to lead to an improvement in functional status we would have hoped to have seen.