This is a Satellite Symposium from ASN 2000 in Toronto. The focus is on cost-effectiveness and economic issues relating
to anemia management. Dr. James Kaufmann, the spiritus movens behind the VA Cooperative EPO Trial, discusses the
pharmacokinetics and economics, as well as practical issues relating to SC vs. IV erythropoietin administration. Dr.
Wish covers EPO resistance, and presents new data suggesting relative EPO resistance in patients with certain forms of
vascular access. Dr. Golper describes a number of new forms of erythropoietic substances that will be coming on the
market in the next several years, including forms of depot-erythropoietin, small EPO-like peptides, and a new form of
erythropoietin that may be marketed by Aventis (the company that supported this satellite symposium), which is made by
a method different from that used by Amgen, but which apparently results in a very similar product. Some legal patent
issues remain to be settled among the various companies attempting to enter this field. Finally, Dr. Aronoff presents a
very interesting discussion on how changes in HCFA reimbursement strategies for EPO appeared to drive changes in
erythropoeitin usage. For those interested in economic issues involved in running a dialysis unit, and how
erythropoietin can impact the income of a dialysis unit, the talk by Dr. Aronoff presents information that is rarely
available from other sources.
This is from the ASN Renal Week series of talks given at Toronto in October of 2000. Dr. Appel begins by discussing HIV
nephropathy. He covers pathology (different in African Americans vs. Europeans) with special emphasis on pathology in
the case of co-infection with HCV. Dr. Appel discusses hyper-echogenicity, tubular microcysts, collapsing GN,
tubuloreticular inclusions, and lupus-like and IGA-containing variants. He then moves on to therapeutic approaches, and
covers HAART, ACE inhibition, and prednisone therapy. He then covers renal disease associated with hepatitis B virus
infection and approaches to treatment. In the final part of the talk, HCV infection is discussed, and results with
interferon and ribavirin therapy are presented, and the role of cyclosphosphamide therapy is analyzed.
This is the second of five or six talks that HDCN will be posting from the ASN 2000 Board Review Course that was held in
San Francisco in September. In a 3-part talk, Dr. Alpern begins by discussing how potassium is handled in the nephron,
with an emphasis on the role of distal (cortical collecting duct) events as mediated by mineralocorticoid action as well
as by distal sodium delivery. Then he discusses in detail the approach to the work-up of a patient with hypokalemia. A
detailed analysis of Bartter's and Gitelman's syndrome is included, including the latest findings from molecular
biology. In part three, the approach to hyperkalemia is described.
This FREE ZONE lecture series was given as a Satellite Symposium at ASN in Toronto. The symposium includes Dr.
Fishbane's overview and introduction, plus four lectures. Dr. Jay Wish gives an update of the latest K-DOQI guidelines
pertaining to iron replacement in anemia management. Dr. Seligman and Dr. Eschbach present data regarding iron kinetics
and safety when sodium ferric gluconate is given by slow IV push as opposed to a slow infusion at the end of dialysis.
These are new Phase IV study results. Dr. Seligman's data has to do with the extent of transferrin saturation and free
iron in the minutes to hours after a slow IV push dose of sodium ferric gluconate. Dr. Eschbach discusses a new safety
analysis of the slow IV push approach to giving sodium ferric gluconate. Because the actual data was presented at the
ASN a day or two after this scheduled symposium, only blinded data were presented. The abstract reporting the
unblinded study results can be found at the ASN website (search under Eschbach, A1313). Finally, Dr. Nissenson
completes the presentations with a discussion of the optimal approach to iron therapy based on recent data.
If you want CME credits, you can get them via this web-based educational program. Simply print out the evaluation and
post-test forms from the appropriate link page, and send the completed forms to Medical Education Resources, the CME
sponsor of this symposium. They will send you a certificate, assuming you answered a sufficient number of the post-test
questions correctly and have completed the evaluation form.
This talk was given to fellows at Renal Week as part of the ASN 2000 Annual Scientific Meeting. It is not the much
longer and more detailed lecture given by Dr. Platt at the plenary session. Dr. Platt begins by making a case why
xenotransplantation is necessary, and why pigs are a reasonable candidate donor animal. He then goes through hyperacute
rejection, acute vascular rejection, and cellular rejection, and discusses how each problem in turn is being resolved
with xenografts. He also discusses concerns that PERV, porcine endogenous retrovirus, may theoretically be transmitted
to humans along with porcine xenografts.
This is the third of many ASN 2000 talks, this one from a symposium on daily hemodialysis. Dr. Depner discusses the
basic principles of uremic toxins and urea kinetics, and then describes new measures of dialysis adequacy that can be
used in situations where dialysis therapy is given more than 3x/week. The talk includes a discussion of the Casino-
Lopez equivalent renal clearance (EKR), and the Gotch standard Kt/V.
This marks the beginning of a patient-education project organized by HDCN. In the past, we have placed on HDCN a number
of lectures that were actually given to a patient audience, but which the editorial board of HDCN believed might also be
appropriate for medical professionals. These included the excellent series on Proteinuria/Nephrotic Syndrome, on
Hemolytic Uremic Syndrome, and on IgA Nephropathy organized by Dr. Ron Hogg. Other patient oriented lectures on HDCN
are those sponsored by the Polycystic Kidney Research Foundation (see the
FREE ZONE INDEX for hyperlinks to these particular symposia). Nevertheless, we wanted to start something more
specifically for patients. Accordingly, we have set up a new site called Doc-To-
Me.
The initial content for this site is now posted. The material consists of a series of 8 lectures given to a patient
audience at Toronto in October after the ASN meeting. The focus of these initial lectures was pre-ESRD, as we believed
that this area was somewhat underserviced. Dr. Mendelssohn, who runs a pre-ESRD clinic at St. Michael's Hospital in
Toronto, starts off by talking about a comprehensive approach to reduce the rate of renal progression. Dr. Eli Friedman
discusses the key aspects of the care of diabetic patients with kidney disease. Dr. Adrian Fine talks about protein
restriction and its role in kidney disease. Dr. Adeera Levin discusses anemia. Dr. Jill Lindberg reviews bone disease.
Dr. Robert Toto shares new findings suggesting the benefits of a lower target blood pressure in renal patients. The
last two talks, by Dr. Peter Blake and Dr. Tom Peters focus on modality choice, with Dr. Blake discussing options
available in terms of dialysis, and Dr. Peters talking candidly about the transplantation option. The generous support
of Dialysis Clinic, Inc. in making this symposium possible is gratefully acknowledged.
Password access to Doc-To-Me talks: Your FREE ZONE or KEY ZONE login ID and password will work to enter the
Doc-To-Me site. In addition, a separate registration for Doc-To-Me content only has been set up. All material on the
Doc-To-Me site will be available free of charge.
This is the second of many talks that we will be posting from the October 2000 meeting of the ASN. Dr. George Aronoff
first describes the scope of the problem - 25% US adults hypertensive, and many taking multiple antihypertensive
medications. He goes over a practical schema to group drug-drug interactions, and goes over each class of anti-
hypertensives in turn, focusing on common problems both with other antihypertensives and with medications used to treat
different conditions.
This is the last of the lectures to be posted from the May, 2000 Annual Scientific Meeting of the American Society of
Hypertension (ASH). This particular talk was part of a symposium on hypertension in the diabetic. Dr. Sowers begins
by pointing out the increased cardiovascular risk that diabetics suffer from, and talks about the constellation of risk
factors that accompanies central obesity, often associated with type 2 diabetes, which is similar to risk factors found
in patients with microalbuminuria. He then shows that in diabetics, although risk is great, the benefits of treatment
are also proportionately greater, and discusses diabetic-subpopulation trial results in studies such as SHEP, HOT, and
Syst-Eur, and then talks about results with more recent trials such as CAPPP and HOPE.
This is the last of the lectures to be posted from the NKF Spring Clinical Nephrology meetings held in May, 2000. In
this talk, Dr. Barker first gives example of post-natal sex determination in animals, and then discusses the theory of
how birth weight, including fetal nutrition, may determine all sorts of cardiovascular risk, including coronary artery
disease, and insulin resistance. The link to the upcoming Congress cited in Professor Barker' talk, namely the First
World Congress on the Fetal Origins of Adult Disease, to be held in Bombay, India, Feb 2-4, 2001, is here.
This is first of many talks that we will be posting from the ASN 2000 Annual Scientific Meeting and Renal Week in
Toronto. Dr. Ward first speaks of the risks dialysis patients faced due to their exposure to large amounts of dialysis
water, reviews the principal contaminants to be concerned about, and touches on AAMI water standards and HCFA
regulations. He then discusses the matter in terms of organ systems affected, and talks about anemia or erythropoietin
resistance due to chloramines, aluminum, and zinc, bone disease due to aluminum and fluorides, and encephalopathy. he
talks about problems in removing aluminum by deionization and the problem of fluoride release from deionizers. The last
part deals with bacterial contamination, cytokine generation, chronic inflammation syndrome, and carpal tunnel syndrome,
including the potential benefits of using ultrapure water.
This talk is from the ASH 2000 Annual Meeting. It is from a series of talks on Diabetes and Hypertension, many of which
are posted on HDCN. Dr. Giles talks about the increased risks of cardiovascular disease found in diabetics, discusses
possible mechanisms as well as treatment strategies.
This is the first of five talks that we will be posting from the ASN Annual Board Review Course organized by Dr. Bob
Narins and held late this summer at San Francisco, California. Dr. George Bakris discusses the treatment approaches to
hypertensive urgencies and emergencies, why sublingual nifedipine is no longer an acceptable therapy, why he prefers
oral clonidine, hepatotoxicity problems with labetalol, and the wonderful renal effects of the dopaminergic receptor
antagonist felodopam. He also points to practical difficulties in treating hypertensive crises in an inner city
population, where cocaine abuse is not uncommonly a contributing cause.
Every year HDCN selects about 200-250 key clinical abstracts from the ASN, and with the permission of the Society, posts
these on HDCN and archives them for several years. Also, for the past three years, the ASN has made all of the
abstracts available from each meeting for a one-year period directly via its website. The archive is completely
searchable, and is an extremely valuable resource for those wanting truly cutting edge information. A caution for the
uninitiated: abstracts often present unreviewed data, and typographical and (usually minor) data errors are not
uncommon. The ASN Annual Meeting begins this October 10th at Toronto. HDCN will archive perhaps as many as 40 selected
talks from the annual meeting and post them over the ensuing 6 month period.
This completes our series of lectures from the Polycystic Kidney Research Foundation Annual Meeting. Dr. Torres
discusses pain in PKD in a general sense, and points out that, with chronic pain, pain sensitivity is increased to the
extent that pain may persist without further kidney inflammation or apparent root cause. He touches on mechanisms of
how chronic pain can alter pain perception at the peripheral, spinal cord, and central level, and outlines the overall
strategy of pain management in PKD patients.
Dr. Valente, a surgeon, focuses on the subset of PKD patients who have severe pain or other complications from kidney
or liver cysts. He describes the new technique of minimally invasive surgery and gives numerous examples of how
specific cases are approached. Renal denervation, hand-assisted laparoscopic surgery, and laparoscopic donor
nephrectomy are also described.
These talks are in the FREE ZONE of HDCN, their web presentation having been supported by an unrestricted educational
grant from Sigma-Tau Pharmaceuticals, Inc.
There is no slide/audio lecture this week. The site of the week is a wonderful database that includes approximately
four thousand actively recruiting protocols. The site is maintained by the National Institutes of Health and the
National Library of Medicine. It includes protocols sponsored by entities other than the federal government. Protocols
are searchable by
disease entity, by
sponsor, or by
key word.
. There is also a
focused
search, that allows one to combine disease entity, sponsor, location, etc.
See also, the Centerwatch site, which is a private site, with a
greater emphasis on pharmaceutical industry sponsored trials. All of these links have been added to the home page of
HDCN.
The fourth of seven talks we are posting from the May, 2000 American Society of Hypertension Annual Meeting. This talk
capitalizes on the results of a recent study by Dr. Bert Pitt which showed that an aldosterone antagonist reduces
mortality in congestive heart failure (Dr. Pitt's lecture on this topic will be posted in the next few weeks). Dr.
Soberman begins by pointing out that the prevalence of congestive heart failure is increasing, and the death rate is
worse than that of some cancers. She discusses pathophysiology of heart failure in some detail, and cites several
important papers where aldosterone was linked to myocardial fibrosis. Links between aldosterone and left ventricular
mass index, diastolic dysfunction, large vessel compliance, and endothelial dysfunction are presented. The role of
aldosterone in norepinephrine uptake is discussed, as well as the potential importance of associated electrolyte
abnormalities. Causes of elevated aldosterone in heart failure are listed, including decreased hepatic clearance, and
the importance of aldosterone escape is stressed. Finally, outcome data are presented, which point the way to potential
treatment of heart failure with aldosterone antagonists.
This talk was from the so-called "Coping Tract" from the annual PKD meeting sponsored by the Polycystic Kidney
Research Foundation. Two more lectures from this series will be posted in the near future. The talk was given to a
patient audience. Part One begins with a discussion of protein restriction and how this impacts the progression of
renal disease in animal models of PKD. The MDRD study is then discussed in detail, along with the results of a recent
meta-analysis. In the rest of Part One, Dr. Steinman covers essentially all aspects of the diet in patients with renal
disease with emphasis on the special needs of PKD patients. He covers protein, energy and fat intake, sodium,
potassium, phosphorus, and use of vitamins and supplements. The role of acidosis in accelerating cyst formation is also
covered. Most of the discussion is quite applicable to patients with renal insufficiency from any cause.
In Part Two, Dr. Steinman focuses specifically on new data suggesting that a soy diet may have protective effects
against atherosclerosis. He discusses the possible mechanisms for this, along with data in an animal model in which a
soy diet was found to reduce cyst size and slow the rate of progression of renal disease.
This talk is very informal, with frequent questions and interruptions from the audience. A revised set of slides was
prepared after the talk to better focus the rather freewheeling but fascinating discussion that took place. This talk
should be useful not only to patients, but also to healthcare professionals, who, as Dr. Steinman points out, often
receive insufficient formal training in the nutrition area.
August 27 - September 3, 2000
Renal Ultrasonography
(W. Charles O'Neill, M.D., NKF 2000 Spring Clinical Annual Scientific Meeting, Washington, D.C.)
This talk was given as part of an interventional nephrology symposium at the Ninth Annual Spring Clinical Meetings of
the U.S. National Kidney Foundation. Dr. O'Neill begins by pointing out that one of the originators of diagnostic
abdominal ultrasound, Dr. Joseph Holmes, was a nephrologist. He then goes over a laundry list of fears which explain
why many nephrologists shy away from doing ultrasounds, and proceeds to dispel each one. He discusses the indications
for renal ultrasound, and the benefits to both patient and physician when these are done promptly by the nephrologist.
Dr. O'Neill talks about issues of training and certification and recounts the experience at Emory in both areas.
In the second part of the talk, Dr. O'Neill discusses the principles of ultrasound machines and how they work, and the
various operator adjusted controls and what they do. He discusses the uses of various ultrasound probes, and the
effects of using different frequencies. He then presents a series of ultrasounds of various pathological conditions
involving both native kidneys and allografts.
Dr. O'Neill holds courses at Emory on a regular basis for nephrologists to teach them how to do ultrasounds. He has much
information available in this area at the Emory Renal Division
Website, and he has just written a book on the subject soon to be published by W.B. Saunders. You can find
this book, the Atlas of Renal Ultrasonography, by going to
http://catalog.wbsaunders.com/ndNSAPI.nd/catalog/PgCatalog, and typing "O'Neill" into the search
engine author line.
This is the third of six talks that HDCN is posting from the May, 2000 ASH meeting in New York.
Dr. Grimm begins by reviewing the risk factors for erectile dysfunction (ED) in normal men, and
identifies age and typical cardiovascular risk factors as the most important causes. Similar
risk factors are found in hypertensive males. He then describes the TOMH study and other trials comparing the
prevalence of ED with various hypertensive drugs, and identifies at least one drug that appears to have a higher
prevalence of ED, and one which has a lower prevalence of ED. He then moves on to talk about sildenafil citrate, and
its use in patients with hypertension and other comorbid conditions, going over side effects and efficacy in this
population.
This is the second of about 5-6 talks that HDCN is posting from the May, 2000 ASH meeting in New York. The lecture was
part of the opening symposium of the ASH meeting, which focused on diabetes and cardiovascular disease. Dr. Mark Cooper
discusses experimental data pointing to both glucose-mediated and blood-pressure mediated injury to blood vessels in
diabetes. He first goes over some outcomes data from the UKPDS (UK Prospective Diabetes Study) and then proceeds to
experimental data. He reviews the Brenner glomerular capillary hyperfiltration model, the role played by pro-
sclerosing mediators in diabetes including the induction of TGF-beta and type IV collagen mRNA in diabetes. He
discusses the potential therapeutic rationale for using AII blockers and ACE inhibitors. He then presents data relating
to diabetic retinopathy, including a new animal model, and data from his own laboratory examining the mesenteric
vasculature. The role of endothelin and the potential usefulness of the endothelin antagonist bosentan are described.
The role of endothelin-rich mast cells in the pathogenesis of diabetic vascular pathology is described as well.
Finally, there is a brief discussion of advanced glycation end-products and data in animal models using soluble AGE
receptor (sRAGE), and new AGE crosslink breaking compounds. The talk ends on a clinical note, regarding optimum
glycated hemoglobin levels and blood pressure control (requiring multiple antihypertensive drugs).
Technical note:
The last 2 min of PART ONE were lost when the tape was changed at the meeting. We recorded the missing segment and
added this in. At this point, PART ONE ends. You will need to scroll to the bottom of PART ONE and click on the
hyperlink to PART TWO to hear the remainder of the talk.
This is the last of the talks from ASN 1999. Dr. Anderson first describes theoretical differences in how AII blockers
vs. ACE inhibitors affect the vasoactive hormonal milieu. She then goes over some
studies comparing efficacy in lowering blood pressure with the two agents, and then moves rapidly to the prime focus of
her talk: renoprotection. She describes comparative studies on the effects of AII blockers vs. ACE inhibitors on
glomerular capillary pressure, proteinuria, Heymann nephritis, tubulo-interstitial nephritis, and obstructive uropathy.
Dr. Anderson then talks about the effects of these two classes of agents in lowering renal levels of sclerosing
mediators such as TGF-beta and plasminogen activator inhibitor-1. She then describes the results of various crossover
and parallel group studies in patients, as well as results with combination therapy.
This is a talk from the National Kidney Foundation Spring Clinical Meetings held in April, 2000.
Dr. Work begins by pointing out that currently, 15-20% of hemodialysis patients have chronic venous catheters
in place. He discusses DOQI recommendations for insertion of chronic venous catheters,
focusing on preferred location, which of course is the internal jugular vein. He presents evidence detailing the
benefits of ultrasound-guided insertion, and for the need for post-insertion fluoroscopy. Potential complications are
discussed, as are the common anatomical variants of the internal jugular vein and carotid artery locations in the neck.
A number of case presentations are given illustrating common insertion problems. The insertion methodology and required
equipment are shown in detail, and the advantages of various competing tools are discussed. Various insertion tips are
presented. Data about flow through different brands of catheters are reviewed. Finally, Dr. Work ends by describing
two up and coming IJ vascular access methods, namely, the Dial-lock system by Biolink and the LIfe-Site system by Vasca.
Almost all journals have on-line sites. Only a minority offer free access to full text articles, among them the British
Medical Journal, or BMJ. Now the BMJ has expanded the utility of this approach by grouping their free full text articles
into collections. The collections pertaining to Cardiovascular Medicine and Renal Medicine are of most interest to HDCN readers.
Interestingly, in addition to each BMJ article collection, the BMJ is also collecting free full text article links from
other journals. For example, for hypertension, there is a BMJ Hypertension Collection link, and a non-BMJ Hypertension Collection link.
Although not all of
the articles in these collections are of broad interest, included are many fine papers.
In addition to journals, the BMJ collections offers links to several full text books on-line. So far in this category
there appear two books of general interest: Epidemiology for the Uninitiated by Coggon, Rose
and Barker, and Statistics at Square
One by TDV Swinscow. This is a fine resource for people interested in basic clinical trial design.
Dr. Hill gave this presentation at the May, 2000 American Society of Hypertension meeting in New York. This is the
first of a number of lectures that HDCN will be posting from that meeting. Dr. Hill begins with an overview of the body
mass index values of US inhabitants. These are increasing to the point that the majority of the US population can be
considered either obese or pre-obese. He touches on experimental animal work suggesting genetic causes for obesity, and
then reviews epidemiologic energy intake data, as well as data suggesting that the degree of physical inactivity in the
US population is increasing. An interesting example is the BMI in Pima indians living on reservations in the US and
their genetic counterparts in Mexico living a more ancestral life style. The Mexican Pima indians have a far lower
prevalence of obesity. The conclusion is, that nature and nurture interact, and there is difficulty in restricting
energy intake when physical activity level falls.
Dr. Ojo gave this talk as part of a special symposium at the NKF Ninth Annual Spring Clinical Meetings in April of this
year. He begins by reviewing the particular susceptibility of African Americans to develop ESRD, whatever the level of
blood pressure, and then discusses level of pharmacologic control of BP in various ethnic groups as per the NHANES
database. He describes the relative classes of antihypertensive agents and how their common usage differs in African
Americans vs. non-Hispanic whites. He focuses on the low percentage of ACE inhibitor/AII blocker use in African
Americans, and presents data that these agents may be cardioprotective and renoprotective. The level of BP control is
also discussed, as pertains to rate of progression of renal failure, and the point is emphasized that usually 3 drugs or
more will be required to obtain adequate BP control. He also discussed the particular efficacy of the DASH diet in
African American hypertensive patients, and concludes by puncturing a number of common myths about hypertension in this
important population segment.
This is part of the wonderful educational effort of the NKF CyberNephrology team and the ISN Informatics Commission.
Copyright permission was obtained to post the entire five volume set of Schrier's Atlas of Diseases of the Kidney
on the internet in .pdf format. However, the second phase of the project, now completed, was to make available the
images from the Atlas as downloadable Power Point presentations. These are now complete, and can be found at the above
hyperlink. They do not include some of the high-definition pathology images, which must be downloaded separately from this link .
These slidesets serve as a wonderful educational tool for faculty and fellows assigned to give lectures on a nephrology
related topic to audiences made up of their peers, other specialists, generalists, or medical students. The Power Point
and High Resolution Graphics pages can be reached via the main link to the
Schrier Kidney Atlas on the home page of HDCN.
There is no slide/audio talk this week, by the way. We will resume the talks next week with a presentation by Dr.
Akinlolu Ojo from the University of Michigan about Hypertension in African Americans.
This is part of the Women in Nephrology symposium given at the Ninth Annual NKF Spring Clinical Meetings. We will be
posting 4-5 lectures from this meeting. Low birthweight has been incriminated in several cardiovascular disorders,
including susceptibility to renal failure and hypertension. Dr. Chapman begins by defining Syndrome X, and then
describes a very recent study in the Southeast United States, where low birthweight was linked to development of early
onset renal failure. Whether low birthweight might also lead to Syndrome X remains a matter of active investigation.
She then describes a second study where maternal blood pressure during pregnancy was inversely associated with infant
birth weight. She then describes her own work where she followed systemic and renal hemodynamics, as well as levels of
various hormones (renal, vasopressor, reproductive, and second messenger) in a cohort of women prior to pregnancy, and
then throughout gestation.
See also a related "classic" talk on HDCN given at the 1997 ASN meeting by Dr. Marshall Lindheimer entitled Physiologic Changes during Pregnancy.
Dr. Moss describes the new RPA / ASN (a host of other societies were involved as well) guidelines pertaining to
initiation of and withdrawal of hemodialysis. He first describes the concept of a clinical practice guideline. This is
the second guideline issued under the leadership of the RPA, and was felt to be an area where some guidance was acutely
necessary. A formal, evidence-based approach was used. Dr. Moss goes over some data about the rising incidence of ESRD
in the elderly, and the high rate of voluntary withdrawal from dialysis. A number of prognostic scoring indices for
acute renal failure are described, including one formulated by the Cleveland Clinic. The guidelines are not presented in
didactic fashion, but in the course of presenting four illustrative cases. Issues of conflict resolution and
palliative care also are discussed. A toolkit is also described for dealing with the disruptive patient. The actual
guidelines can be obtained by emailing the RPA, or ordered via their website, which will soon be operational.
These two presentations represent the extremely practical and clinically useful presentations offered by the RPA Annual
Meeting. In the first presentation, Dr. Jack Work describes the RPA's work in developing credentialing criteria for
peritoneal and vascular access procedures performed by nephrologists.
The second presentation is an account of the tremendous improvements in vascular access management made at the
University of Alabama over the past 2-3 years as a result of setting up a multidisciplinary team. Donna Carlton, R.N.,
the vascular access coordinator, describes how this team was set up, and how it was used to decrease graft thrombosis,
to shift initial declotting procedures from surgery to radiology and from inpatient to outpatient, to increase the
percent fistula placement, and to decrease the rate of surgical complications.
Dr. Bergström starts out by recounting the long history suggesting that salt intake exacerbates hypertension.
While salt may be tolerated by patients with normal renal function quite well, in patients with CRF, it causes marked
increases in blood pressure. Dr. Bergström then goes over the hemodynamic mechanisms of hypertension in ESRD, and
admits that factors other than extracellular fluid volume may be operative. He then turns to the high prevalence of
hypertension in ESRD patients, but remarkably, not in patients treated at Tassin, France, where the use of anti-
hypertensive drugs is only 2%. Dr. Bergström describes the Tassin data in detail, and talks about the "lag
phenomenon", namely that several months may be required for blood pressure to normalize after reducing ECF volume.
He then describes the results of several studies he has been involved with comparing ECF volume, inferior vena cava
diameter and isotopic measurement of blood volume in hypertensive vs. normotensive Swedish dialysis patients, and also
including such measurements in patients receiving dialysis at Tassin.
Dr. McMurray talks about the changing way in which the role of an ESRD Facility Medical Director is being perceived by
the U.S. Government, as well as by dialysis providers. At issue is documentation of reimbursement and avoidance of
violating Medicare anti-kickback statutes. Helpful tools and tips are provided in these areas, and a recent legal case
is discussed where physicians were actually sent to jail for accepting money in a medical director role where no
services for this payment could be discerned. A second part of the talk discuses the role of the Medical Director in
quality assurance projects and CQI. As examples, three projects carried out by the speaker are discussed, one in the
area of dialysis adequacy, one relating to peritoneal catheter exit-site infection, and one related to prevention of
foot ulcers and amputations in ESRD patients, especially diabetics.
Dr. Paganini discusses the changing role of the nephrologist in the intensive care unit, and in particular, the
challenge of CRRT being increasingly performed by intensivists without recourse to nephrologic consultation.
Dr. Goodship opens by discussing protein turnover in the body and emphasizes flux between body proteins and the large
amino acid pool. He then describes how nitrogen balance values can be similar with low, normal and high rates of
protein synthesis. In the initial part of the lecture the focus is the effect of acidosis on nitrogen balance and
protein breakdown. Dr. Goodship cites a number of clinical studies where nutritional parameters seemed to be improved
with alkali administration. He then focuses on the ubiquitin-proteasome pathway of protein degradation and how this is
affected by acidosis. The permissive role of glucocorticoids is stressed. Then Dr. Goodship talks about how insulin
appears to reduce protein breadown and ubiquitin concentration in muscle. Further discussion focuses on the controversy
of whether hemodialysis is a catabolic event, and if hemodialysis-associated catabolism is related to biocompatibility.
Finally, Dr. Goodship presents some data suggesting that in chronic renal failure, patients on either a low or high
protein diet have similar levels of nitrogen balance and protein breakdown as non-uremic controls.
Dr. Unwin begins by talking about the three main classes of calcium channel blockers and discusses how they differ, both
pharmacalogically and in terms of indications. He also discussed the difference in pharmacokinetics between short and
long-acting dihydropyridines. He then talks about the importance of proteinuria as a surrogate marker for renal injury,
and data suggesting that the CCBs are not as effective against proteinuria as ACE inhibitors. He points out the many
CCBs affect primarily the afferent arteriole, then talks about potential benefits of non-dihydropyridine CCBs and the
benefits of ACE/CCB combination therapy.
In part two of the talk, Dr. Unwin discusses the outcomes data suggesting increased cardiovascular risk, cancer risk,
bleeding risk, and depression risk that have been alleged for CCBs, and presents the controlled studies both supporting
and refuting these potential hazards. His conclusion is that CCBs are a worthwhile agent to use in both ESRD and CRF,
and, given the resistant hypertension of these populations, the issue of first-line agents becomes moot.
Dr. Williams, a nephrologist at Boston's Joslin Diabetes Center, begins by discussing how advanced glycosylation end-
products (AGEs) are formed and disposed of within the body. He then presents evidence for increased levels of AGEs in
various organs of diabetics. He then focuses on renal insufficiency, and evidence that AGEs are also increased in
patients with high serum creatinine levels. AGEs can cause vascular damage and are localized within the renal cortex,
and can be found in mesangial nodules in diabetic kidneys. Dr. Williams finally goes over experimental animal results
with aminoguanidine (pimagedine) and describes some preliminary results from the ACTION I trial where this drug was used
in an attempt to retard the onset of diabetic complications in humans.
This is a talk from the ASN Annual Meeting in Miami in November of 1999. Dr. Ward begins by detailing the procedural
and patient costs associated with clotting of the extracorporeal circuit. He then details expectations of an ideal
anticoagulant for CRRT. Choices include heparin, citrate, prostacyclin, nafamostat mesylate, and others. Controlled
low-dose heparin, the standard, is described, and the use of protamine is also detailed. Dr. Ward's citrate protocol is
discussed in some detail for CVVHDF, as well as the Palsson and Niles approach using citrate for CVVH. Treatment of
patients with heparin-induced thrombocytopenia is described, and recommendations are made for patients in different
bleeding risk categories.
This is the last of a quartet of talks on renal transplantation featured at the 1998 ASN Meeting in Philadelphia.
Initial posting of the talk was delayed due to technical reasons. Dr. Helderman first discusses the issue of whether
long-term cyclosporin use is associated with nephrotoxicity, and whether one can find a dose low enough where this does
not occur. He then discusses the pharmacokinetics of cyclosporine, and the variability in the trough levels as well as
area under the curve. He compares pharmacokinetic values between Sandimmune and Neoral. He presents data from the
Global Network Database detailing results of switching from Sandimmune to Neoral in terms of pharmacokinetics, efficacy,
and toxicity. He closes with a discussion of comparative pharmacokinetics of the new Sang-35 cyclosporin preparation.
Dr. First uses the extensive database from the Cincinnati Transplant Tumor Registry begun by Dr. Sol Penn and continuing
to this day, to describe many aspects of tumors occuring after transplantation of kidneys and other organs. Basic
information such as tumor type and time to onset is presented, along with comparison of kidney allograft recipients vs.
recipients of other organs. Treatment recommendations and summaries are also provided.
Dr. Hariharan talks about the problem of chronic graft loss, of which a substantial portion is recurrence of the primary
renal disease. The problem is most important in patients with native kidney diagnoses of FSGS, IgA, and diabetes, and
overall accounts for 12% of chronic graft loss. Dr. Hariharan talks about the implications of recurrence for graft
survival, and then discusses in turn recurrence with FSGS, IgA, and diabetes. He also presents data from Milwaukee
linking FSGS recurrence to presence in the serum of a permeability factor which affects permeability to albumin of
isolated rat glomeruli. He presents interesting data how the presence of this factor in serum is linked to clinical
risk of recurrent FSGS post-transplant.
Dr. Kasiske discusses cardiovascular risk factors, hypertension, lipid disorders, homocysteine, and smoking in renal
transplant recipients. Much of the discussion is in the form of presenting brief case vignettes and asking the audience
how they would treat a hypothetical case with certain characteristics. This was part of the Renal Week presentations
for Renal Fellows given at the 1999 ASN Meeting in Miami in November.
These talks comprised a Satellite Symposium given in Miami at the ASN meetings on November 5, 1999.
The symposium was funded by an unrestricted grant from Genzyme Therapeutics, and hence is in the FREE ZONE
of HDCN. The focus is phosphorus, and why hyperphosphatemia is bad for you, although Dr. Bushinsky's talk is primarily
about the effects of acidosis on bone. Dr. Slatopolsky goes over substantial in vitro and animal data suggesting direct
stimulation of PTH production by phosphorus, and prevention of uremic hyperparathyroidism by a phosphorus restricted
diet. He touches on the molecular mechanisms for this: apparently phosphorus may stimulate hyperplasia by inducing TGF-
beta. Interestingly, he shows data that a low phosphorus diet in animals can prevent hyperparathyroidism, but is not
very good at reversing it once developed. Dr. Slatopolsky also presents new data regarding paucity of calcium-sensing
receptor in parathyroid glands of uremic animals, and how this suppression of CaR expression is exacerbated by
hyperphosphatemia.
Dr. Bushinsky goes over 20 years of work from his laboratory detailing how metabolic acidosis increases proton flux into
bone and increases calcium efflux from bone. This is a cellular effect, and is mediated by stimulation of osteoclasts
and suppression of osteoblasts. The effect is reversed in culture conditions mimicking metabolic alkalosis. Dr.
Bushinsky also shows some nice data using a scanning ion microprobe, which can detect the presence of various ions the
the surface of bone. In a mouse model fed ammonium chloride (causing metabolic acidosis), bone surface sodium and
potassium levels are reduced, along with bone surface phosphate and bicarbonate concentrations.
Dr. Chertow goes over the USRDS data published by Block suggesting that mortality is increased in ESRD patients with
high phosphorus levels, and with high Ca x P products. He cites data by Levin et al, also using the USRDS database,
that suggests most of this excess mortality is cardiovascular. Dr. Chertow then presents some preliminary analyses of
his own data using the Fresenius medical database, suggesting the mortality effect due to high serum phosphorus levels
is magnified in men and in diabetics (of both sexes). No effect of phosphorus on mortality could be found in non-
diabetic women, or, in fact, in the overall analysis.
By the way, you can get 1.5 hours of free CME credit for listening to this symposium. You need to print out the
enrollment, evaluation, and post-test forms and mail them in to the University of Minnesota's CME office to get your
certificate.
This is a lecture targeted to Renal Fellows given in Miami in November of 1999, describing basic
elements of renal histology, vasculature, and pathology. The first part makes extensive use of
scanning electron microscope photographs to depict the vascular architecture of the kidney from the
lobar to glomerular level. Dr. Cohen shows how the glomerulus is assembled from its various
constituent pieces. In part 2 of the talk, he discusses commonly used stains and how they are used
to assess various parts of the glomerulus. He also talks about how various parts of the glomerulus
are altered in disease conditions. An extensive discussion of use of fluorescent stains is
provided, as well as use of PAS stain and silver stain to assess intramembranous deposits and the
appearance of the basement membrane. In part 3 of the talk Dr. Cohen focuses on tubular anatomy, how
a pathologist assesses the interstitium and the appearances of blood vessels in vascular
inflammatory states.
February 6 - 12, 2000
Atlas of Kidney Disease
(Dr. Robert Schrier, Editor, Blackwell Science, Inc., Jan, 1999. Web-posting by the
US NKF's Cybernephrology Group and the ISN Informatics Committee)
This is an unprecedented internet resource. A comprehensive, five-volume atlas of kidney disease
that is available in its entirety, chapter by chapter, as .pdf files (you need to download Acrobat
Reader, free software, to read .pdf files). Also, the entire text is accessible via a search engine
created by Dr. Bill Marovitz. Downloadable Power Point slidesets are also in preparation, according
to Dr. Kim Solez, head of NKF's Cybernephrology project and the ISN Informatics Committee.
Incidentally, the Atlas of Renal Pathology,
which has been growing every month since early 1998, is also a wonderful educational resource on the
internet, available at the AJKD Website.
We have added links to both of these wonderful sources of information from the home page of HDCN.
This week we are posting the second two lectures from this 4-part symposium, as well as the question
and answer period.
This was a four-talk ASN Satellite Symposium, presented at the November, 1999 Miami meeting, and
sponsored by an educational grant from Schein Pharmaceuticals, Inc. We posted the first two
talks, by Dr. Fishbane (Components of Anemia Therapy) and Dr. Nissenson (Optimal Target Hematocrit)
last week, while the remaining two talks (Dr. Owen on US Patterns of Iron Utilization, and Dr.
Nissenson on New Advances in Iron Therapy) are to be posted tomorrow. If you get a message for the
Owen and Nissenson talks, that the talk is to be posted later, please hit reload on your browser to
flush your cache. These last 2 talks will be ready Sunday evening (January 22, 2000), about 8 PM
Chicago time).
This was a four-talk ASN Satellite Symposium, presented at the November, 1999 Miami meeting, and
sponsored by an educational grant from Schein Pharmaceuticals, Inc. We are posting the first two
talks, by Dr. Fishbane (Components of Anemia Therapy) and Dr. Nissenson (Optimal Target Hematocrit)
this week, while the remaining two talks (Dr. Owen on US Patterns of Iron Utilization, and Dr.
Nissenson on New Advances in Iron Therapy) will follow next week.
This talk was for the Fellows and given as part of Renal Week. Dr. Winchester begins by going over
some epidemiologic data, and lists the reasons why use of emetics such as Ipecac has been decreasing
in popularity, and the increased use of multiple dose activated charcoal. He then talks about
salicylate poisoning and lithium intoxication in detail. In part two of the talk, the focus is on
methanol and ethylene glycol poisoning, paraquat, and appropriate use of hemoperfusion vs.
hemodialysis.
