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(listed in reverse chronological order)

December 18 - 25, 2001


Dr. Appel
Management of the Nephrotic Syndrome
(Gerald B. Appel, M.D., ASN/ISN World Congress of Nephrology, October, 2001)  

Management of hypoalbuminemia, edema, hyperlipidemia, and the hypercoagulable state associated with the nephrotic syndrome are the problems. What are the solutions? What is the pathogenesis of low serum albumin? Of edema? How do we treat this? What is the best schedule for diuretics? How do we manage hyperlipidemia in NS? Is there increased CV risk? How does RV thrombosis present? Do we anticoagulate prophylactically? Are vitamin D and thyroid defects common? What about non-specific Rx? Cyclosporine? ACE-inhibitors? What does RENAAL teach us in this regard?


Global Management of Chronic Renal Insufficiency: Practical Issues.   


Dr. Lindberg

Dr. Coyne

(Two Speakers: Dr. Jill S. Lindberg and Dr. Daniel W. Coyne. ASN/ISN World Congress of Nephrology Evening Symposium, October, 2001)

This evening symposium focused on management of bone disease and anemia in chronic kidney disease. Dr. Lindberg discusses bone disease, taking a view broader than one limited to renal osteodystrophy. Osteoporosis is also important, as is development of peak bone mass in patients who may be amenorrheic and on immunosuppressive medication that may affect bone formation. When does vitamin D and PTH dysregulation begin in CKD? How do we best control phosphate? Does use of vitamin D help? What are practical treatment algorithms?

Dr. Coyne then focuses on anemia management. When does anemia begin in CKD? How widely in CKD is EPO used? What are the benefits of correcting anemia in CKD? Are there benefits in terms of LVH? What EPO compounds can we use and what is an accepted dosing interval? When should iron be given to CKD patients? At what dose? What are the safety profiles of iron dextran vs. sodium ferric gluconate?

CME credits are offered for this symposium. You need to print out the evaluation form, take the post-test, and send it to the CME provider for your CME certificate (up to 1.25 hours of Category I credit).



December 10 - 17, 2001


Dr. Burkart
PD Adequacy Guidelines: What Targets and Why?
(John M. Burkart, M.D., ASN/ISN World Congress of Nephrology, October, 2001)  

Dr. Burkart, current Chair of the NKF K-DOQI guideline committee for PD adequacy, talks about how the original guidelines have been modified in the face of new data. In the 2000 modification of the guidelines, target weekly creatinine clearance is lower in low transporters. Canadian and UK guidelines are similar. Is the target for anuric patients still too high? Do peritoneal clearances predict outcomes? Which is the most relevant target: Kt/V or ClCr? What should be done with the NIPD / CCPD targets? Do the results of the ADEMEX study change everything?


Management of Intradialytic Hypotension: A Clinical Challenge.   


Dr. Schreiber

Dr. Daugirdas

Dr. Sherman

Dr. Perazella

(Four Speakers: Dr. Martin J. Schreiber, Jr., Dr. John T. Daugirdas, Dr. Richard A. Sherman, Dr. Mark A. Perazella, ASN/ISN World Congress of Nephrology Evening Symposium, October, 2001)

This evening symposium focused on intradialytic hypotension. Dr. Schreiber opens the discussion: Does intradialytic hypotension result in bad outcome; e.g., increased mortality or hospitalization? What are the clinical steps that can be used in managing IDH? Dr. Daugirdas follows with physiology. How can we remove the whole plasma volume over 3 hours and have the patient still survive? What are the determinants of vascular refilling? What affects venous capacity and cardiac filling? Is cardiac output or vascular resistance more important? What about heart rate? What is the adenosine hypothesis? What is sympathetic withdrawal during dialysis? Dr. Sherman speaks practically at several maneuvers, many first described by him, of maintaining blood pressure during dialysis: hematocrit, cool dialysis, higher calcium dialysis. He also discusses sodium gradient methods that may be useful. Dr. Perazella talks pharmacology: ephedrine, fludrocortisone, caffeine, vasopressin, sertraline, L-carnitine, and midodrine. An approach to safe dosing of midodrine and strategies of using midodrine vs. cool dialysate are presented.

CME credits are offered for this symposium. You need to print out the evaluation form, take the post-test, and send it to the CME provider for your CME certificate (up to 2.0 hours of Category I credit).




December 3 - 9, 2001


Dr. Glassock
IgA Nephropathy: 2001 Update
(Richard J. Glassock, M.D., ASN/ISN World Congress, October, 2001)   

From the Renal Week talks on GN. Is the incidence IgA increasing? Are Hispanics especially susceptible? What is the age distribution? What percentage is familial? How are the familial cases characterized? What are the current theories as to pathogenesis? What are the risk factors for progression? What is the role of triglycerides, obesity? How might organic solvent exposure be involved? What is the Toronto formula to estimate progression? When do we treat with ACE inhibitors? When should we apply specific therapy? What is the "anti-progression cocktail"? These questions are addressed by one of the most respected authorities in the field of glomerulonephritis.




November 26 - December 2, 2001


Dr. Cattran
Treatment of Membranous Nephropathy
(Daniel Cattran, M.D., ASN/ISN World Congress, October, 2001)   

From the Renal Week talks on GN. What is the natural course of membranous nephropathy? How can we group patients into low, medium, and high-risk? Having done this, what is a reasonable treatment algorithm for each group? Are steroids alone useful? When should we use cytotoxic agents? Cyclosporine? What adjunctive treatment measures are useful?




November 19 - 25, 2001


Dr. Jahansouz
Drug Dosing in CRRT
(Farivar Jahansouz, Pharm.D. ASN/ISN World Congress, October, 2001)   

From the Renal Week talks on CRRT. Which drugs need dosing adjustment during CRRT? What is a simple method to obtain this dosage adjustment? When is therapeutic drug monitoring indicated? What are the limitations of published guidelines in this area? Dr. Jahansouz presents an ICU patient receiving multiple drugs in whom CRRT is initiated, and discusses how each of his drug doses might be altered.




November 11 - 17, 2001


Dr. Blake
Physiology of Peritoneal Dialysis
(Peter G. Blake, M.D., ASN/ISN World Congress, October, 2001)   

Another talk from the October 2001 World Congress in Nephrology held in San Francisco (ASN/ISN), from the Renal Week course on PD. What is the 3-pore model? What are the six resistances to fluid transfer? What is MTAC, the Mass Transfer Area Coefficient? What are the key factors controlling diffusion and ultrafiltration? What are the four types of UF failure? How can one calculate PD clearance? What is the role of icodextrin?


Dr. Bennett
Pain Management in PKD
(William M. Bennett, M.D., PKD Foundation Annual Meeting, June, 2001)   

This is our second talk from the annual meeting of the PKD Foundation. Dr. Bennett discusses pain management. First he gives some anatomic correlations, then gives practical hints about what pain medicines to use in this population, and when referral to a surgeon may be required. He finishes off with some pointers about cyst infection.




November 4 - 11, 2001


Dr. Schreiber
Peritoneal Catheter Placement
(Martin J. Schreiber, M.D., ASN/ISN World Congress, October, 2001)   

This the first of many talks to be posted from the October 2001 World Congress in Nephrology held in San Francisco (ASN/ISN). We will be posting a series of talks on basic PD. What are the layers of the abdominal wall and how does their healing impact PD catheter function? Is silicone rubber or polyurethane better? Are the antibiotic or silver coatings useful? One or two-cuff? Straight or pigtail? Straight tunnel or swan neck? What are the indications for the presternal catheters? How do insertion techniques compare? What kind of catheter survival should we expect? What are the details of pre-, intra-, and post-operative management? What are the complications and how are they managed?


Dr. Perrone
Polycystic Liver Disease in PKD
(Ronald D. Perrone, M.D., PKD Foundation Annual Meeting, June, 2001)   

Each year for the past three years we have been posting two talks from the annual meeting of the PKD Foundation. This year is no exception, and Dr. Perrone talks to a patient audience about PKD genetics, the prevalence of liver cysts, how they present, and how they are managed. We will follow with a presentation soon by Dr. William Bennett on management of pain in PKD patients. By the way, the audiotape of this talk was muffled - so the sound quality is not up to our usual high standards.




October 28 - November 3, 2001


Dr. Arruda
Renal Tubular Acidosis: Case Presentations (Part Two of Two)
(Jose A. Arruda, M.D., ASN Board Review Course, August 2001)   

Part One of this talk was given last week and is a pre-requisite to this series of five case presentations, where Dr. Arruda gives five illustrations of patients with hyperchloremia and acidosis, not all of which have garden-variety RTA. Hyperkalemic distal RTA, hypokalemic distal RTA, the so-called voltage defect, and mixed cases of proximal and distal RTA are discussed, as well as issues of distal sodium delivery and spurious elevations of the urine net charge. Mutations of the proton-ATPase, the sodium channel, and the Cl-HCO3 exchanger, as well as Gordon's syndrome are also covered.




October 21 - 27, 2001


Dr. Arruda
Renal Tubular Acidosis: Basic Proximal and Distal RTA (Part One of Two)
(Jose A. Arruda, M.D., ASN Board Review Course, August 2001)   

Why is there no type III RTA? What is a sensible classification? How do proximal and distal handling of bicarbonate differ? How do you separate proximal from distal RTA? Is the urine pH useful? What are the causes of each? Why are kidney stones common in distal RTA but not in proximal RTA? What is the histology of the bone disease that patients with RTA get? How do patients with RTA present clinically? Children? Adults? What tests do we use? How does the urine net charge reflect ammonia? What about the osmolar gap? When can these tests fail? Next week: More advanced acidosis topics and patient cases.




October 14 - 20, 2001


Dr. Stehman-Breen
Estrogen Deficiency in ESRD: To treat or not to treat?
(Catherine Stehman-Breen, M.D., NKF Spring Clinical Meeting, April, 2001)   

What are the main reasons to give post-menopausal estrogen therapy? Hip fracture, dementia prevention, and cardiovascular disease prevention have all been advocated. What is the evidence? What did the Nurses' Health Study show with regard to CV disease? The HERS Study? The Womens Health Study? What effect do estrogens have on lipids in the general population? In dialysis patients? What percentage of ESRD patients is receiving hormonal therapy? What subgroups are more or less likely to get this? What are the potential treatment regimens and their complications? What are the contraindications to use of postmenopausal estrogens in dialysis patients? Do they cause access thrombosis? Here is the July 23rd, 2001 AHA advisory regarding use of postmenopausal estrogens in the general population to affect cardiovascular disease (they should not be used for this purpose). Please note that Dr. Breen's talk was given prior to the release of this advisory (Dr. Breen's recommendations do not conflict with this advisory).




October 7 - 13, 2001


Ms. Hansen
Non-Compliant Patients
(Susan K. Hansen, RN, CNN, CHT. HDCN Nurse Lecture Series (CEU). October, 2001).   

What is the proportion of non-compliant patients? Is US data similar to that in the rest of the world? What are main causes of chronic non-compliance? What is situation analysis? These questions are answered, and then four non-compliance situations are presented as examples: (1) Young single male living alone, (2) Patient with psychiatric problems, (3) Serious family problems or conflict, (4) Acute behavior change. This marks the first of a series of lectures to be offered on the HDCN nursing channel. 1.0 CEU credits are available to nurses and technicians who complete the educational program from Renal Education Associates.




September 30 - October 6, 2001


Dr. Palevsky
Continuous Renal Replacement Therapy
(Paul M. Palevsky, M.D., ASN Annual Board Review Course. August, 2001, Chicago).   

How widely used is CRRT? What are the differences among SCUF, CHD, CHF, CHDF? What are the differences between convective and diffusive clearances? How does predilution affect clearance with CHF? What are the advantages of various replacement fluids? Are there bicarbonate-buffered fluids available for use in the United States now? What are the options for anti-coagulation? Are there advantages to removal of inflammatory mediators by these therapies? What about adequacy? What did the Ronco study show? How can we compare adequacy with continuous and intermittent therapies? What about outcomes? Is CRRT better than intermittent HD for ICU patients?




September 16 - 29, 2001


Dr. Falk
Serologic Diagnosis of Glomerular Disease
(Ronald J. Falk, M.D., ASN Annual Scientific Meeting. Renal Week, October, 2000, Toronto).   

Serologic tests for glomerular disease cost about $100 U.S. each. How many of them should one order and under what circumstances, pre-biopsy vs. post-biopsy? For post-infectious GN, what is the best combination of tests? What about antiviral tests, including those for syphilis, the hepatitis viruses, and HIV? Which are the best lupus tests? Which are the best tests for scleroderma? ANCA tests are now being ordered widely. What is the difference in sensitivity and specificity between immunofluorescence- and antigen-derived ANCA tests? What is an overall approach to such patients?




September 9 - 15, 2001


Dr. Moe
Bones, Hormones, and ESRD
(Sharon M. Moe, M.D., NKF Spring Clinical Meetings, April 2001, Orlando).   

A 50 year old white female patient on dialysis sustains a hip fracture. Is this an expected event? Is the risk of hip fractures increased in dialysis patients? If so, why? What is the pathophysiology of renal osteodystrophy and how is this different from osteoporosis? What are the risk factors for osteoporosis in dialysis patients? Are race and gender risk factors? What about serum PTH levels? Is there a modality difference in bone mineral density among dialysis patients? How should such a patient be treated?




September 2 - 8, 2001


Dr. Levin
Intradialytic Complications: Monitoring, Prevention and Intervention
(Nathan W. Levin, M.D., NKF Singapore Nephro-Asia Meeting, June, 2001, Singapore).   

Hypotension is the most commonly encountered intradialytic complication. What are its causes? What is dry weight? How is it determined? What are the problems if dry weight is set too high? Too low? What did the Tassin group demonstrate regarding hydration status of patients on standard dialysis? How are changes in blood volume monitored? Does the Crash Crit work? Is the change in blood volume reliable from session to session? What is segmental bioimpedance and how can this help us with dry weight? What about dialysate sodium? Is there a patient-specific sodium setpoint? What about sodium gradient dialysis? Does increasing sodium increase interdialytic weight gain? What about low temperature dialysis - how does this work to minimize hypotension? What is a practical approach to minimize dialysis hypotension?



August 26 - September 2, 2001


Dr. Mani
The Prevention of Chronic Renal Failure at the Community Level.
(M.K. Mani, M.D., NKF Singapore Nephro-Asia Meeting, June, 2001, Singapore).   

How do you approach renal disease in a country like India, where 70% of the population is rural, with a total population of more than a billion people, many of whom live below the poverty level, and where the per capita income is $280 per year? Dr. M.K. Mani, from the Apollo Hospital in Madras, India, describes some of the demographics of renal failure in his region. Chronic interstitial nephritis is a major cause of ESRD, as is IgA nephropathy. The incidence of the latter is rising. Of course diabetes and hypertension are of key importance in India as they are in Western countries. Under the auspices of a foundation called the Kidney Help Trust, Dr. Mani, in one geographic region of 25,000 people, has set up a door-to-door screening process for renal disease, and a cost- effective way of both diagnosing and treating hypertension and diabetes. He describes his experiences and findings and talks about the possibilites of expanding this very successful and important program.


Dr. Blantz
Training and Renal Manpower Needs. A Serious Challenge Worldwide.
(Roland Blantz, M.D., NKF Singapore Nephro-Asia Meeting, June, 2001, Singapore).   

At the same meeting, Dr. Blantz, President-Elect of the American Society of Nephrology, discusses the demographics of renal disease in a developed country, namely the United States, and presents data that the number of patients with ESRD that is projected will by far exceed the ability of nephrologists to care for them. U.S. nephrologists are facing 96-hour workweeks, and many of the trainees have visa problems and will return to their home countries after training. A case is made for more training slots and perhaps relaxation on policies regarding physician shortage areas and visas.




August 19 - 25, 2001


Ms. Kirkpatrick
Psychosocial Issues: Living Donor Transplantation
(Beverly Kirkpatrick, M.S.W. NKF Annual Spring Clinical Meeting, April, 2001, Orlando, FL.   

Part One of this talk deals with general issues with regard to patient evaluation (both donor and recipient) in transplantation. How do you find a transplant center? Can you apply to more than one? How does one explain the risks vs. benefits? What evaluation procedures does the recipient typically undergo? What comprises the social worker evaluation? What type of medical insurance coverage is available? What are the Medicare rules? What are the most important post-transplant issues?

Part Two deals with the Live Donor Consensus Conference sponsored by the NKF and published in JAMA in December of 2000. Who can be a donor? What are the costs? What does donor surgery entail? What is the applicable legislation? Insurance coverage? Will donor life insurance be affected? What about unrelated donors? What comprises the psychosocial evaluation of potential donors? What are the red flags? The factors of ambivalence, guilt, depression, substance abuse, possible coercion - how are these assessed? The .PDF file link for the text of the Consensus Conference is available in the References section at the end of Part Two.



August 12 - 18, 2001


Dr. De Broe
Herbs and the Kidney: What to Beware of.
(Marc E. De Broe, M.D., Ph.D. NKF Annual Spring Clinical Meeting, April, 2001, Orlando, FL.   

Herbs can affect the kidney directly, and are a leading cause of renal problems in Africa. They also can affect the kidney indirectly, e.g., St. John's Wort lowering cyclosporine levels and increasing the risk of rejection. Chinese herb nephropathy, more correctly termed aristolochic acid nephropathy, originally reported in Belgium, was found in one clinic giving a cocktail of diet drugs, including two Chinese herbs, which were later shown to contain aristolochic acid. Are the herbs or aristolochic acid alone responsible for this disease? What could be cofactors? How is aristolochic acid nephropathy different from Balkan nephropathy and analgesic nephropathy? What is the characteristic pathology? How can one deal with the increased risk of uroepithelial cancer? Is this just a Belgian problem, or is it being reported in other countries?



August 5 - 11, 2001


Dr. Sprague
Nephrolithiasis: Pathogenesis, Diagnosis, and Treatment.
(Stuart M. Sprague, D.O., ASN Annual Board Review Course, September, 2000, San Francisco, CA)  

The basics of renal stone disease. What's the incidence and prevalence? What are the mechanisms for stone formation? What is nucleation? Epitaxy? What are the risk factors? How do we classify stones? What are the categories of hypercalciuria? What is the role of an acid-ash diet? What are the most important non-calcium stones?

Part two deals with diagnosis and treatment. What is the diagnostic approach to a patient with a single stone? Multiple stones? What drugs can cause stones? Which associated illnesses? What laboratory test do we order, and how do we treat each type of stone?



July 29 - August 4, 2001


Dr. Nickeleit
Renal Allograft Viral Infections: How Important are They?
(V. Nickeleit, M.D., Ph.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

CMV and BK (polyoma) virus are the focus of this talk. CMV infection in renal allografts (Part 1): How often does it occur? Is it ever limited to the kidney or is this a manifestation of systemic infection? How is it diagnosed by transplant biopsy? Is CMV a cause or an effect of acute rejection? Does CMV antigenemia impact long-term graft survival? Now to BK virus (Part 2 - diagnosis, and Part 3 - management): What is BK-virus nephropathy? Does it manifest early or late after transplantation? How is it diagnosed? What are decoy cells? What about plasma PCR for BK-virus DNA? How can one separate BK-virus infection from rejection? What are the risk factors for BK-virus nephropathy? How does one manage this condition?



July 22 - 28, 2001


Dr. O'Neill
Renal Biopsy
(W. Charles O'Neill, M.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

From an interventional nephrology series of talks at ASN 2000, Dr. O'Neill, who is an expert in renal ultrasound as well, discusses the basic techniques used to perform renal biopsies. What are the best needles to use? How do you position the patient? Left or right kidney? How does one use ultrasound guidance? How do you identify once you are in the kidney? Is real time guided-ultrasound necessary? What are the complications and how can they be avoided? How should the patient be monitored post-biopsy?



July 16 - 22, 2001


Dr. Brooks
Endothelin Blockers: Clinical Trials
(David P. Brooks, Ph.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

Endothelin receptor antagonists can be mixed, or selective against ETA or ETB, and can be given IV or orally. A number of them have reached Phase II and III clinical trials. Endothelin is hypertensive, but also increases renal vascular resistance. The antagonists lower BP and attenuate the effects of endothelin on RVR. Do they reduce the risk of contrast nephropathy? Do ET antagonists have adverse effects? What about their use to treat hypertension? Endothelin levels are two to fivefold elevated in heart failure. Do ET antagonists have a place in treatment of CHF? What hemodynamic changes to they cause? What are their effects on pulmonary hypertension? What do the Phase II and III trials in CHF and pulmonary hypertension show?



July 8 - 15, 2001


Dr. Appel
Lupus Nephritis. Prognostic Factors, Conventional Therapy, and Novel Treatments.
(Gerald B. Appel, M.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

Prognostic factors for severe lupus include baseline serum creatinine, hematocrit, proteinuria, and race plus activity and chronicity indices. What is the best treatment? Steroids? Cyclophosphamide? Azathioprine? Cyclosporine? Which combinations work best, and for how long should each be given? Do some combinations work for membranous lupus but not for DPGN? Of the newer therapies, including IV gamma globulin, LJP-394, anti-CD40 ligand, Bindarit, and mycophenolate mofetil, which show the most promise? Can MMF be used in place of cyclophosphamide initially? As maintenance therapy? What are the three cardinal rules for treating patients with severe lupus nephritis?



July 1 - 7, 2001


Dr. Massy
Oxidative Stress in Chronic Renal Failure
(Ziad Massy, M.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

What is oxidative stress? Carbonyl stress? Nitrosative stress? Chlorinative stress? What biomarkers of oxidative stress are elevated in chronic renal failure and why? Is it production or impairment of anti-oxidant enzymes, or both? Is there evidence that oxidative stress in CRF is linked to cardiovascular outcome? How does oxidized LDL cause atherosclerosis? Is there more than one type of oxidized LDL? Does use of IV iron increase oxidative stress? What about treatments? Does use of a biocompatible dialyzer membrane help? How about use of a vitamin-E coated cellulosic membrane? What is the role of ACE inhibitors, statins, or folate supplementation?



June 24 - 30, 2001


Dr. Gonin
Homocysteine in Patients with End Stage Renal Disease
(Joyce Gonin, M.D., ASN Annual Scientific Meeting, October, 2000, Toronto, Ontario, Canada)  

Dr. Gonin reviews what homocysteine is and how it is metabolized. She then summarizes data in nonuremic populations linking elevated homocysteine levels to increased cardiovascular risk. Data linking homocysteine to impaired forearm vasodilatation are presented, and then the discussion shifts to ESRD patients. The possible mechanisms of homocysteine elevation in uremia are discussed, including alterations of the remethylation pathway and of the trans-sulfuration pathway. Studies that tried to lower homocysteine in ESRD are critically assessed, including Dr. Gonin's own randomized study presented at ASN 2000 in abstract form. Effects of B-vitamin supplementation in ESRD and in transplant patients are evaluated, and the mechanisms whereby homocysteine may cause atherosclerosis and worsen vascular damage due to reactive oxygen species are delineated.



June 17 - 23, 2001


Dr. Arduino
Isolation and Reuse Guidelines for Infected Dialysis Patients
(Matthew Arduino, M.D., RPA 2001 Annual Meeting, March, 2001, Washington, D.C.)  

Dr. Arduino from the United States Centers for Disease Control reviews current recommendations. What are standard precautions? Airborne? Droplet? Contact? Which need to be used in all dialysis patients? In those with HIV? Can patients with HBsAg+ participate in a reuse program? Under what conditions? What about patients with HIV? HCV? The talk briefly covers the salient points and refers to a newly issued set of guidelines by the CDC on these issues. The guidelines he alludes to are available as a 63 page document in .PDF format from the CDC. Click on this link to download.



June 10 - 16, 2001


Dr. August
Management of Hypertension in Pregnancy
(Phyllis August, M.D., ASN Renal Week, October 2000, Toronto, Ontario, Canada)  

Dr. August focuses her presentation around two cases, the first a woman with chronic hypertension who presents in the first timester, and the second a patient with more severe hypertension who presents with preeclampsia. The normal fall in blood pressure in pregnancy is discussed, along with various management strategies during all stages of pregnancy. A detailed discussion of drug therapy is included, including the safety or lack thereof of certain classes of antihypertensive drugs in this situation. Finally, indications for workup of secondary hypertension in pregnant women are also considered.



June 3 - 9, 2001


Dr. Danovitch
Diagnosis and Management of Renal Allograft Dysfunction
(Gabriel Danovitch, M.D., ASN Renal Week, October 2000, Toronto, Ontario, Canada)  

Dr. Danovitch begins by dividing 4 clinically relevant time frames for graft dysfunction, and then talkes about early vs. late differential diagnosis. He emphasis donor status, particularly as it relates to delayed graft function, and discusses several methods of potentially minimizing post-transplant ATN. Various pharmacologic and immunologic approaches are also presented. Then he moves on to acute rejection, calcineurin nephrotoxicity, drug-induced hemolytic uremic syndrome, and finally, chronic allograft failure.



May 27 - June 2, 2001


Dr. Ponticelli
Alternatives to Corticosteroid Treatment in Patients with FSGS
(Claudio Ponticelli, M.D., ASN Annual Scientific Meeting, October 2000, Toronto, Ontario, Canada)  

Following up on last week's presentation by Dr. Steve Korbet, where the role of steroid therapy in FSGS was discussed, Dr. Ponticelli covers alternative treatments for this condition. The benefits of obtaining a remission on ultimate prognosis is emphasized at the outset. Azathioprine and MMF use against FSGS is reviewed, with the conclusion that the sparse data and small patient sizes combine to result in insufficient information regarding their utility here. More data are on hand regarding alkylating agents, and the randomized trial of Tarshish et al and other non-randomized data, including the use of the Mendoza protocol, are reviewed. Cyclosporine and tacrolimus may well be useful, and several randomized trial results are analyzed. Finally, novel therapies including plasmapheresis, LDL-apheresis, and immunoadsorption can be tried, and the data from the literature is summarized.



May 20 - 26, 2001


Dr. Korbet
Treatment of FSGS: Conservative vs. Steroid Therapy
(Stephen M. Korbet, M.D., ASN Annual Scientific Meeting, October 2000, Toronto, Ontario, Canada)  

Dr. Korbet starts out with a discussion of prognosis in FSGS as a function of disease severity, and in particular, the prognostic implications of heavy proteinuria. Conservative options such as good BP control and ACE inhibitor use are discussed, along with data specific to FSGS patients. Then Dr. Korbet turns to steroid therapy, and describes the low- and high-dose regimens which have been used, and covers the roles of steroid dose, duration of treatment, and and presence of cellular lesions on prognosis.



May 13 - 19, 2001


Dr. Bolton
Use of Physician Extenders in the Dialysis Unit
(W. Kline Bolton, M.D., RPA Annual Meeting, March 2001, Washington D.C.)  

Dr. Bolton discusses the rather extensive use of nurse practicioners as physician extenders in the dialysis unit at the University of Virginia, and also entertains a broader discussion of use of either physician assistants or nurse practicioners in this capacity. As there was problem showing the slides at the time of the initial presentation, the focus is on an extensive question and answer period, which has been edited and set up in a FAQ format. The audio of a brief introduction by Dr. Bolton, as well as a summation after the Q&A period, are also presented.

The focus of Dr. Bolton's didactic presentation was the Renal Physicians Association Position Paper issued October 29, 2000, on "Development of Effective Collaborative Practice Models for Chronic Renal Failure". This is available free of charge via the RPA website. For non-members, click on Publications, and then on Position Papers. Check the October, 29, 2000 position paper request after filling out the form, and the file will be emailed to you from the RPA Office.



May 6 - 12, 2001


Dr. Moe
Calcium and Phosphorus Regulation: Bone and Soft Tissue
(Sharon M. Moe, M.D., ASN Annual Board Review Course, September, 2000, San Francisco, CA)  

Dr. Moe continues from where she left off last week with a discussion of the basic histology and structure of bone, including a detailed description of how osteoblasts and osteoclasts interact under the influence of various mediators to effect bone remodeling. New information concerning regulation of osteoclast function by osteoprotegerin is highlighted. The abnormal physiology of bone in renal failure is developed, and calcium and phosphorus balance associated with various forms of hemodialysis and peritoneal dialysis therapy are presented. The positive calcium balance associated with calcium-containing phosphorus binders is stressed, and data documenting accelerated vascular calcification in coronary arteries in ESRD patients is reviewed. The question of what is a safe calcium x phosphorus product is debated, and the potential role of vascular calcification in the atherosclerotic process is considered.



April 29 - May 5, 2001


Dr. Moe
Calcium and Phosphorus Regulation: Gut, Parathyroid Glands, and Kidney
(Sharon M. Moe, M.D., ASN Annual Board Review Course, September, 2000, San Francisco, CA)  

As a complement to Dr. Stanley Goldfarb's presentation on magnesium, this week, Dr. Moe reviews the basics of calcium and phosphorus regulation. She discusses gut absorption of calcium and phosphorus, and calcium and phosphorus balance and disposition. Regulation by vitamin D PTH, and calcitonin is discussed, with emphasis on the newly appreciated role of phosphorus. A detailed segment by segment discussion of the renal handling of calcium and phosphorus is presented, included an up-to-date review of the role played by the calcium-sensing receptor and phosphatonin. Next week, we will present the second portion of Dr. Moe's talk that focused on bone.



April 22 - 28, 2001


Dr. Kliger
Patient Safety in ESRD
(Alan S. Kliger, M.D., RPA 2001 Annual Scientific Meeting)  

The focus of the annual RPA meeting this year was patient safety. Go to their website and download the RPA report on ESRD patient safety: the direct link to the report is here.. We will be posting 4-5 talks from the Annual RPA meeting on HDCN. Dr. Kliger's talk focuses on patient safety. Dr. Kliger begins by discussing three representative patient cases. He describes how error analysis and root cause methods can be used to identify the cause of such errors, and talks about the progress that has been made, and that needs to be made in further defining patient safety issues, including adoption of a common taxonomy, developing an appropriate information gathering and reporting system, staff education and training, and broader use of existing error-reduction hardware such as non-interchangeable Luer-Lock systems for fluid infusions, and bar coding to ensure matching of patient treatment materials with their intended recipients.



April 15 - 21, 2001


Dr. Mehta
Acid-Base and Electrolyte Complications in CRRT
(Ravindra Mehta, M.D., ASN 2000 Annual Scientific Meeting)  

This was part of a symposium on ICU nephrology held at the Toronto meeting. Dr. Mehta begins with an overview of base transport during intermittent hemodialysis, extended daily hemodialysis, SLED, and CRRT. He discusses lactate clearance and the compositions and benefits of various replacement fluids. Dr. Mehta then discusses sodium balance and hypernatremia, glucose absorption and hyperglycemia, calcium and phosphorus kinetics and hypocalcemia and hypophosphatemia, and hypothermia. Finally, he describes some work from a collaborative study concerning acid-base and electrolyte abnormalities related to citrate anticoagulation.



April 8 - 14, 2001

Contemporary Issues in Transplantation: Delayed Graft Function -- Clinical Issues and Case Management

Dr. Brayman

Dr. Matas

Dr. Delmonico

Dr. Bloom

(Four lectures and panel discussion: Drs. Kenneth L. Brayman, Arthur J. Matas, Francis L. Delmonico, and Roy Bloom
ASN 2000 Satellite Symposium)  

Dr. Brayman begins by introducing the scope of the problem; kidney loss due to delayed graft function is now more of a problem than acute rejection, and the problem is worsening as the average donor age increases and as cold ischemia time lengthens. Dr. Matas provides an in-depth review of the delayed graft function. It is associated with increased graft loss and with an increased incidence of acute rejection. Some mechanistic explanations are proposed. Interestingly, kidneys taken from brain dead animals have poorer survival. The concept of "slow graft function" is also introduced, and some preventive strategies are discussed. Dr. Delmonico talks about causes of DGF, and potential strategies relating to organ allocation strategies to minimize DGF, including less emphasis on HLA matching. Practical methods are presented to reduce cold ischemia time to 6 hours from cadaver kidneys. Dr. Bloom focuses on the pathogenesis of DGF as a form of reperfusion injury, and presents his data that DGF incidence can be reduced by induction therapy with Thymoglobulin.


April 1 - 7, 2001


Dr. Hricik
Clinical Issues in Kidney - Pancreas Transplantation
(Dr. Donald E. Hricik, ASN 2000 Scientific Meeting. Renal Week)  

Dr. Hricik begins his talk by acknowledging the great potential of islet cell transplantation (Edmonton protocol), but admits that whole pancreas transplantation remains the current standard of care, especially for diabetic patients with ESRD. Renal transplantation results in better survival than dialysis for diabetics with ESRD, and combined kidney - pancreas transplantation does not impair results with the transplanted kidney. Selection criteria are discussed, as well as different surgical techniques (bladder drainage vs. enteral drainage). Survival results are improved with newer immunosuppressive agents. Diabetic nephropathy can be reversed, but it takes 5-10 years. Retinopathy stabilizes but does not improve. Effects of pancreas transplantation on hypertension, quality of life, and costs, including hospitalization days are reviewed.



March 25 - 31, 2001


Dr. Vincenti
Induction Immunosuppressive Therapy - An Update
(Dr. Flavio Vincenti, ASN 2000 Scientific Meeting. Renal Week)  

This is one of a series of talks given at a Renal Transplantation Update symposium during Renal Week. Dr. Vincente begins with a discussion of the changing pattern of use of antilymphocyte antibodies, with a marked increase in the usage of anti-IL2R antibodies as well as of thymoglobulin in the past few years. For those of you who need a refresher course on the anti-IL2R antibodies, please see the list of ASN 1998 lectures for an introductory lecture on this subject by Dr. John Neylan. Dr. Vincenti begins with a rationale for using anti-IL-2R monoclonals, in that they interact only with the IL-2R-alpha chain, thus leading to a more selective inhibition of the immune response. Differences between daclizumab and basiliximab are touched upon, and the phase III trials with both antibodies are presented. Newer applications of these drugs are in combination with triple therapy, with tacrolimus, or even in steroid-sparing regimens. Use of sirolimus is also discussed in combination with these antibodies in the discussion section. Also, their place vs. polyclonal antilymphocyte antibodies, especially ATGAM, is also considered.



March 18 - 24, 2001

Evidence-Based Treatment Directives: Anemia Correction in Early Renal Insufficiency


Dr. Owen

Dr. Collins

Dr. McClellan

Dr. Cerami

Dr. Parfrey
(Five speakers: Drs. Allan J. Collins, William M. McClellan, Carla Cerami, Patrick S. Parfrey, and William F. Owen, Jr., ASN 2000 Satellite Symposium)  

Another satelite symposium from ASN 2000 Toronto focusing on both anemia and early chronic kidney disease. Put together by Excerpta Medica, this symposium offers CME credits ($15.00) for those who complete the program and mail in a post- test and evaluation form to the address listed.

Dr. Allan Collins begins with data from the USRDS regarding geographic variation of treatment of anemia. His message is, that at the outset or initiation of dialysis, the Hct and use of EPO are rising over the past several years, but usage is still well below optimal levels. Considerable geographical variation in EPO use is documented. Dr. McClellan analyzed NHANES III data and presents his findings that anemia increases as estimated creatinine clearance falls, and that low CrCl and anemia seem to act synergistically to reduce QOL scores. Dr. Carla Cerami presents some very interesting data in rats showing that EPO crosses the blood-brain barrier, and that systemically administered EPO protects the brain in an experimental cerebral artery occlusion model as well as in a cortical trauma model. Dr. Parfrey presents a very detailed review of cardiovascular disease both in ESRD and early renal insufficiency (ERI) patients, citing often from the Canadian prospective cohort study. He also analyzes the issue of optimal hemoglobin level, and discusses results both from Dr. Besarab's NEJM study as well as the Canadian Normal Hemoglobin Study. Finally, Dr. Bill Owen, Chair of the symposium, presents a very useful practice plan approach to treating patients at the ERI stage, and focuses on means which a clinic can use to increase early referral of such patients to specialty care.

Incidentally, this program will also be available on CD-ROM. Those interested in obtaining a copy should send an email to Mark Lutz at Virtual Factory, mark@virtualfactory.com.


March 11 - 17, 2001


Dr. Linas
Hypertension in Dialysis Patients
(Stuart L. Linas, M.D., ASN 2000 Renal Week)  

Dr. Linas participated in a symposium at ASN 2000 Renal Week in Toronto focusing on hypertension in various groups. Dr. Linas discussed dialysis patients. He begins by talking about epidemiologic data, and the fact that mortality is not so easily tied to blood pressure in dialysis patients as in the non-uremic population. The J-curve and U-curve mortality to BP relationships found by some authors are analyzed. Dr. Linas then focuses on outcomes data linking hypertension to cardiac disease, including LVH, and to other target organ damage. Various therapies are discussed, and the utility of various classes of antihypertensive agents in this population are compared. The role of erythropoietin and other causes is also touched upon, and the role of extracellular volume is examined in detail.



March 04 - 10, 2001


Dr. Anderson
Hypertension in Diabetes
(Sharon Anderson, M.D., ASN 2000 Renal Week)  

Dr. Anderson chaired this very interesting symposium on the optimal treatment of hypertension in various patients subgroups at the Toronto ASN's Renal Week. We are posting a number of talks from this session. Dr. Anderson's talk focused on diabetes and was divided into renal protective ability of various classes of antihypertensive drugs vs. their cardiac protective effects. The recent trial results are reviewed, including HOPE, micro-HOPE, FACET, ABCD, UKPDS, CAPPP, and Syst-Eur.



February 18 - March 03, 2001


Dr. Besarab
Vascular Access Surveillance Using Pressures and Flows
(Anatole Besarab, M.D., ASN 2000 Renal Week)  

Dr. Besarab, creator of the static pressure monitoring concept for monitoring vacular access function, spends the first part of his talk describing the finer points of pressure monitoring, including differences in monitoring the inflow and outflow pressures, and differences in pressures between grafts and fistulas. He presents some interesting case case reports showing how these pressures change with intervention and how they correlate with flow. In the second part of the talk, Dr. Besarab describes various methods of access flow monitoring and how access flow measurements can be used to predict access thrombosis.


Role of Intrarenal Angiotensin II in the Pathophysiology of Hypertension


Dr. Weinberg

Dr. Navar

Dr. Miller

Dr. Fisher

Dr. Lalouel
(Five Speakers: Dr. Marc Weinberg, Dr. Judith Miller, Dr. Gabriel Navar, Dr. Naomi Fisher, and Dr. Jean-Marc Lalouel, ASN 2000 Satellite Symposium)  

This symposium focuses on the role of angiotensin II in hypertension, and particularly, on the fact that intrarenal angiotensin II levels can be higher than plasma levels, and that high intrarenal AII levels may participate in the progression of renal impairment in vulnerable populations such as diabetics and African Americans. The avant-garde of therapy in this area is use of supramaximal doses of AII receptor blockers or combinations of ACE inhibitors and AII receptor blockers in an attempt to counteract high intrarenal AII levels in certain conditions, further lower proteinuria and, ultimately, to retard progression of renal failure. The preliminary clinical trial results in this area are presented by Dr. Marc Weinberg.

Dr. Navar and Dr. Lalouel present basic science oriented lectures in the field. Dr. Navar has shown how intrarenal AII levels may be higher than circulating levels and has suggested mechanisms of why this may be so. Dr. Lalouel shows work suggesting that angiotensinogen may be implicated in certain forms of hypertension. Dr. Fisher presents data suggesting a role for intrarenal AII in renal hemodynamics in Blacks and diabetics, while Dr. Miller presents some very interesting work linking poor control of diabetes and high glucose levels with renal damage via the AII system.

CME credits are offered for this symposium. You need to print out the evaluation form, take the post-test, and send it to the CME provider for your CME certificate (up to 2.5 hours of Category I credit).


February 11 - 17, 2001


Dr. Sands
Doppler Ultrasound for Access Evaluation
(Jeffrey Sands, M.D., ASN 2000 Renal Week)  

Most of the interest in vascular access monitoring has been in following static or dynamic intra-access pressures or access flow measurements. Color flow Doppler imaging, previously more widely used, has occupied a secondary place in the United States, most likely due to difficulties in obtaining reimbursement for this procedure. Dr. Jeff Sands presents a very convincing case that the utility of color flow Doppler may be seriously underestimated. He begins by presenting a beautiful set of images demonstrating the power of color flow Doppler imaging, and then describes in detail how Doppler can be used to estimate access flow. The second part of the talk shows how Doppler ultrasound can be used as part of a vascular access monitoring program to maintain patency and guide early intervention.



February 4 - 10, 2001


Dr. Goldfarb
Syndromes of Hypo- and Hypermagnesemia
(Stanley Goldfarb, M.D., ASN 2000 Board Review Course)  

This year we are posting talks from the Board Review Course on the divalent cations and potassium. Dr. Goldfarb first goes over the basics of magnesium chemistry, including the distribution of magnesium among various body organs, and talks about the problems in assessing magnesium deficiency when measuring serum levels. A magnesium retention test is described, and then he discusses normal magnesium metabolism in general. GI absorption is touched upon, and then the discussion centers around renal handling of magnesium, furosemide and thiazide effects, and the physiology of magnesium handling in various parts of the nephron. The possible role of calcium-sensing receptors is emphasized.

Part two of the talk deals with clincal causes of magnesium deficiency, including redistribution, decreased intake, and renal wasting. New data by Simon, Lifton, et al, regarding paracellin-1 are described. Clinical consequences of magnesium deficiency are discussed, and the evidence regarding usefulness of pharmacologic use of magnesium is presented, especially post MI. Finally, the causes and symptoms and consequences of hypermagnesemia are reviewed.



January 28 - February 3, 2001


Dr. Kasiske
Treatment of Hypertension in Renal Transplant Recipients
(Bert Kasiske, M.D., ASN 2000 Renal Week)  

This was part of a hypertension symposium chaired by Dr. Sharon Anderson during Renal Week in October, 2000 at Toronto. Dr. Kasiske starts by discussing the studies linking poor outcome in renal allografts and high blood pressure, emphasizing that causality is not yet proven. Then he covers cyclosporine and tacrolimus contributions to high blood pressure. He then discusses at what level BP treatment should begin and goals of therapy. He proposes a management algorithm and discusses how various classes of antihypertensive drugs may affect the course of several aspects of renal transplantation. Refractory hypertension management is also presented, as well as practical drug combinations to use in these patients.



January 21 - 27, 2001


Dr. Dworkin
Treatment of Hypertension in Patients with Chronic Renal Insufficiency
(Lance D. Dworkin, M.D., ASN 2000 Renal Week)  

This was part of a hypertension symposium chaired by Dr. Sharon Anderson during Renal Week in October, 2000 at Toronto. Dr. Dworkin begins by discussing cardiovascular disease prevalence and risk factors during the period when patients have mild to moderate chronic renal insufficiency. BP results of the MDRD study are described, and then issues of target blood pressure and choice of anti-hypertensive agents are discussed extensively, focusing on ACEIs, ARBs, CCBs, and use of combination therapies. The major trials in this area, including the diabetes-captopril trial, the European benazepril study, ABCD, and REIN are described and some newer, smaller trials focusing on combination ACEI / ARB therapy and ACEI vs. ARBs are touched upon.



January 14 - 20, 2001

Redefining Chronic Renal Insufficiency: Emerging Role of Anemia

Dr. Nissenson

Dr. Levin

Dr. London

Dr. Fishbane

Dr. Churchill

Dr. Pereira
(Three talks and two panel discussions: Drs. Pereira, Levin, Churchill, London, Fishbane, and Nissenson)  

This ASN Satellite Symposium sponsored by Tufts University School of Medicine emphasizes the lack of attention currently being paid to anemia in patients with chronic renal insufficiency. Anemia in this population begins early and has been linked to both cardiovascular disease and to poor outcome (mortality and morbidity). Despite this fact, use of EPO in the CRI population is far from universal, even among patients under nephrologist care. CME Credit is available for those who listen to the material and successfully complete a post-test / evaluation form. The latter should be printed out and mailed to Tufts per the instructions on the form.

The structure of this symposium is a bit different from that of those usually archived on HDCN. There were three slide lectures, by Dr. Pereira, Levin, and Churchill. But there were also two panel discussions, one among Drs. Fishbane, Nissenson, and London, and one among all of the faculty. These are reproduced both in FAQ mode and in video mode. Whereas we don't believe that video mode works for the usual slide-accompanied lecture, it does add to the experience of such panel discussions.

The video is presented in both Real Media and Windows Media Player formats at a variety of connection speeds. All those connecting to the internet with modems should use the lowest connection speed video option. Those with faster connections can experiment with the larger file-size video options. If your connection speed is too slow, the video will not move or else it will be refreshed very slowly. If this happens, you will have a better experience connecting to the slower video option link.


Dr. Korbet
The Dysproteinemias
(Dr. Stephen M. Korbet)  

Another lecture from the ASN 2000 Annual Meeting (Renal Week) in Toronto. Dr. Korbet focuses on three areas: Amyloidosis, with the emphasis being on AL amyloid, Congo Red negative glomerulopathies with monoclonal immunoglobulin deposition, so-called MIDD, and immunotactoid glomerulopathy. Typical biopsy findings, clinical presentation, and treatment are discussed for each of these three unusual forms of kidney diseases.



January 7 - 13, 2001


Dr. Luce
Permissive Hypercapnia as Part of a New Strategy of Mechanical Ventilation
(Dr. John M. Luce)  

Another lecture from the ASN 2000 Annual Meeting in Toronto. Dr. Luce describes the new intensivist approach to ventilating critically ill patients with lung injury, where a lower tidal volume is used, and, in some variants, PEEP is used early to aid alveolar recruitment. Dr. Luce reviews a number of important papers and randomized trials in which the survival benefits of such new ventilator strategies were established, including the large ARDS-net trial in which his center participated. Some of these new ventilator strategies result in hypercapnia, and Dr. Luce goes over both the potential adverse and beneficial effects of respiratory acidosis and the pros and cons of treating this with alkali, including THAM.





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