HDCN Multimedia Lecture or Case of the Week: 2000 Archive    
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Multimedia Lecture or Case of the Week: 2000 Archive
(listed in reverse chronological order)

December 31, 2000 - January 6, 2001

New Concepts in Anemia Management
(Four talks: Drs. Kaufman, Golper, Wish, and Aronoff)  

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.

December 17 - 30, 2000

The Viral Nephritides
(Dr. Gerald B. Appel)  

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.

December 10 - 16, 2000

Potassium Physiology and Pathophysiology
(Dr. Robert J. Alpern,)  

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.

Iron Management in the Year 2000: Is There Anything New?
(Drs. Fishbane, Wish, Seligman, Eschbach, and Nissenson,)  

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.

December 3 - 9, 2000

(Dr. Jeffrey L. Platt)  

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.

November 26 - December 2, 2000

Dialysis Frequency, Urea Kinetics, and Solute Removal: An Integrated Approach
(Dr. Thomas A. Depner)  

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.

Staying Healthy with Bad Kidneys. Doc-To-Me Pre-ESRD Patient Lectures
(Dr. David Mendelssohn, Dr. Eli Friedman, Dr. Adrian Fine, Dr. Adeera Levin, Dr. Jill Lindberg, Dr. Peter Blake, Dr. Robert Toto, and Dr. Thomas Peters)  

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.

November 19 - 25, 2000

Antihypertensive Drug Interactions
(Dr. George R. Aronoff)  

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.

November 12 - 18, 2000

Therapeutic Approach in the Year 2000 to the Diabetic Hypertensive
(Dr. James R. Sowers)  

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.

November 5 - 11, 2000

Is Adult Cardiorenal Risk Determined in Utero?
(Dr. David Barker)  

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.

October 29 - November 4, 2000

The Do's and Don'ts of Water Treatment for Hemodialysis
(Richard A. Ward, Ph.D.)  

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.

October 21 - 28, 2000

Diabetic Cardiomyopathy
(Thomas D. Giles, M.D.)  

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.

October 8 - 20, 2000

Treatment of Hypertensive Urgencies and Emergencies
(George A. Bakris, M.D.)  

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.

October 1 - 7, 2000

ASN 2000 abstracts on the Web   

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.

September 24 - 30, 2000

Pain Management in Polycystic Kidney Disease  
(Vicente E. Torres, M.D., 11th Annual Meeting of the PKRF, June 2000, Oakbrook, IL)   

Minimally Invasive Surgery Applications in Polycystic Kidney Disease  
(John Valente, M.D., 11th Annual Meeting of the PKRF, June 2000, Oakbrook, IL)   

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.

Please look at the related talks on polycystic kidney disease from the 1999 PRKF annual meeting, as well as from the 1998 PRKF annual meeting.

September 17 - 23, 2000

Clinical Trials Database  
(NIH / NLM)   

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.

September 10 - 16, 2000

Revisiting Aldosterone in Congestive Heart Failure  
(Judith E. Soberman, M.D., Am Soc Hypertens (ASH) Annual Scientific Meeting, May, 2000, New York, NY)   

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.

September 3 - 9, 2000

Diet in Polycystic Kidney Disease  
(Theodore I. Steinman, M.D., 11th Annual Conference on PKD, Oak Brook, IL)   

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.

August 20 - 26, 2000

Erectile and Sexual Dysfunction in Hypertension  
(Richard H. Grimm, Jr., M.D., ASH 2000 Annual Scientific Meeting, New York)   

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.

August 13 - 19, 2000

Mechanisms of Diabetic Vasculopathy  
(Mark E. Cooper, M.D., Ph.D., ASH 2000 Annual Scientific Meeting, New York)   

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.

August 6 - 12, 2000

Are Angiotensin-II Receptor Antagonists better than ACE Inhibitors?  
(Sharon Anderson, M.D., ASN 1999 Annual Scientific Meeting, Miami)   

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.

July 30 - August 5, 2000

Insertion and Management of Tunneled Venous Catheters  
(Jack Work, M.D., NKF 2000 Spring Clinical Annual Scientific Meeting)   

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.

July 16 - 29, 2000

The British Medical Journal Full Text Journal and Book Collection On-Line  
(various authors)   

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.

July 9 - 15, 2000

The Obesity Epidemic: Roles of Gluttony, Sloth, and Genetics  
James O. Hill, M.D.   

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.

July 2 - 8, 2000

Hypertension in African Americans  
Akinlolu Ojo, M.D.   

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.

June 26 - July 2, 2000

Power Point Slide Files: Schrier's Atlas of Diseases of the Kidney  
(Various authors)   

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.

June 18 - 25, 2000

Maternal Hemodynamics and the Fetal Environment  
(Arlene Chapman, M.D., NKF 2000 Spring Clinical Annual Scientific Meeting)   

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.

June 11 - 17, 2000

Shared Decision Making in the
Appropriate Initiation of and Withdrawal from Dialysis
(A.H. Moss, M.D. RPA 2000 Annual Meeting)   

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.

June 4 - 10, 2000

Credentialing of Nephrologists for Access Procedures  
(Dr. Jack Work, RPA 2000 Annual Meeting)   
Multidisciplinary Approach to Vascular Access Management  
(Donna Carlton, RN, BSN, RPA 2000 Annual Meeting)   

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.

May 28 - June 3, 2000

Volume Control and Blood Pressure in ESRD Patients  
(Dr. Jonas Bergström, ASN 1999 Annual Scientific Meeting)   

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.

May 21 - 27, 2000

ESRD Facility Medical Director Role  
(Dr. Stephen McMurray, RPA 2000 Annual Meeting)   

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.

May 14 - 20, 2000

Role of the Nephrologist in the Intensive Care Unit  
(Dr. Emil P. Paganini, RPA 2000 Annual Meeting)   

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.

May 7 - 13, 2000

Protein Catabolism in End-Stage Renal Disease:
Roles of Inflammation, Acidosis, and Specific Humoral Markers
(Dr. Timothy Goodship, ASN 1999 Annual Scientific Meeting)   

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.

April 30 - May 6, 2000

Should Calcium Antagonists be First-Line Anti-hypertensive Therapy in CRF/ESRD?  
(Dr. Robert Unwin, ASN 1999 Annual Scientific Meeting)   

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.

April 23 - 29, 2000

Glycation and Its Inhibition: Therapeutic Implications  
(Dr. Mark Williams, ASN 1999 Renal Week)   

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.

April 16 - 22, 2000

Anticoagulation for Continuous Renal Replacement Therapies  
(Dr. David Ward, ASN 1999 Renal Week)   

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.

April 9 - 15, 2000

Optimal Cyclosporin Dosing  
(Dr. J. Harold Helderman, ASN 1998 Renal Week)   

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.

April 2 - 8, 2000

Tumors after Solid Organ Transplantation  
(Dr. M. Roy First, ASN 1999 Renal Week)   

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.

March 26 - April 1, 2000

Recurrence of Renal Disease in Transplant Recipients  
(Dr. Sundaram Hariharan, ASN 1999 Renal Week)   

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.

March 19 - 25, 2000

Cardiovascular Disease in Renal Transplant Recipients  
(Dr. Bert L. Kasiske, ASN 1999 Renal Week)   

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.

March 5 - 18, 2000

Consequences of Hyperphosphatemia: Are We Accepting the Unacceptable?  (Three lectures, by Dr. Eduardo Slatopolsky, Dr. David Bushinsky, Dr. Glenn Chertow)   

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.

February 13 - March 4, 2000
Common Renal Pathology and Renal Biopsy Interpretation Tools  
(Dr. Arthur H. Cohen, 1999 Renal Week Lecture)   

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.

January 23 - February 5, 2000
Anemia Management: Changing Spectrum of Care: Part Two  
(Dr. Steven Fishbane, Dr. Allen R. Nissenson, and Dr. William F. Owen, Jr.)   

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).

January 16 - 22, 2000
Anemia Management: Changing Spectrum of Care: Part One  
(Dr. Steven Fishbane, Dr. Allen R. Nissenson, and Dr. William F. Owen, Jr.)   

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.

January 2 - 8, 2000
Treatment of intoxications  
(Dr. James F. Winchester)   

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.