Shayan Shirazian

Gastrointestinal disorders and renal failure: exploring the connection.

Gastrointestinal complications are known to commonly occur in patients with renal failure. Uremia and dialysis have long been speculated to increase the risk of lesions in the gastrointestinal tract and accessory organs. In addition, gastrointestinal procedures such as gastrointestinal bypass surgery and the administration of colonoscopy preparations can lead to the development of renal complications. Results from studies that have attempted to define the association between renal dysfunction and gastrointestinal complications are, however, conflicting and limited by small and varied sample populations. No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This Review examines the existing data on gastrointestinal complications in patients with chronic kidney disease and end-stage renal disease and aims to outline the etiology and management of common gastrointestinal disorders in such patients.

Monoclonal IgG1κ anti-glomerular basement membrane disease: a case report.

We report a case of anti-glomerular basement membrane (anti-GBM) nephritis with indolent course, monoclonal IgG1κ (immunoglobulin G, subclass 1, κ light chain) linear staining of the GBM, and multifocal GBM breaks but without crescents or detectable serum anti-GBM antibody in a patient followed over 9 years. Atypically, anti-GBM nephritis follows an indolent course. A very small fraction of patients with anti-GBM nephritis lack detectable circulating anti-GBM antibodies, and rare reports of monoclonal anti-GBM nephritis exist. We report what is to our knowledge the first case manifesting all 3 of these rare variations. Our patient initially presented with asymptomatic decreased kidney function following an upper respiratory tract infection. He was found to have microhematuria and subnephrotic proteinuria with mild diffuse endocapillary proliferative and exudative glomerulonephritis with linear IgG1κ staining of the GBM. He was treated with an induction regimen of intravenous cyclophosphamide and corticosteroids followed by maintenance monotherapy with mycophenolic acid. Nine years later, repeat kidney biopsy for worsening kidney function after an upper respiratory tract infection showed persistent monoclonal staining of the GBM and acute glomerulonephritis with increased chronicity, including a single fibrocellular crescent. Despite extensive clinical investigations spanning nearly a decade, no circulating anti-GBM antibody or monoclonal protein has been detected. In this case report, we explore the unique features of this monoclonal IgG1κ-associated anti-GBM nephritis.

Underprescription of renin-angiotensin system blockers in moderate to severe chronic kidney disease.

Background:Renin–angiotensin system (RAS) blockers slow the progression of chronic kidney disease (CKD). Despite this, up to 40% of patients with CKD and an indication for RAS blockade do not receive these medications. The purpose of this study was to examine variables associated with the prescription of RAS blockers in patients with CKD and to identify opportunities to increase their use. Methods:The electronic medical records of patients with moderate to severe CKD and an indication for RAS blockade were reviewed. For patients with an indication for RAS blockade who were not prescribed these medications, previous notes were reviewed to ascertain reasons why RAS blockade was not prescribed. Results:Six hundred twenty-seven patients with moderate to severe CKD and an indication for RAS blockade were identified. Of these patients, 225 (36%) were not prescribed RAS blockade. This group was found to have significantly less diabetes, to be significantly older and to have significantly lower estimated glomerular filtration rate and blood pressure than the group on RAS blockade. For the majority (59%), no documented reason for not being prescribed RAS blockade was found. Among documented reasons, hyperkalemia and a history of acute kidney injury were the most common. Conclusions:The authors found that a large proportion of patients with CKD and an indication for RAS blockade were not prescribed these medications. For the majority, there was no provider-documented reason explaining why these medications were not prescribed, and the findings suggest that there may be opportunities to increase RAS blocker prescribing.

Longitudinal Predictors of Uremic Pruritus

OBJECTIVE Pruritus is a common problem among hemodialyzed patients. Its causes are poorly understood, and, as a result, itching is often attributed to elevated serum phosphorus and other disorders of bone and minerals. The primary purpose of this study was to analyze the relationship between pruritus and common tests of bone and mineral disease. METHODS This study was a post hoc analysis of data from a randomized controlled trial of 3 months of ergocalciferol versus placebo treatment in 50 hemodialysis patients with uremic pruritus. A pruritus survey was administered at baseline and then every 2 weeks for 12 weeks. Concurrent serum phosphorus, intact parathyroid hormone (PTH), serum calcium, and calcium-phosphate product were measured. RESULTS Pruritus score was not found to be associated or correlated with serum phosphate, intact PTH, serum calcium, or calcium-phosphate product at each time interval or over time. Likewise, when analyzed by original study group (placebo or ergocalciferol), no association or correlation between the mineral and bone indicators and itching were found. CONCLUSION Neither serum phosphate nor other tests of bone and mineral status were found to be significant predictors of pruritus at any point in time or over time.

A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease.

BACKGROUND Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training. OBJECTIVE The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease. METHODS In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior. RESULTS 2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease. CONCLUSION The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

Complexity of differentiating cerebral/renal salt wasting from SIADH: Emerging importance of determining fractional urate excretion

The current approach to the diagnosis and treatment of hyponatremia is in a state of flux, largely because of an unresolved controversy regarding the relative prevalence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting, or preferably renal salt wasting (RSW). The recent awareness that symptoms are now being attributed to even mild hyponatremia has led to recommendations to treat virtually all hyponatremics. (Arief et al, 1976; Berl et al, 2010; Decaux, 2006, 2009; Gankam Kegne et al, 2008; Hoorn et al, 2009; Renneboog et al, 2006; Sterns et al,2009; Schrier, 2010) This tendency to treat even mild hyponatremia introduces an urgency to resolve the diagnostic dilemma of differentiating two syndromes, SIADH and RSW, with divergent therapeutic goals, to water-restrict in SIADH or administer salt and water in RSW. We propose to define RSW by supporting data and review the pathophysiology of RSW, the derivation and evolution of the controversy over the relative prevalence of SIADH and RSW, and methods to differentiate SIADH from RSW. We will also review the emerging value of determining fractional excretion (FE) of urate in the evaluation of patients with hyponatremia by emphasizing our recent observations in reset osmostat, identify conditions that predispose to RSW, amplify the possibility that RSW might exist in patients with an increased FEurate without hyponatremia and propose an algorithm where FEurate is central to the evaluation of hyponatremia. We will also advocate and hopefully justify changing the designation, cerebral salt wasting, to renal salt wasting, and briefly discuss different strategies to treat hyponatremia.

The self-management experience of patients with type 2 diabetes and chronic kidney disease: A qualitative study

Background The purpose of this study was to explore views related to the self-management of type 2 diabetes and chronic kidney disease. Methods We conducted three semi-structured focus groups in participants with type 2 diabetes and chronic kidney disease. Interviews were transcribed, coded, and analyzed using thematic analysis. Credibility was supported through triangulation of data sources and the use of multiple investigators from different disciplines. Results Twenty-three adults participated. Three major themes were identified: emotional reactions to health state, the impact of family dynamics on self-management, and the burden of self-management regimens. Family dynamics were found to be a barrier and support to self-management, while complicated self-management regimens were found to be a barrier. Additionally, participants expressed several emotional reactions related to their CKD status, including regret related to having developed CKD and distress related both to their treatment regimens and the future possibility of dialysis. Conclusions This exploratory study of patients with type 2 diabetes and chronic kidney disease describes barriers and supports to self-management and emotional reactions to chronic kidney disease status. Future research should confirm these findings in a larger population and should include family members and/or health care providers to help further define problems with self-management in patients with type 2 diabetes and chronic kidney disease.

Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management

Depression is highly prevalent and is associated with poor quality of life and increased mortality among adults with chronic kidney disease (CKD), including those with end-stage renal disease (ESRD). However, there are several important differences in the diagnosis, epidemiology, and management of depression between patients with non−dialysis-dependent CKD and ESRD. Understanding these differences may lead to a better understanding of depression in these 2 distinct populations. First, diagnosing depression using self-reported questionnaires may be less accurate in patients with ESRD compared with CKD. Second, although the prevalence of interview-based depression is approximately 20% in both groups, the risk factors for depression may vary. Third, potential mechanisms of depression might also differ in CKD versus ESRD. Finally, considerations regarding the type and dose of antidepressant medications vary between CKD and ESRD. Future studies should further examine the mechanisms of depression in both groups, and test interventions to prevent and treat depression in these populations.

Treating desmopressin-induced hyponatremia: a case using hypertonic saline.

Desmopressin acetate (DDAVP), a medication used in the treatment of bleeding and polyuric disorders, has the potential to cause hyponatremia when free water is not appropriately restricted with its use. This free water retention is reversible when DDAVP is discontinued. We report a case of symptomatic DDAVP-induced hyponatremia in which discontinuation of DDAVP led to a rapid increase of serum sodium. In order to prevent rapid free water excretion, DDAVP and hypertonic saline were used concurrently. With close monitoring, this can be an effective treatment strategy in patients with DDAVP-induced hyponatremia.

The effect of hemodialysis ultrafiltration on changes in whole blood viscosity

Increased whole blood viscosity (WBV) can be injurious to the vascular endothelium and increase the risk of atherothrombotic events. This study examined the effect of hemodialysis ultrafiltration (UF) on WBV, with a focus on high vs. low‐volume UF patients. In stable hemodialysis patients, blood was drawn for hematocrit (Hct) and WBV at the start, midpoint, and at the end of dialysis. For analysis, patients were divided into high UF (≥2700 mL) or low UF (<2700 mL) groups. A total of 59 patients completed the study. Mean Hct increased during dialysis in both groups. The intradialytic increase in Hct was significantly greater in the high vs. the low UF group (3.2% vs. 1.28%, P = 0.01), with a significantly higher end‐dialysis Hct in the high UF group (40.5% vs. 38%, P = 0.02). At the end of dialysis, both high shear rate WBV (P < 0.01) and low shear rate WBV (P < 0.01) were significantly higher in the high UF compared with the low UF group. There was an approximately two‐fold greater increase in high shear rate (P < 0.01) and low shear rate (P = 0.01) WBV during dialysis in high vs. low UF groups. The increase in high shear rate WBV during dialysis was significantly correlated with an increase in Hct (R2 = 0.63, P < 0.01). We found that hemodialysis UF causes a surge in WBV. The surge was of greater magnitude in high than in low UF patients.