Showing papers by "Amir Kazory published in 2018"

Cardionephrology: Proposal for a Futuristic Educational Approach to a Contemporary Need.

Abstract: The field of cardiorenal medicine is vast, rapidly expanding, and complex. Conventional nephrology training programs provide the fellows with the necessary core knowledge to provide general care for patients with renal and cardiovascular diseases. However, there is a need for focused training of interested physicians to master the specialized aspects of these exceedingly common clinical scenarios and optimize the care of such patients. A cardionephrology-focused training can add value to the nephrology subspecialty and potentially increase its attractiveness for a significant subset of trainees. Herein, we provide a proposal for the framework and content of such an educational activity. Creation of an international multidisciplinary workgroup to formulate a comprehensive curriculum for a dedicated cardionephrology track would be the first step. A variety of practical aspects such as implementation methods, the identification of the required skills, and the development of educational assessment tools are discussed. While this proposal primarily focuses on the integration of the curriculum into the training of nephrology fellows, it would also be appropriate (albeit in a modified and customized format) for a wider range of trainees, including cardiology fellows.

Team-Based Learning Activities for First-Year Medical Students: Perception of the Learners.

Abstract: Objectives Team-based learning (TBL) is an active learning strategy that is used increasingly in medical education to promote critical thinking, knowledge application, teamwork, and collaboration The aim of this study was to assess the students' perspective on the utility of TBL compared with traditional lectures Methods We used a validated TBL student assessment instrument comprising three subscales studying accountability, preference for lecture or TBL, and student satisfaction First-year medical students enrolled at the University of Florida College of Medicine in spring semester 2016 were asked to complete the questionnaire Results The response rate was 50% (70/138) Although 81% of students reported that they had to prepare before TBL and believed they had to contribute to the learning of their team, only 52% believed that they were accountable for team learning The majority believed that TBL activities are an effective approach to learning (74%), with 78% agreeing that TBL activities helped them recall information Fewer than half (45%), however, believed that TBL helped improve their grades Conclusions Students reported a preference and satisfaction with TBL over traditional lectures, but a mixed response was noted on the questions pertaining to accountability for team learning

Better late than never: the true results of CARRESS-HF.

Abstract: Grodin and colleagues are admirable for their courage to examine and present, albeit with a 5-year delay, the per-protocol analysis of the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF) in this issue of the Journal.1 With the inclusion only of subjects who received their randomized treatment, the authors found that ultrafiltration (UF) was associated with higher cumulative fluid loss, net fluid loss and relative reduction in weight compared to stepped pharmacological therapy (SPT). The UF group had higher serum creatinine (sCr) and blood urea nitrogen by 72 h.1 Grodin and colleagues deserve heartfelt congratulations for using the term ‘increase in sCr’ to describe their findings, rather than worsening renal function (WRF) or acute kidney injury (AKI). Unfortunately, the assumption that ‘increased sCr’, WRF and ‘AKI’ are merely different names of the same pathological entity, still pervades the cardiorenal literature.2 An increasing number of publications, however, suggest that transient increases in sCr may not represent renal tubular damage and instead signify a haemodynamically-driven reduction in glomerular filtration rate, indicative of effective decongestion which portends improved outcomes.3 Indeed, a recent analysis from the Low Dose Dopamine or Low-Dose Nesiritide in Acute Heart Failure with Renal Dysfunction (ROSE-AHF) trial, in which all patients received aggressive diuresis regardless of randomization, showed that increases in either sCr or markers of tubular damage were not only poorly correlated with each other and with diuretic effect, but may have contributed to premature cessation of decongestive therapies.4 Indeed, the data from ROSE-AHF revealed that increases in neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-β-D-glucosaminidase (NAG) and kidney injury molecule-1 (KIM-1) were paradoxically associated with improved survival. These findings lend strong support to the results of previous studies suggesting that fluid overload is a ‘greater evil’ than

Hyperkalemia Associated with Renin-Angiotensin-Aldosterone System Inhibition in Patients with Heart Failure; Underexplored and Overrated?

Abstract: Dear Editor, Inhibition of the renin-angiotensin-aldosterone system (RAAS) is recognized as a key strategy in the management of chronic heart failure (HF) due to its established salutary impact on the outcomes. Hyperkalemia is a known complication of RAAS inhibitors that can potentially limit their widespread use; however, its clinical relevance and practical implications still remain uncertain in this setting. To explore this further, we searched the available literature in the past 30 years on the incidence of hyperkalemia in HF patients taking RAAS inhibitors (i.e., angiotensin-converting enzyme inhibitors [ACE-I] and angiotensin receptor blockers [ARB]). We excluded articles related to aldosterone receptor antagonists as they were primarily evaluated as an add-on medication rather than monotherapy. A total of 113 relevant studies were found; 12 that were randomized controlled trials were selected (7 with ACE-I and 5 with ARB), with a total of 45,073 patients (Table 1). The baseline serum creatinine level ranged from 1.0 to 1.2 mg/dL and the incidence of hyperkalemia was 0.9–6.4% in the active arm. Four studies reported the incidence of serum potassium greater than or equal to 6.0 mmol/L, which ranged from 2 to 3%. The RAAS inhibitor discontinuation rate due to hyperkalemia was reported as low as 0.1% to 3.4%, and interestingly, no strong association was reported between hyperkalemia and worse outcomes. As such, the incidence of clinically relevant hyperkalemia in the few trials that evaluated it was found to be very low, albeit for those patients with normal or near-normal renal function. Moreover, hyperkalemia does not appear to have an adverse impact on the outcomes. It has been shown that cessation of ACE-I and ARB in patients admitted with HF is associated with increased rates of mortality and readmission [1, 2]. Therefore, in our opinion, it would be prudent to closely monitor serum potassium and creatinine in these patients and manage mild to moderate hyperkalemia with dietary modifications and judicious use of diuretics, rather than discontinuation of RAAS inhibitors. It is noteworthy, however, that the included studies were not specifically designed to evaluate the incidence of hyperkalemia. As such, it is conceivable that some cases of hyperkalemia might have been coded only as adverse events leading to drug discontinuation or dose adjustment, hence leading to an underestimation of the magnitude of this complication. A detailed evaluation of the safety databases of these trials would be needed to address this shortcoming. Moreover, certain patient subgroups (e.g., those with baseline renal dysfunction) may benefit from monitoring for hyperkalemia-induced electrocardiographic (EKG) changes and possibly measuring plasma potassium in the appropriate clinical setting (e.g., point-ofcare testing in the emergency department). Hyperkalemia may be managed with novel potassium-binding agents, such as patiromer and sodium zirconium cyclosilicate. However, one has to be careful in prescribing these newly marketed agents, as their longterm safety is not yet well-established [3]. Future research should focus on studying the potential role of various potassium-lowering strategies in enabling the use of RAAS inhibitors in a broader range of HF patients, such as those with chronic kidney disease.

Diabetes and pregnancy: Risks and opportunities.

Abstract: Diabetes in pregnancy increases the risk of adverse maternal, obstetric, fetal, and neonatal outcomes. Internists can reduce these risks by optimizing glycemic control before conception and providing effective counseling on strategies to reduce the risks associated with pregnancy and diabetes. Routine screening of reproductive-age women with diabetes should include a comprehensive physical examination and laboratory tests to identify at-risk patients and begin strategic management. A review of medications for teratogenic potential is also needed.

Renal Revival: The Hidden Benefit of Antirejection Medications.

Abstract: S focal segmental glomerulosclerosis (FSGS) is the primary renal disease in approximately 10% of pediatric renal transplant recipients. Although posttransplant immunosuppressive medications are essential for prevention of renal allograft rejection, they could also portend salutary impact on the underlying glomerular disease of the native kidneys. A 38-year-old African American man was referred to nephrology clinic to reestablish care for his transplanted kidney after he was lost to follow-up for about 20 years. He had a history of end-stage renal disease secondary to idiopathic FSGS and received a living-related donor kidney transplant from his father at the age of 10 years. He did not receive plasmapheresis perioperatively. Although he was on dialysis briefly before transplant, he was never anuric. Posttransplant, he received azathioprine and prednisone for about 10 years with a baseline serum creatinine of approximately 1.6 mg/dL. Then, the patient stopped taking all immunosuppressive medications and was lost to follow-up. At the time of presentation to our clinic, serum creatinine was found to be 3.4 mg/dL with a urine albumincreatinine ratio of 75 mg/g. He was presumed to have developed chronic allograft nephropathy (rejection), leading to chronic kidney disease stage 4T (“T” is used to denote transplanted kidney) because he was not taking immunosuppressive medications for over 2 decades. Surprisingly, ultrasound of the right lower quadrant, performed twice,

Distinct renal outcomes for transcatheter aortic valve replacement and surgical repair.

Abstract: To the editor, Aortic stenosis is one of the most common cardiac degenerative valvular diseases with an estimated prevalence of 1.3% in patients aged between 65 and 74 years and 2.8–4.6% in those aged 75 or more [1, 2]. Transcatheter aortic valve replacement (TAVR) has emerged as a viable option for the treatment of patients with aortic stenosis who are not suitable candidates for surgical aortic valve replacement (SAVR). Acute kidney injury (AKI) is considered an established postoperative complication that is associated with a significant increase in the risk of mortality [3]. We sought to explore the available evidence on the risk of AKI after TAVR as compared with SAVR. We searched the articles cited in PubMed database from years 2000 to 2017 using key words “aortic stenosis” and “transcatheter aortic valve replacement”, and those evaluating the role of TAVR in management of aortic stenosis were reviewed. Randomized controlled trials (RCT) that contained data on comparative impact of TAVR and SAVR on renal function were selected [4–7]. Relevant data including baseline renal function, definition of AKI, and incidence of AKI were extracted and compared (Table 1). Using Altman formula, the relative risk (RR) of AKI, its standard error, and 95% confidence intervals (CI) were extracted and compared for each study. A total of 113 citations were reviewed and after exclusion of duplicate studies, 4 RCTs with 3310 participants (1640 TAVR and 1584 SAVR) were included. The weighted mean age was 81.6 years and 55.2% were men. There existed substantial variation across studies in the degree of baseline renal function and the definition of AKI. Two studies defined AKI as the need for renal replacement therapy [4, 5], one as an increase in serum creatinine greater than 50% of the baseline [6], and the other as KDIGO stage 2–3 [7]. The incidence of AKI was reported between 2.9–5.8% and 0–13.5% for TAVR and SAVR, respectively. Three main studies (including 98% of the included patients) reported lower incidence of AKI with TAVR compared to SAVR. Two studies [6, 7] reached statistical significance (RR 0.43, 95% CI 0.27–0.69, and RR 0.41, 95% CI 0.22–0.74, respectively) and one [5] did not (RR 0.96, 95% CI 0.53–1.74). The RR of AKI could not be calculated from the smallest study [4] that included 70 patients because there were no cases of AKI in the SAVR group. The limited number of RCTs that have compared TAVR and SAVR used diverse definitions for post-procedural renal complications. Currently available evidence suggests that the two options for treatment of aortic stenosis might portend distinct impact on renal function; TAVR is associated with lower RR of AKI compared to SAVR. Future prospective studies with pre-defined renal endpoints are needed to confirm these findings and evaluate the impact of baseline renal function on the incidence of post-procedural renal complications. Author contributions All the authors had access to the data and contributed to writing of the manuscript.

Catheter Cuff Extrusion Following Exit-Site Infection in an Immunosuppressed Patient: One Case and Two Lessons.

Abstract: To the Editor, A well-recognized complication of peritoneal dialysis (PD) is the catheter exitsite infection. While the common causative organisms include Staphylococcus species [1], immunocompromised patients are susceptible to atypical or resistant infections and serious complications [2, 3]. This is particularly important as the number of patients initiating dialysis after a failed renal transplant is increasing; hence there is the need for continued immunosuppressive therapy to prevent allosensitization in anticipation of a potential re-transplant. A 60-year-old woman with a history of end-stage renal disease treated with PD presented with a 2-day history of pain, redness, and purulent discharge from the catheter exit site (Fig. 1a). There were no symptoms or signs of tunnel infection or peritonitis. She had a failed renal transplant one and a half years ago and was followed up by a transplant nephrologist who continued treatment with azathioprine 75 mg/day and prednisone 10 mg/day. Three months earlier, she had completed a 9-month antibiotic course for Mycobacterium fortuitumassociated exit-site infection, albeit without modification of her immunosuppression regimen. This time, she was empirically started on oral ciprofloxacin without any improvement, and 3 days later, she experienced a spontaneous extrusion of the external cuff of the PD catheter. Exit-site culture grew extended-spectrum beta-lactamasepositive Escherichia coli resistant to multiple antibiotics. She was treated with intraperitoneal imipenem-cilastatin and it was decided that immunosuppressive agents be reduced (azathioprine 50 mg/day and prednisone 5 mg/day). On doing this, significant clinical improvement was observed within a week (Fig. 1b). This case highlights the importance of the judicious use of immunosuppressive agents after a failed transplant; the expected benefits of such an approach should be carefully balanced against its potentially serious risks. Moreover, the phenomenon of skin changes that occur at the exit-site leading to extrusion of the external cuff is a rare and less well-recognized complication of the exit-site infection [4]. It may indeed start a vicious cycle by further increasing her susceptibility to future PDrelated infections in the background of continued immunosuppression.