With the ongoing workforce crisis in nephrology, it is critically important to engage medical students early in their educational arc with continued touch points throughout the curriculum. Ideally, this begins with the preclinical learning experience as nephrology is notoriously one of the most difficult subjects in medicine to master. Over the last decade, medical schools have made a significant push toward shortening the preclinical experience from 2 years to less than 18 months to allow students earlier exposure to clinical medicine and a more deliberate integration of basic science concepts into the third- and fourth-year curriculum.
Oncosurgery is a surgical specialty that focuses on the diagnosis, staging, and management of cancer and cancer-related complications. Acute kidney injury is a common and important complication related to oncologic surgery, associated with longer hospital length of stay, greater costs, increased risk of incident or progressive chronic kidney disease (CKD), and higher mortality. The pathogenesis of oncosurgery-related acute kidney injury is multifactorial and determined by different variables, including patient characteristics (comorbidities, volume status, age, pre-existing CKD), specific cancer type or location, surgical procedure involved, as well as intrinsic neuroendocrine and hemodynamic responses to anesthesia and/or surgery. Early nephrology evaluation may be helpful to assist with preservation of kidney function and prevention of further kidney injury.
Sickle cell disease causes several kidney manifestations. They include defects in urine concentration, impaired handling of potassium and hydrogen ion, albuminuria, acute kidney injury, and chronic kidney disease to name a few. Glomerular hyperfiltration, tubular hyperfunctioning, endothelial damage from repeated sickling and vaso-occlusive episodes, and iron-induced proinflammatory changes in the glomerular mesangium and tubulointerstitium are some of the mechanisms of kidney damage. Albuminuria is one of the most and common clinical features of kidney disease and progresses with age. Kidney disease in patients with sickle cell is associated with increased mortality. Annual screening for proteinuria starting at age 10 years and limiting the use of nonsteroidal anti-inflammatory agents and the use of angiotensin-converting enzyme inhibitors may help in early detection and delaying the progression of kidney disease. Adequate hydration, angiotensin-converting enzyme inhibitors, and adequate control of sickle cell are the main stay of treatment for albuminuria. The hemoglobin goal for patients with sickle cell nephropathy is lesser (10 g/dL) than that for patients with chronic kidney disease due to other causes given that a higher hemoglobin level increases viscosity and the risk of precipitating vaso-occlusive episodes. A multidisciplinary approach is recommended for managing patients with sickle cell and kidney diseases.
Chronic kidney disease (CKD) is a major global epidemic associated with increased morbidity and mortality. Despite the effectiveness of kidney protection strategies of hypertension, diabetes, and lipid control and use of newer hypoglycemic agents and anti-angiotensin II drugs, the nephropathy in CKD continues unabated toward irreversible kidney failure. Thus, interventions targeting modifiable risk factors in CKD such as metabolic acidosis (MA) are needed. Acid reduction with sodium-based alkali has been shown to be an effective kidney-protection strategy for patients with CKD and reduced glomerular filtration rate (GFR). Small-scale studies reveal diets emphasizing ingestion of plant-sourced over animal-sourced protein reduce dietary acid, improve MA, and slow further nephropathy progression in patients with CKD and reduced GFR. Additionally, veverimer, an investigational, nonabsorbed polymer that binds and removes gastrointestinal hydrochloric acid, is being developed as a novel treatment for MA. As further studies define how to best use these interventions for kidney protection, clinicians must become aware of their potential utility in the management of patients with CKD. The aim of the present review is to explore the various intervention strategies that increase or normalize serum [HCO3-] in patients with CKD-associated MA or low normal serum [HCO3-] that may further slow progression of CKD.
Metabolic acidosis is common in people with chronic kidney disease and can contribute to functional decline, morbidity, and mortality. One avenue through which metabolic acidosis can result in these adverse clinical outcomes is by negatively impacting skeletal muscle; this can occur through several pathways. First, metabolic acidosis promotes protein degradation and impairs protein synthesis, which lead to muscle breakdown. Second, metabolic acidosis hinders mitochondrial function, which decreases oxidative phosphorylation and reduces energy production. Third, metabolic acidosis directly limits muscle contraction. The purpose of this review is to examine the specific mechanisms of each pathway through which metabolic acidosis affects muscle, the impact of metabolic acidosis on physical function, and the effect of treating metabolic acidosis on functional outcomes.
Nephrology education has changed significantly since the first nephrology fellowship programs were established in the United States in the 1950s and 1960s. The past several years have seen increased opportunities for subspecialization in areas such as interventional nephrology, onconephrology, and glomerular disease. Notable trends in fellowship curricula include the expansion of education in home dialysis and palliative care, driven by policy changes and focus on patient-centered care. In addition, point-of-care ultrasound has garnered significant interest due to its potential to provide diagnostic information that improves patient care. An important area that remains largely unaddressed appears to be education about the business and administrative aspects of nephrology. Meanwhile, the importance of training in hemodialysis catheter placement and kidney biopsy has come into question due to the small proportion of nephrologists performing these procedures today. Nephrology fellowship programs should strive to tailor their curriculum to meet the interests and needs of individual fellows.
Hematopoietic stem cell transplantation (SCT) provides a curative option for the treatment of several malignancies. Its growing use is associated with an increased burden of kidney disease. Acute kidney injury is usually seen within the first 100 days of transplantation and has an incidence ranging between 12 and 73%, with the highest rate in myeloablative allogeneic SCT. A large subset of patients after SCT develop chronic kidney disease. They can be broadly classified into thrombotic microangiopathy, nephrotic syndrome, and calcineurin toxicity. Dialysis requirement after SCT is associated with mortality exceeding 80%. Given the higher morbidity and mortality related to development kidney disease, nephrologists need to be aware of the various causes and best treatment options.
Recent advances in the management of kidney tubular diseases have resulted in a significant cohort of adolescents and young adults transitioning from pediatric- to adult-focused care. Most of the patients under adult-focused care have glomerular diseases, whereas rarer tubular diseases form a considerable proportion of pediatric patients. The purpose of this review is to highlight the clinical signs and symptoms of tubular disorders, as well as their diagnostic workup, including laboratory findings and imaging, during young adulthood. We will then discuss more common disorders such as cystinosis, cystinuria, distal kidney tubular acidosis, congenital nephrogenic diabetes insipidus, Dent disease, rickets, hypercalciuria, and syndromes such as Bartter, Fanconi, Gitelman, Liddle, and Lowe. This review is a practical guide on the diagnostic and therapeutic approach of tubular conditions affecting young adults who are transitioning to adult-focused care.
Evaluation of acid-base status depends on accurate measurement of acid-base variables and their appropriate assessment. Currently, 3 approaches are utilized for assessing acid-base variables. The physiological or traditional approach, pioneered by Henderson and Van Slyke in the early 1900s, considers acids as H+ donors and bases as H+ acceptors. The acid-base status is conceived as resulting from the interaction of net H+ balance with body buffers and relies on the H2CO3/HCO3- buffer pair for its assessment. A second approach, developed by Astrup and Siggaard-Andersen in the late 1950s, is known as the base excess approach. Base excess was introduced as a measure of the metabolic component replacing plasma [HCO3-]. In the late 1970s, Stewart proposed a third approach that bears his name and is also referred to as the physicochemical approach. It postulates that the [H+] of body fluids reflects changes in the dissociation of water induced by the interplay of 3 independent variables-strong ion difference, total concentration of weak acids, and PCO2. Here we focus on the physiological approach and Stewart's approach examining their conceptual framework, practical application, as well as attributes and drawbacks. We conclude with our view about the optimal approach to assessing acid-base status.
Nephrologists have a significant role in educating and mentoring trainees. They are considered role models and a major reason for fellows to be attracted to the specialty. Nephrology training programs not only support fellows in their teaching endeavors but also provide them with the necessary knowledge and skills required for advancing their careers as clinician educators. However, such career development tracks are limited in number and most focus on early career faculty. Here we present an overview of the various teaching opportunities for fellows at the University of North Carolina (UNC) Nephrology fellowship program and the development of a fellow-oriented clinician educator track. Our goal as part of the nephrology community is to empower the current nephrology fellows to develop fulfilling careers as nephrology clinician educators.
We are experiencing a revolution in nephrology education. In all phases of a learner's career—undergraduate medical education (UME), graduate medical education, and postgraduate education—shifts in priorities, funding, and patient care have dramatically altered how we teach.1Summer R. Wiener R.S. Carroll D. et al.Physician perception of the impact of productivity measures on academic practice.Arch Intern Med. 2012; 172: 967-969Crossref PubMed Scopus (13) Google Scholar,2Seifert W.E. Strobel H.W. Values, RVUs and teaching.Med Sci Educator. 2010; 20: 62-65Google Scholar Developing novel ways to teach nephrology, at all learner levels, will be critical to meet the needs of restructured UME curricula, the increased prevalence and treatment modalities for kidney disease, and the changing nature of renal fellowship. In this edition of the Advances in Chronic Kidney Disease (ACKD), we highlight innovative nephrology curricula, developed by leading educators, and share how to implement these tools more widely at other institutions. As of 2018, approximately half of medical schools had shifted from a 2-year preclerkship phase to an 18-month or shorter preclerkship phase, and data from the American Association of Medical Colleges (AAMC) show 85% of medical schools are planning or have implemented a new curriculum within the past 3 years, suggesting more schools are moving toward this timing.3Structure of pre-clerkship curriculum. AAMC.https://www.aamc.org/data-reports/curriculum-reports/interactive-data/structure-pre-clerkship-curriculumDate accessed: August 30, 2022Google Scholar,4Curriculum change in medical schools. AAMC.https://www.aamc.org/data-reports/curriculum-reports/interactive-data/curriculum-change-medical-schoolsDate accessed: August 30, 2022Google Scholar This shortening of the preclerkship years requires an emphasis on essential and clinically oriented topics, with a resultant reduction of content deemed less relevant to clinical practice.5Pock A.R. Durning S.J. Gilliland W.R. et al.Post-carnegie II curricular Reform: a North American survey of Emerging trends & challenges.BMC Med Education. 2019; 19: 1-12Crossref PubMed Scopus (16) Google Scholar Additionally, schools are placing a greater emphasis on small-group, active learning and shifting away from a lecture-heavy teaching strategy.5Pock A.R. Durning S.J. Gilliland W.R. et al.Post-carnegie II curricular Reform: a North American survey of Emerging trends & challenges.BMC Med Education. 2019; 19: 1-12Crossref PubMed Scopus (16) Google Scholar This, combined with the recognition of the vast impact of social determinants of health and racism on patient care, has dramatically altered the UME educational landscape.5Pock A.R. Durning S.J. Gilliland W.R. et al.Post-carnegie II curricular Reform: a North American survey of Emerging trends & challenges.BMC Med Education. 2019; 19: 1-12Crossref PubMed Scopus (16) Google Scholar, 6Borrell L.N. Elhawary J.R. Fuentes-Afflick E. et al.Race and Genetic Ancestry in medicine - a time for Reckoning with racism.N Engl J Med. 2021; 384: 474-480Crossref PubMed Scopus (187) Google Scholar, 7Hardeman R.R. Medina E.M. Kozhimannil K.B. Structural racism and Supporting Black Lives - the role of health Professionals.N Engl J Med. 2016; 375: 2113-2115Crossref PubMed Scopus (238) Google Scholar These changes can present a challenge to nephrology educators who have developed rich curricula with a heavy emphasis on glomerular and kidney physiology. Dr Stern and colleagues describe the challenges and opportunities for nephrology educators to adapt to a shorter preclerkship phase by focusing on more clinically relevant topics and replacing lectures with faculty-led small-group sessions. They propose innovative additions to the curriculum, including dialysis policy, and using the lessons of apolipoprotein L1(APOL1) to demonstrate the pitfalls of conflating race and biology. To help implement inquiry-based, active learning of complex renal physiology topics, Dr Hoenig and colleagues present their "hands-on" kidney physiology lab, where students review and interpret original data from seminal experiments to better understand kidney physiology. These laboratories exploit students' natural curiosity in order to teach fundamental kidney physiologic concepts while providing an opportunity for self-directed learning and enhancement of problem-solving skills. Finally, Paloma Orozco-Scott, MPH, Jerrel Cattlett, and others propose a framework for antiracist teaching, which provides educators with an actionable and stepwise plan for grappling with the social construct of race, which is often presented as a biologic fact. Taken together, these 3 articles provide UME educators with the necessary tools to create and teach a modern, antioppressive, exciting, hands-on, and clinically focused preclerkship nephrology course. For almost a decade, trends in graduate training of medical residents demonstrated a declining interest in nephrology, leading to a decrease in the number of nephrology applicants and eventually a relative reduction in the nephrology workforce.8Nair D. Pivert K.A. Baudy At Thakar C.V. Perceptions of nephrology among medical students and internal medicine residents: a national survey among institutions with nephrology exposure.BMC Nephrol. 2019; 20: 146Crossref PubMed Scopus (25) Google Scholar By changing the current paradigms of how we educate, we have the opportunity to reverse this disheartening trend and enhance recruitment of trainees into our discipline. This challenge can be tackled by those in academic institutions as well as by community-based nephrologists who may be an untapped resource to encourage trainees in pursuing nephrology as a career choice. There have been several initiatives by training programs to attract residents into nephrology, ranging from alterations to work schedules to subspecialization into focused career pathways. Additionally, compared to historical methods, there has been a new focus on how the nephrology community teaches and evaluates trainees. Our challenge is not only to kindle a love of nephrology in students but also to continue that excitement during the continuum of their training as internal medicine residents. Dr Hilburg and colleagues assert that our goal as nephrology educators in teaching residents should predominantly be centered on resident education rather than on recruitment. They describe their ambulatory nephrology curriculum for all internal medicine trainees at the University of Pennsylvania. This curriculum focuses on common renal disorders encountered in general medicine and prepares internists to deliver superb care to a growing population of CKD patients; it does so in non–hospital-based settings, a domain of kidney care delivery often overlooked when planning traditional nephrology electives during their internal medicine training. Dr Kwon describes how nephrologists in private practice—who comprise the majority of practicing nephrologists—can be a valuable yet an untapped resource in complementing nephrology education and recruitment, especially for residents in community programs.9Quigley L. Salsberg E. Collins A. Report on the 2018 Survey of Nephrology Fellows. American Society of Nephrology, WA, DC2018Google Scholar While there are many limitations compared to academic settings, including time, personnel, and resources, she presents a compelling argument for the many rewards inherent to resident teaching. She describes how to delicately balance teaching and patient care duties and provides substantial resources and ideas for other private practitioners interested in teaching medical residents. Other ideas to enhance interest in nephrology include broadening the curricular offerings in fellowship programs and preparing fellows for the future in addition to the present. Dr Greenberg and colleagues describe the modern nephrology fellowship, which includes formal curricula in home dialysis, palliative care, and point-of-care ultrasound. They provide actionable ideas on how such curricula can be designed, and how fellowship programs that do not have access to these resources can partner with other groups to create meaningful learning opportunities for their fellows. Other important areas, such as the necessity to develop stellar clinician educators, are explored by Dr Jain and colleagues who describe a novel fellow educator pathway concomitant with the nephrology fellowship. The need for robust kidney pathology education to complement clinical training cannot be overstated. Dr Kuperman and Dr Caza and colleagues provide a perspective on educating nephrology fellows and practicing nephrologists in nephropathology. This form of teaching expands beyond formal classroom didactics and ranges from online resources, educational courses/symposia, and mentorship opportunities. Education in nephrology expands beyond the fellowship training phase that includes more than nephrologists. An expansion of advanced practice providers (APPs) in nephrology has led to increased multidisciplinary approaches of care and, hence, different approaches to dissemination of knowledge. However, since the training of APPs is apprentice-based, most APPs will begin their nephrology career without prior exposure to nephrology. Amy Sears, DNP, Kim Zuber PA-C, and Jane Davis DNP present a much-needed discussion on the necessity, benefits, and limitations in training for APP in nephrology. They propose the ideal training platform that would be beneficial for a successful partnership between APPs and physicians and outline current and past initiatives. Finally, nephrologists are more than clinicians—they are medical directors of dialysis units and serve in executive as well as operational roles and as entrepreneurs.10"Dr. Paul Klotman's Biography." Baylor College of Medicine.https://www.bcm.edu/about-us/leadership/dr-paul-klotmans-biographyDate accessed: October 12, 2022Google Scholar Leadership skills are necessary to function as a nephrologist but are typically not a part of nephrology training. Dr Yau and Dr Auguste discuss how to incorporate such training into a fellow curriculum and in continuing medical education. We are excited to present this ensemble of work for this unique issue of ACKD. We thank all our authors and reviewers for their contributions and Dr Charuhas V. Thakar for inviting us to be guest editors.
Machine learning is the field of artificial intelligence in which computers are trained to make predictions or to identify patterns in data through complex mathematical algorithms. It has great potential in critical care to predict outcomes, such as acute kidney injury, and can be used for prognosis and to suggest management strategies. Machine learning can also be used as a research tool to advance our clinical and biochemical understanding of acute kidney injury. In this review, we introduce basic concepts in machine learning and review recent research in each of these domains.
Common causes of pediatric ESRD are distinct from those seen in the adult population. In the pediatric population, the most common are congenital anomalies of the kidney and urinary tract (CAKUT), affecting approximately 30% of children with CKD. These structural anomalies often require coordinated care with the pediatric urology team to address voiding issues, bladder involvement, and the potential need for surgical intervention. For pediatric nephrologists and urologists, common CAKUT that are encountered include antenatal hydronephrosis, obstructive uropathies (eg, posterior urethral valves), and vesicoureteral reflux. As more pediatric patients with CAKUT, CKD, and ESRD transition to adult care, it is important for receiving adult nephrologists to understand the clinical presentation, natural history, and prognosis for these diagnoses. This review outlines the diagnosis and potential interventions for these conditions, including strategies to address bladder dysfunction that is often seen in children with CAKUT. A discussion of these management decisions (including surgical intervention) for CAKUT, which are quite common to pediatric nephrology and urology practices, may provide unique learning opportunities for adult nephrologists who lack familiarity with these pediatric conditions.
Acid can have ill effect on bone health in the absence of frank clinical acidosis but affecting the bone mioneral matrix and bone cells via complex pathways botyh ascute;y and chronically. While the reaction of bone to an acid load is conserved in evolution and is adaptive, the capacity can be overwhelmed resulting in dire consequences. The preclinical an clincl evidence of the acdi effect on bone is very convincing and the clinical evidence in both association and interventiopn studies are also quite credible, The adverse effects of acid on bone is underappreoicated, under-investigated, and the potential benefits of alkali therapy is not generrally known.
Normallly the kidneys handle the daily acid load arising from net endogenous acid production from the metabolism of ingested animal protein (acid) and vegetables (base). With chronic kidney disease, reduced acid excretion by the kidneys is primarily due to reduced ammonium excretion such that when acid excertion falls below acid porduction, acid accumulation occurs. With even mild reductions in glomerular filtration rate (60 to 90 ml/min), net acid excretion may fall below net acid production resulting in acid retention which may be initially sequestered in interstitial compartments in the kidneys, bones, and muscles resulting in no fall in measured systemic bicarbonate levels (eubicarbonatemic metabolic acidosis). With greater reductions in kidney function, the greater quantities of acid retained spillover systemically resulting in low pH (overt metabolic acidosis). The evaluation of acid-base balance in patients with CKD is complicated by the heterogeneity of clinical acid-base disorders and by the eubicarbonatemic nature of the early phase of acid retention. If supported by more extensive studies, blood gas analyses to confirm the acid-base disorder and newer ways for assessing the presence of acidosis such as urinary citrate measurements may become routine tools to evaluate and treat acid-base disorders in individuals with CKD.
An integral part of a physician's practice includes being a leader, especially as there is a strong need for skilled leaders to advocate and navigate patient-centered and organizational outcomes. Nephrologists undertake multiple leadership roles, but dedicated leadership training is lacking in medical and postgraduate education. Given the growing need for physician leaders, practitioners in nephrology and beyond must become better equipped in understanding the role of leadership skills in medical practice. Nephrology and the medical community as a whole should focus on intentional and dedicated leadership in medical education training to better groom physicians for leadership roles. In this paper, we define and discuss the components and styles of leadership. We further propose cognitive models that allow one to apply leadership theory in common practice.
Although medical schools across the United States have updated their curricula to incorporate active learning techniques, there has been little discussion on the nature of the content presented to students. Here, we share detailed examples of our experience in using original experiments to lay the groundwork for foundational concepts in renal physiology and pathophysiology. We believe that this approach offers distinct advantages over standard case-based teaching by (1) starting with simple concepts, (2) analyzing memorable visuals, (3) increasing graphical literacy, (4) translating observations to "rules," (5) encouraging critical thinking, and (6) providing historical perspective to the study of medicine. Although we developed this content for medical students, we have found that many of these lessons are also appropriate as foundational concepts for residents and fellows and serve as an excellent springboard for increasingly complex discussions of clinical applications of physiology. The use of original experiments for teaching and learning in renal physiology harnesses skills in critical thinking and provides a solid foundation that will help learners with subsequent case-based learning in the preclerkship curriculum and in the clinical arena.
Anemia is a common medical problem among patients with cancer and chronic kidney disease (CKD). Although anemia in patients with CKD is often treated with iron and erythropoietin-stimulating agents, there are controversies with regard to the use of erythropoietin-stimulating agents in cancer patients. In this article, we review the treatment of anemia in patients with cancer and CKD, in addition to summarizing the current guidelines in treatment of anemia in these patients.
Adolescent obesity and CKD are both significant public health issues independently. When seen as comorbid conditions, they can cause deleterious health outcomes that put them on the fast track to necessitate dialysis or transplantation. This paper analyzes the effects of various biomarkers and comorbidities seen in the intersection of obesity and CKD in the adolescent population. We illustrate the estimated prevalence of these biomarkers and comorbidities through a review of the literature, available treatment, and obesity-related glomerulopathies. We found significant prevalence of the biomarkers, microalbuminuria (9.42% ± 9.31% and interquartile range [IQR] of 9.5%), hypertension (23.60% ± 22.5% and IQR of 9.5%), low high-density lipoprotein (14.34% ± 5.46% and IQR of 5%), hyperfiltration (3.12% ± 5.16% and IQR of 4%), and lower estimated glomerular filtration rate 4.59 ± 2.75 and IQR of 3%. Identification of prevalent biomarkers and their manifestations can serve to inform clinicians what to look for in daily setting and help elucidate the magnitude of this growing issue. Additionally, pertinent treatment options from pharmacotherapy to bariatric surgery are outlined to provide care providers with the full spectrum of treatment options for obesity in adolescent populations.
The transient receptor potential (TRP) channels form a superfamily with six transmembrane structures, which is common in other types of voltage-dependent channels. The TRP-melastatin (TRPM) subfamily includes the putative tumor-suppressor melastatin, which was originally found as a down-regulated protein in melanoma tumor cell lines. Here, we report a novel TRP-related protein that is a murine orthologue of human TRPM4. The function of the novel murine TRPM4 was studied in HEK-293 cells using a fluorescent calcium indicator, fura-2. The removal and re-introduction of extracellular calcium triggered changes in the intracellular calcium only in cells expressing TRPM4a, which suggests that this novel channel plays a role in the calcium entry process. We also isolated a splice variant of TRPM4 that was proven to be non-functional. Both TRPM4 variants integrated into the plasma membrane. Furthermore, FRET analysis revealed that TRPM4a and TRPM4b localized close together, suggesting a multimerization of the two molecules.
