An interesting case of new onset HTN and hypokalemia in a patient with leiomyosarcoma

Serum K 2.9
BP 150/90
No accompanying acidosis or alkalosis👇🏽
1/

#onconephrology Step 1: Is the hypokalemia due to renal K losses or extra-renal K losses?

24 hour urine K was 46 mEq/L so renal K losses were contributing to hypokalemia

Serum magnesium was normal

Patient was not on diuretics👇🏽
2/

The most anticipated nephrology trial of the year has been published!
“Empagliflozin in Patients with Chronic Kidney Disease” #Kidneywk
⁦@NEJM⁩ nejm.org/doi/full/10.10… EMPA-KIDNEY trial is a randomized, parallel-group, double-blind, placebo-controlled trial designed to assess the effect of empagliflozin on progression of kidney disease & CV disease, & to examine safety profile of the drug in a wide range of pts. w/ CKD

📌 Tweetorial on “IgA Nephropathy: Approach to treatment” based on @goKDIGO webinar by Dr. Richard Lafayette

🔸First step in management of IgAN: Determine the risk of disease progression based on GFR, proteinuria, BP & kidney biopsy findings👇🏽
1/ 📌 Approach to treatment of IgAN based on @goKDIGO guidelines👇🏽

🔸This Rx algorithm is NOT applicable to IgA deposition with minimal change disease, IgAN with AKI, IgAN with RPGN, IgA vasculitis, IgA-dominant post-infections GN & secondary forms of IgAN👇🏽
2/

📌 Tweetorial on Diagnosis & Pathogenesis of IgA Nephropathy (IgAN) based on @goKDIGO webinar by @AgnesFogo & Dr. Jurgen Floege
#IgAN
🔸Interesting fact: IgAN is not a new disease
First known case of IgAN was found in Prince Joseph of Austria (1776-1847)
1/ 📌 IgAN is characterized by:

🔸Mesangial immune-complex deposits which sometimes can extend to the capillary loops & sub-endothelial locations

🔸 Dominant IgA deposits compared to the other immunoglobulins
2/

Dr. Carlos Flombaum from @MSK_Neph gave a holiday lecture full of historic pearls. We are so lucky to have Dr. Flombaum in our division!
Did you know how Cisplatin was ‘accidentally’ discovered?👇🏽
1/ Did you know that allopurinol was first studied as an anti-neoplastic agent. Well, it didn’t work as a cancer therapy but it was eventually used to treat gout and hyperuricemia
2/

Workup for detection of Monoclonal Immunoglobulin (MIg) in patients with Monoclonal Gammopathy of Renal Significance (MGRS)

(Talk by Dr. Frank Bridoux at the Kidney Week)
#Onconephrology #MGRS Workup for detection of Monoclonal Immunoglobulin

1. Find the circulating monoclonal Ig:

-SPEP & UPEP to quantify the Monoclonal (M) spike

-Serum & Urine Immunofixation to identify the monoclonal Ig & also to monitor response to Rx

High Impact Clinical Trials
TESTING Study: Steroids vs. Placebo in High Risk IgAN @VladoPerkovic

💥Conclusion: A 6-9 month course of oral methylprednisolone reduced risk of major kidney outcomes by 47% and kidney failure by 41%
#KidneyWk TESTING Study - Basline Characteristics

Polyuria : The Perfect Storm

-Nephrology is consulted for Urine output of 9L in one day

-Pt. with AML, T2DM has been in the hospital for > 2 weeks for pneumonia, sepsis & subsequently developed Sweet Syndrome & was started on steroids

1/ Approach to polyuria
Step: 1
Is this water diuresis or solute diuresis?

-Check urine osmolality
Measured Urine osm. = 368 mOsm/kg
So, total daily osmole excretion = 3312 osmoles (368 X 9 L as the patient’s urine output is 9L)

This is solute diuresis
2/

💥Parathyroid Hormone-related Protein - PTHrP

⚡️Who was the first person to postulate the existence of PTHrP?

⚡️What is the mechanism of PTHrP mediated hypercalcemia of malignancy?

⚡️Does PTHrP have a physiological function?

#Onconephrology
#PTHrP
1/ Dr. Fuller Albright, in 1941, was the first to postulate the presence of a ‘substance’ that caused features of hyperparathyroidism in a cancer patient
2/

“Antibody response to Moderna (mRNA-1273) vaccine in hemodialysis patients with and without prior COVID-19”- our manuscript published in @CJASN

@LilCh4n, @Nick84130497 @ZeldisEtti @kirkcampbell @NephJC

👉🏽 cjasn.asnjournals.org/content/early/…

Study findings 🧵
1/ ⚡️Antibody (Ab) response to Pfizer vaccine in hemodialysis pts. has been reported, but the Ab response to Moderna vaccine in hemodialysis patients is not well known
Here we report Ab response to Moderna vaccine in patients on maintenance hemodialysis
2/

💥What is Monoclonal Gammopathy and when does it’s presence indicate presence of cancer?

💥What is MGUS and MGRS?

#Onconephrology
1/ 💥Monoclonal gammopathy is presence of monoclonal immunoglobulin (Ig) in serum, urine or both

💥Monoclonal immunoglobulins are produced by either clonal Plasma cells (often) or by
B lymphocytes (less often)

2/

💥Endocrine adverse effects of Immune Checkpoint Inhibitors - a brief Tweetorial for Nephrologists

A thread based on an article published in @NatureRevEndo

👉🏽 nature.com/articles/s4157…

#Onconephrology
1/ ⚡️It important for Nephrologists to be familiar with immune checkpoint inhibitor induced endocrinopathies as thyroid, pituitary & adrenal disorders can present with👇🏽
-Hyponatremia
-Hyperkalemia
-Metabolic acidosis
-Hypotension
2/

💥Happening now: Dialysis vascular access emergencies at @nkf Meeting

Rapidly enlarging AV access pseudoaneurysms @bharvioza
Steal Syndrome @aurbanes
AV Access related malignancy @JeremyCraneMD
HD CVC related R atrial thrombus @SaadTheodore #NKFClinicals Rapidly enlarging pseudoaneurysms by @bharvioza

💥‘Pseudohyperkalemia’ Tweetorial

⚡️Pseudohyperkalemia
⚡️Seasonal Pseudohyperkalemia
⚡️Reverse Pseudohyperkalemia

Let’s review these conditions
1/

#Onconephrology
#Hyperkalemia ⚡️An important point to remember is that 98% of the potassium (K) stores in the body are intracellular so even a small amount of K released from the cells can significantly affect the concentration of ‘measured’ extracellular potassium
2/

💥 Tweetorial on ‘Cryoglobulinemia’

⚡️What are Cryoglobulins?

⚡️When should a clinician suspect Cryoglobulinemia & Cryoglobulinemia vasculitis?

⚡️How to establish the diagnosis?

⚡️Significance of Rheumatoid Factor
1/
@GlomCon
#Onconephrology ⚡️Cryoglobulins are immunoglobulins that reversibly precipitate in the serum at <37 degree C & re-dissolve at >37 degree C

⚡️The fundamental mechanism behind Cryoglobulin formation is aberrant antibody (Ab) production by B cells & B cell proliferation

2/

⚡️Clinical Case of Acute pain & redness over AVF following ligation of the AVF - by Dr. K.C. Janga @ASDINNews

#ASDIN2021
1/ ⚡️40 yr. female had a successful kidney transplant 14 months ago
-She presents with enlarging aneurysm of AVF
-On exam AVF was not collapsible on arm elevation test
-As AVF was not being used for dialysis, minimally invasive ligation of AVF was done👇🏽
2/

💥 An interesting case of Right hand pain in a patient with ipsilateral Gracz AVF - by @AdinaVoiculescu @dialysisaccess1 @ASDINNews

⚡️Live Clinical Case discussion #ASDIN2021
1/ ⚡️42 year old female on hemodialysis has right hand pain, hand discoloration & swelling
- She has an ipsilateral AVF👇🏽
2/

💥 Another interesting clinical case of “Dizziness following angioplasty of the right forearm AVF in a hemodialysis patient” - by @AdinaVoiculescu @ASDINNews @dialysisaccess1

⚡️Live Clinical Case #ASDIN2021
1/ ⚡️81 year old hemodialysis patient with a right radial cephalic AVF (created recently) and a left brachial cephalic AVF created a year ago and abandoned due to low AVF flow (but the left AVF was not ligated)👇🏽
2/

💥”Alternative Techniques for Perm Cath Insertion” - by @NMawlaMD @ASDINNews

⚡️Clinical Case Discussion #ASDIN2021

☄️Cervical plexus block
☄️Single incision method
1/ ⚡️Cervical Plexus Block technique for perm cath insertion using 5-10 cc of lidocaine and a standard needle👇🏽
⚡️For more information on this technique go to: nysora.com
2/

💥 Role of Stents in Dialysis Vascular Access - Tweetorial

⚡️Indications for Stent Use

⚡️Recent Clinical Trials of Stents in Dialysis Vascular Access

⚡️Complications associated with Stent Use

1/
@ASDINNews
#VascularAccessPearls ⚡️Arterio-venous (AV) Access
causes significant morbidity & mortality in patients on hemodialysis

⚡️Most AV access associated complications are due to vascular stenosis👇🏽
2/

💥”Adverse Effects of SGLT2”
- amazing talk by @jardine_meg

#KidneyWk @ASNKidney

⚡️SGLT2i adverse events data from the major SGLT2i trials including the CV outcomes trials, Heart failure trials, CREDENCE trial and DAPA-CKD Trial ⚡️Overall the serious adverse events associated with SGLT2i use were lower than the adverse events seen with placebo use in most of the large SGLT2i trials👇🏽