nephrology: the branch of medical science that deals with the kidney.
The field of nephrology has always fascinated me, and this year an urge pulled me to the San Diego Convention Center, to attend the ASN American Society of Nephrology conference. Held once a year, this conference draws around 11,000 people from 130 different countries around the world, hoping to learn more about this remarkable organ that contains more than a billion complex cells. The kidney is a puzzle we have yet to solve.
I became a nephrologist for exactly that reason. No matter which organ is failing, I have the fascinating task of assembling all of the puzzle pieces together to figure out the why. A patient walks into my exam room with complaint A, I want to know how it ails them, and how we can resolve it. Or the very least learn to live with it. Kidneys regulate our body water, remove waste, produce hormones, govern electrolytes and most importantly the acidity of blood. The kidney must not be overlooked when surveying human health and disease.
I was called to consult on a case of a 95 year old woman with kidney disease and fluid disturbance. After my initial examination and blood work, I realized she had developed a case of acute interstitial nephritis, an allergic reaction within the kidneys commonly caused by drugs. I dug deeper, asking her family members and doctors the timing when all this began. The culprit was furosemide, a common diuretic. The inflammation in her kidneys was so severe, she did not respond at all to the steroids I gave her. In fact, the electrolytes became more deranged. We were left with no choice, but dialysis. A risky endeavor, most definitely, but lucky for her one that proved fruitful. Her skyrocketing blood pressure was gently brought down from 220 mmHg to 140 mmHg, and she felt sudden relief. The field of nephrology has fortuitously evolved whereby a 95 year old can be dialyzed safely and effectively, a feat that was unheard of a decade ago when I was a fellow.
Despite these innovative procedures, one of the most surprising things that I discovered at the ASN, is that resident physicians are not choosing to go into this field as much as they were even three years ago. Before 2013, eager candidates were banging down our doors for the opportunity to be a part of one of the most sought after subspecialties in internal medicine. Suddenly, the rates of nephrology fellows dropped dramatically deserting many promising spots in programs throughout the country. We all wondered why. Was it the change in the job market? The aftershock of Obamacare or the bundling of payments to large scale organizations, like dialysis centers? Was it all about the money? Whatever the case may be, after the conference I found myself just as fascinated by this field as ever before. It gave me the comforting notion that the physicians who are drawn to the enigma of the kidney, will find their way to the field of nephrology. Here are some of my favorite pearls from this year’s ASN.
TOP FIVE IMPORTANT NEW DISCOVERIES IN THE FIELD OF KIDNEY HEALTH
- Markers of diabetes in chronic kidney disease (CKD) or dialysis patients has been inaccurate all along. For decades we’ve been measuring Ha1c, or glycosylated hemoglobin to learn about the degree of hyperglycemia in a diabetic patient with CKD. Now we believe a test called glycosylated albumin or frustosamine, can be more sensitive markers in this disease population.
- Despite what has been formally known, lowering blood pressure with a multitude of medications does not lead to better health outcomes in older individuals or in pregnant women. Those 65 and older should especially be concerned about complications of drugs because their kidneys function with diminished speed and flexibility.
- Jardiance, a new diabetic medication taken once daily, lowers cardiovascular mortality by many folds. The Food and Drug Administration stopped the study early in order to hasten the product’s emergence into the market. I’ve decided to wait a few more months to observe the medical community’s experience with this drug before prescribing it.
- The Young Investigator Award went to Dr. Janos Peti-Peterdi from USC, for real-time imaging of the kidney under fluctuating mediums, taking us to a deeper level of understanding of this complex puzzle within a puzzle. He showed us how kidney stem cells differentiate into their destined cell types, as a response to the changing medium of blood: salty, sugary, proteinaceous, acidic, etc. The cells then adapt to their environment by listening and signaling each other through various hormones. Check out his amazing research here.
- The Human Kidney on a Chip. Harvard scholar, Dr. Ingber, Founding Director of Wyss Institute designed a biologically active microchip that breeds individual colonies of human progenitor cells to actual organs. We can then examine the effects both good and bad of many substances on our kidneys, hearts and lung without the inhumane use of laboratory animals.