NephMadness 2014 • Sweet 16 Results
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Toxins
Aristolochic Acid versus DSHEA 1994
Winner: Aristolochic Acid
Aristolochic acid’s connection to medicine began as a curious case series out of Belgium. A series of middle-aged women who developed kidney failure due to what was initially called Chinese herb nephropathy. This outbreak, traced to a slimming clinic who’s recipe was contaminated with Aristolochia instead of Stephania tetrandra as the herbalist prescribed. A handful of years after the outbreak of kidney failure the victims began to develop unusual transitional cell cancers. They occurred in low risk patients like a 28 year old and in unusual locations, the renal papilla of 42 year old and multifocal disease of the ureters. This lead to the discovery that aristolochic acid covalently binds to the DNA and triggers adenine to thymine mutations.
These unusual cancers and the DNA adducts triggered the realization that Aristolochia was responsible for Balkan Endemic Nephropathy, a 50 year old medical mystery responsible for tens of thousands of cases of end-stage renal disease and urogenital cancers in southeastern Europe.
The same clues also led to the possibility that the reason that Taiwan leads the world in both ESRD and GU cancer was the high use of Aristolochia in Chinese herbal therapies. Forty percent of the population of Taiwan has been exposed to Aristolochia at an average dose of 100g per person.
The last piece to this puzzle and the reason Aristolochia is walking all over the Toxins region is the likely possibility that use of Aristolochia is causing kidney failure and cancer in China, where herbal medicine is ubiquitous. Aristolochia is probably the most important public health discovery of the 21st century. Read about this dramatic story here.
Click on the NephMadness Recommended Article for Aristolochic Acid
Check out the entire Toxins SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Hypertension
Systolic Blood Pressure versus JNC8
Winner: JNC8
JNC8 was introduced this past December to a storm of controversy but it represents both a first and a last. It is the last guideline that began its journey under the auspices of the National Heart, Lung and Blood Institute but famously, just as the guidelines were finishing, the organization announced it would no longer be involved in guideline development and would leave that to specialty societies. It represents a first in that the guideline development adhered to the Institute of Medicine’s standards on guideline development. Because of this adherence to the IOM standards, JNC8 is a very different document from JNC7. It is a narrower document that doesn’t attempt to be a comprehensive guide to hypertension. Its use of IOM guidelines and its reliance on only RCT shows the future of clinical guidelines. For more info see this.
Click on the NephMadness Recommended Article for JNC8
Check out the entire Hypertension SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Renal Replacement Therapy
Residual Renal Function versus Urgent Start PD
Winner: Urgent Start PD
Urgent Start PD represents a new way of thinking about how patients are started on renal replacement therapy. This is important as the US has a problem with too few patients on PD versus HD compared to other nations. The notion of starting a patient with progressive CKD with no access on PD seemed unthinkable a few years ago. Now this trend is starting to catch on and as a result we are seeing more and more patients on PD. This is a good thing. Residual renal function should be proud of the deep run they had in this year’s NephMadness. Residual Renal Function is no doubt one of the most important factors contributing to mortality and morbidity in patients with ESRD. Every effort should be taken to preserve this.
Click on the NephMadness Recommended Article for Urgent Start PD
Check out the entire RRT SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Kidney Regeneration
Renal Pericytes versus Bioartificial Kidney
Winner: Renal Pericytes
Team Renal Pericytes take the Kidney Regeneration bracket title and earn a spot in the Sweet 16. Team Bioartificial Kidney put up a good fight; however, this is still more of a dream than a reality. While the Nature Medicine paper published a year ago was a major breakthrough, we still have a long, long way to go. On the other hand, team Pericytes is really starting to create a buzz and hopefully we will start seeing real therapies aimed at pericytes soon.
If you could only read one article on the subject, then this would be it.
Click on the NephMadness Recommended Article for Renal Pericytes
Check out the entire Kidney Regeneration SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Acute Kidney Injury
Contrast Nephropathy versus Balanced Solutions
Winner: Balanced Solutions
Balanced solutions marches on. Sorry Contrast Nephropathy, but we had to go with the renewed study of intravenous solutions as this is a nephrology staple and has the potential to really be a game changer in nephrology. Our NephMadness one article to read recommendation is below.
Click on the NephMadness Recommended Article for Balanced Solutions
Check out the entire Acute Kidney Injury SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Electrolytes
Serum Anion Gap versus Bicarbonate in CKD
Winner: Bicarbonate in CKD
While we have no doubt that team Serum Anion Gap is arguably one of the most useful formulas in nephrology it couldn’t take down team Bicarb in CKD. Large definitive studies still have not been performed but smaller studies have been encouraging. We have highlighted a recent study in CJASN on this topic.
Click on the NephMadness Recommended Article for Bicarbonate in CKD
Check out the entire Electrolytes SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Kidney Stones
Medical Care of Acute Stones versus Oxalobacter formigenes
Winner: Medical Care of Acute Stones
Medical care for acute stones is a way to empower both nephrologists and patients. During Bruce Molitoris’ president address at the ASN he implored nephrologists not to limit their practice to dialysis. He emphasized the need for nephrologists to fight limitations to their scope of practice. Acute kidney stone management is one of the fronts in this battle. Nephrologists should not retreat from kidney stones but fight to keep it. Learn more about acute management of kidney stones here.
Click on the NephMadness Recommended Article for Medical Care of Acute Stones
Check out the entire Kidney Stones SCOUTING REPORTS and FIRST ROUND RESULTS from eAJKD
Biologics
Belatacept versus Eculizumab
Winner: Belatacept
Belatacept represents a new era in transplantation. The potential for a calcineurin-inhibitor free regimen. This is the last remaining transplant-related entity left in NephMadness. Eculizumab has a lot of potential for a variety of glomerular diseases that are complement related. Belatacept on the other hand, has a seat at the table in transplantation. However, cost issues, long term infection concerns, and administration issues (IV only) have hampered their widespread adoption. We link to the pivotal BENEFIT trial published in the American Journal of Transplantation.
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