The Elite 8 is the final four of our tournament. In the NCAA tournament the final four represent the four regional winners. In NephMadness the Elite eight represent the 8 winners of each named region. Here we will get the Heart and Kidney Connection champion, the Critical Care Nephrology champion, the Nutrition in Nephrology champion, etc. So, with no further distractions here are your 2015 NephMadness Regional Champions:
Sudden Cardiac Death in ESRD vs Sodium Restriction for CHF
Winner: Sudden Cardiac Death in ESRD
The winner of the Heart and Kidney Connection Region is Sudden Cardiac Death (SCD) in ESRD. The first round matchup was a 6-1 win over crosstown rival Acute Coronary Syndrome. Which led to some twitter consternation, particularly from the cardiologists. A nice blog post from Adrian Covic further delved into ACS in CKD.
Next up for SCD was the upstart Sacubitril from the PARADIGM-HF trial. SCD took down one of the favorites in a fairly convincing 5-2 match. The BRP seemed to be focusing on problems that need to be tackled and SCD is a big one. According to USRDS data, SCD accounts for nearly 25% of all deaths in both peritoneal and hemodialysis patients.
Some comments from the blue-ribbon panel (BRP): “The way I see it, learning more about arrhythmia and sudden cardiac death is so important in dialysis. Statin trials in ESRD have been underwhelming, suggesting that cardiac disease is different in ESRD than in the general population. Now we just need to determine risk factors and ways to prevent SCD.” Next up for SCD in ESRD is the Critical Care in Nephrology region champion Furosemide Stress Test.
Furosemide Stress Test in AKI vs Vasopressin in Sepsis
Winner: Furosemide Stress Test in AKI
Critical care had some great concepts but the furosemide stress test has marched through the first three rounds to emerge as the champion. The BRP comment summarizes the reason the FST won: “Furosemide stress test, finally an AKI test that might be useful.” Nephrology is hungry for practical prognostic tests to help us in the management of the critically ill renal patient.
We choose the selection committee with little regards to specific concepts, and I must admit that I had never heard of the furosemide stress test. We choose Chawla, the father of the FST and were excited when he suggested it during those early conference calls, it is neat to see it mature into a proper regional champion.
After marching through the critical care bracket, does the furosemide stress test have the legs to go the distance? Stay tuned to the same NephMadness channel…
sFlt1 in Preeclampsia vs Pregnancy in ESRD
Winner: sFlt1 in Preeclampsia
The most common questions we received from members of the BRP was how to judge different concepts. We gave them a number of different axis by which to grade the concepts, but one of them probably carried particular weight when it came to sFlt1:
But beyond just teaching us about endothelial growth and its relationship to placental and renal health, focusing on sFlt-1 holds therapeutic promise. Clearly, this was on the mind of at least one member of the BRP: “sFLT1: I think this will have legs. Someday we will look back and laugh at the days when we could only deliver for pre-eclampsia.” The research this BRP member was almost certainly thinking about was the landmark study in Circulation, Pilot study of extracorporeal removal of soluble fms-like tyrosine kinase 1 in preeclampsia. Imagine a world where nephrologists get consulted for preeclampsia and can apherese the woman to health!
High Sodium Intake and Blood Pressure vs Obesity: ESRD Risk Factor
Winner: Obesity: ESRD Risk Factor
When we created the brackets this year we had some idea of how they could turn out. Sometimes things turn out unexpectedly for unexpected reasons. The intention of the “Obesity: ESRD Risk Factor” was to make the case that obesity was a risk factor for death in ESRD, not that obesity was a risk factor for ESRD. We wanted the pairing to be reverse epidemiology versus normal (forward?) epidemiology. But looking at the comments from the BRP we did not make this clear, “Why does salt have to taste so good? But the link to HTN is hardly worthy of advancement. Obesity as an ESRD risk factor at least is not intuitive when you remove the increased risk of diabetes and HTN from the equation.”
This is not the fault of the BRP, this one is on us. So obesity it is! Onward to the Elite 8!
AD Tubulointerstitial Nephritis vs APOL1
We have seen very few sweeps in NephMadness ‘15. APOL1 keeps moving along by taking down AD TIN. One of the panel members commented: “It’s an all Wake Forest contest: Freedman vs Bleyer. Simply because of the numbers affected the nod must go to APOL1. But AD TIN should go to the final 4 sometime soon”. Another BRP member was heard saying, “APOL1 helps explain hypertensive nephrosclerosis, the AASK and CRIC trial results, other genetic risks for renal disease, sunspots….“ Simply put, the discovery of APOL1 has the potential to usher a new era in nephrology. The future could see not only risk prediction but also novel therapeutics once more is learned about the biology of APOL1. Next up for APOL1, HIVICK, the winner of the ID region.
Vancomycin Renal Toxicity vs HIVICK
In a narrow 4-3 match, HIVICK emerges as the winner of the Infectious Disease in Nephrology region. HIV proper accounted for 2/8 members of the region. But, the lesser known HIVICK (HIV immune complex disease of the kidney) will be the lone representative of the region heading into elite 8 matches. Let’s review HIVICK. This is an immune complex attack on the kidney that leads to a variety of histopathologic glomerular lesions which can include membranous, diffuse/membranoproliferative, and IgA nephropathy. These immune complexes involve specific HIV antigens as the target for the antibody response, and thus require the presence of active HIV viremia. With the advent of HAART therapy we are seeing much less HIVAN and more and more HIVICK in HAART naive patients. Vanco kidney toxicity had a surprisingly decent run and almost made it as a region winner. Here is a comment from a pro-vanco BRP member: “This is tough, I love anything GN, but I’m afraid the ubiquitous use of Vanc makes this a real concern.”
Laparoscopic PD placement vs Downstream Vascular Biology
Winner: Laparoscopic PD Placement
Dog fight. Tight game. Laparoscopic PD placement winning demonstrates the key role that a good access plays in successful renal replacement therapy. This focus on a successful access placement seems to have gotten ahead of the data which shows only marginal benefit of laparoscopic placement over the traditional open placement. But a close win is still a win and laparoscopic PD placement advances!
But is anyone else uncomfortable with laparoscopic PD placement winning the crown in a region called the Vascular Surgery Region?
Tyrosine Kinase Inhibitor Toxicity vs Post Transplant Malignancy
Winner: Tyrosine Kinase Inhibitor Toxicity
Tyrosine Kinase Inhibitor Toxicity (TKI Tox) continues to make an improbable run in this year’s NephMadness. Examples include imatinib, gefitinib, erlotinib, sorafenib, sunitinib, and dasatinib. These are just a few of a growing list. The more time goes on, the more pathways are targeted for cancer therapy. We will continue to see toxicities emerge and it will be up to us to find them before they wreck havoc on the kidney. The wide array of renal manifestations from these agents include acute and chronic interstitial nephritis, hypophosphatemia, and even CKD. TKI Tox has had quite the schedule and each contest was a 4-3 split. Giving Team TKI the closest winning margin in the tourney. First, narrowly escaping VEGF-inhibitor and then barely moving past nephron sparing surgery. The win for TKIs was a battle cry for nephrologists to look closely at the medication list. Oncology therapeutics is growing fast and it will be up to us to recognize toxicity early and educate our peers. Post transplant malignancy is an important topic as well and reminds us that patients who receive kidney transplants need close monitoring for the development of malignancy. Next up for TKIs is the winner of the Vascular Surgery region- Team Laparoscopic PD catheter placement.
Great round, now onward to the Final Four!