#NephMadness 2017: The Saturated Sixteen

Posted on March 26, 2017 by AJKDblog in NephMadness // 0 Comments

The first round results from NephMadness are in. Who’s up? Who’s down? Who’s out? What was your bracket buster? Where did the Blue Ribbon Panel go wrong? Tweet your reaction with hashtag: #Saturated16

Glomerulonephritis Region

Right out of the gate Steroids for IgA took an early lead against Protocol Biopsy for Lupus and despite a furious finish and a withering full court press, Protocol Biopsy couldn’t close the gap.

Steroids for IgA wins 6-3.

Comments from the BRP:

Not sure either of these teams have the resources to run with the field.

Anti-PLA2r with its first appearance in the tournament since 2013 looked well rested and ready to take on the world. Rituximab for minimal change disease looked like a 16 seed and fell without much resistance. Look for Anti-PLA2r to go far.

Anti-PLA2r wins 8-1.

Comments from the BRP:

Identifying the specific antibody causing disease heralds a profound change in therapeusis. On the horizon are specific cell based techniques for suppression of specific antibodies. Identifying such antibodies will lead to treatments that are long lasting and without side effects.

This one is easy. Here’s a molecule that will have far-reaching consequences in understanding pathophysiology of a relatively common glomerular disease. Rituximab on the other hand seems like another non-specific therapy for minimal change disease, although one that reveals the significance of B cells to the pathophysiology.

Anti-PLA2r is the dynasty, but they are getting old. I think they may have 1 more run left in them.

History Of Nephrology Region

History of the Dipstick looked sharp for the first half but a quick jab with a 16 gauge biopsy needle let the air out of their tires and History of the Kidney Biopsy clipped them at the end.

History of the Kidney Biopsy wins, supreme court-like, 5-4.

Comments from the BRP:

The dipstick is under the radar no longer. Uncelebrated and taken for granted, like the back-door cut in the Princeton offense, but incredibly effective and maybe, just maybe, efficient enough to knock off a big guy.

Dipstick story is fascinating.

Did the dipstick advance the field more than microscopy which dates to the 17th century? Or beyond tasting the urine which dates back a couple millennia? The kidney biopsy changed everything.

Tough one – both teams have shaped the game.

History of Hemodialysis came in hot and played like a champion. Despite a deep bench of future NBA stars, the History of Kidney Transplant couldn’t get started and were rolled by the dialysis juggernaut. Look for History of Hemodialysis to make some noise deep in the tournament.

History of Hemodialysis wins 9-0.

Comments from the BRP:

We have come a long way from sausage casings and clamps. Not far enough though. While most people would prefer a kidney transplant, the sheer number of people who have been treated with hemodialysis makes this a force to be reckoned with.

No nephrologist should get through their training without knowing this story.

This is a hard one. Hemodialysis had a more immediate effect on saving hundreds of thousands of lives. I might vote differently in 100 years.

Beating the drum – dialysis has saved more lives than anything else nephrology.

Dialysis Region

Depression in Dialysis came in with a lot of momentum but Kt/V urea is like a zombie and couldn’t be killed despite RCT after RCT.

Kt/V wins 5-4.

Comments from the BRP:

Measurement of dialysis dose and the beginnings of judging adequacy was a worthy goal.

Depression in dialysis doesn’t seem to be old or new or something we have really addressed; it’s always been present.

Depression is the sleeper in this Division.

Neurocognitive declines in HD is a team that has lived by its 3-point shooters all season. But like any team that depends on the three, if they go cold there is no way to win and today, Patient-Reported Outcomes was the beneficiary of those shots not falling.

Patient-Reported Outcomes wins 6-3.

Comments from the BRP:

How often when talking to a dialysis patient do you feel that what you are saying is going in one ear and out the other? Almost like trying to coach Demarcus Cousins…

SONG initiative is really innovative and as far as I know a unique approach and a crucial one to chronic illness

How can patient reported outcomes be meaningful in the patient with cognitive decline? This one ends when neurocognitive declines starts shooting at the wrong net.

Biomedical Research Region

Gene Microarray has a pair of all-conference 7-footers that have been dominating the boards all season. Two-Photon Microscopy’s only chance was to play tight man-to-man defense and hope for turn-overs and a quick paced game. This strategy failed as Gene Microarray showed good ball control and an ability to control the tempo.

Gene Microarray wins 8-1.

Comments from the BRP:

Both of these coming under the heading of “old” have not really reached their potential. Anything with “gene” in it deserves a vote.

We can’t even imagine Gene Microarray’s potential.

It has been a long time since a team came into the tournament riding as much hype as CRISPR-Cas9. Some thought the pressure would get to the rookies, but CRISPR showed poise and destroyed Single Cell RNA Sequencing in a game reminiscent of the Globetrotters versus the Washington Generals.

CRISPR-Cas9 wins 8-1.

Comments from the BRP:

Game changing technology

CRISPR-Cas9 is the REALLY scary choice here. The potential, good and bad, is awesome.

CRISPR is running on all cylinders, and hasn’t yet begun to peak. Watch out!!!

Disparities in Nephrology Region

Genes in ESKD Disparity is largely just a new uniform and name change for 2015’s NephMadness winner APOL1, and the former champs played like the dominant team of 2015. They easily dispatched first round contender Society in ESKD Disparity without breaking a sweat. This is a team with a deep bench of experienced seniors. Expect Genes in ESKD to go deep this year.

Genes in ESKD Disparity wins 8-1.

Comments from the BRP:

We might be able to address genetic issues. Societal issues are another story

I always vote for “genes”

Tight one that could go either way, but Genes has some bench players who could be rested and ready to explode at the end.

The bottom half of the Disparities bracket was no closser. System Factors in Transplant Disparity won the tip off, tossed down an alley-oop and never looked back. By the first TV time-out Patient Factors in Transplant Disparity was down by a dozen and could never fight their way back.

System Factors in Transplant Disparity wins 8-1.

Comments from the BRP:

We need to do much better and this post suggests a pathway

“Patient factors” include “genes”

System factors has the tools to contain patient factors’ weapons.

Genetics Region

This was a match-up that had a lot of hype for possibly being the tightest match of the opening round. The game remained a back and forth toss-up until the final five minutes when Ciliopathies got casual with the ball, and gave up a few consecutive couple of turn-overs. Podocytopathies took advantage with some bombs and suddenly the close game turned into a rout.

Podocytopathies wins 7-2.

Comments from the BRP:

Provocative choice. Podocytopathies must be more far-reaching though recognition of the cilium and its role in PKD is a fantastic breakthrough.

Podacytopathies had a couple big games during the stretch, but the understood pathways of ciliopathies is too deep for the upstarts.

Fish versus Flies was how the commentators hyped this match up but it turned out to be less a game and more of a steam rolling as the breakout surprise of the tournament, Zebrafish, pulled the wings off of Drosophila.

Zebrafish wins 8-1.

Comments from the BRP:

Great potential for the zebrafish approach

Both useful animal models with deep insights obtained.

Drosophila may have better eyes, but zebrafish have better kidneys.

Diabetic Nephropathy Region

Two standards of diabetic management facing off in the first rounds. Fans were screaming for both to win and the selection committee was besieged with complaints for putting two titans up against each other in the first round, but ACEi and ARB shook off the distractions and took their well-crafted RCTs to clean Glycemic Control’s clock.

ACEi and ARB wins 6-3.

Comments from the BRP:

ACE and ARB in diabetes – still the greatest advance in CKD in the last 50 years. Think UCLA under John Wooden – a perpetual winner.

Perhaps the evidence that ACEi/ARBs are useful is more convincing than that for glycemic control. One has to still express some disappointment in the magnitude of their benefit.

ACEi and ARB win this this with tenacious defense.

The bottom half of the Diabetic Nephropathy Region pitted two rookies against each other. Both drugs were coming off of recent RCT wins showing they can reduce kidney events, at least as a secondary outcome. The SGLT2 Inhibitors came to play and were on fire from beyond the arc while playing a lock down zone defense. The GLP1 Agonists could never get any traction and were out of it by the end of the half.

SGLT2 inhibitors win 9-0.

Comments from the BRP:

A vote for the diaper dandies.

SGLT2 inhibitors have a uniquely rapid beneficial effect. Another game changer

Not only did SGLT2i improve glycemic control, and apparently improve both cardiovascular and renal outcomes, they provided a new rationale for understanding and teaching about tubuloglomerular feedback.

GLP1 is a young gun – needs more seasoning before they can run with the big boys.

Nutrition Region

Two dominant teams with completely different philosophies. Everyone agreed the selection committee did a masterful job of pitting these two teams against each other. Protein Restriction in CKD is a defensive mastermind that has re-emerged to enter the tournament after a few decades in the wilderness. Feeding During Dialysis has an offense that wowed fans during the conference tournament. In the this classic match-up of offense versus defense, offense came out on top.

Feeding During Dialysis wins 5-4.

Comments from the BRP:

Protein restriction in CKD hearkens back to when you had 3 free throws to make 2 – it’s just so 1980s. Food is where it is at!

Feeding during dialysis is still under debate which is difficult to understand; a residual bit of authoritarian paternalism. If “patient-reported outcomes” mattered, everyone would be eating while on HD!

Feeding during dialysis seems like a flash in the pan, where protein restriction is a tried and true warrior.

The bottom of the bracket featured a David versus Goliath battle of Microbiome and the Kidney versus Omega 3 Fatty Acids in CKD. And this time Goliath won.

Microbiome and the Kidney wins 9-0.

Comments from the BRP:

Omega 3 fatty acids are simply contributing to over-fishing and depletion of critical fish populations for no real benefit. The microbiome has not achieved any benefit either but if we alter the composition of the microbiota maybe we can favorably affect the composition of the oceans.

This could be a tight battle, but the microbiome has so many weapons it will be hard to contain.