David S. Goldfarb, MD

Dr. Goldfarb is Clinical Chief of Nephrology at NYU Langone Medical Center and Professor of Medicine & Physiology at NYU School of Medicine. He is also Chief, Nephrology of the New York Harbor VA Healthcare System. Follow him @weddellite.

Note: Below is a collection of tweets by Dr. Goldfarb in response to Dr Rosner’s commentary, so read that first. There’s a paragraph at the end for added context. And full disclosure: Dr Goldfarb was on our Blue Ribbon Panel 2015-2017.

Competitors for the Hyponatremia Region

European Guidelines vs US Guidelines

Cerebral Salt Wasting vs SIADH

1/So glad that I chose CSW to go all the way, not just to win the #hyponatremiaregion but to go all the way to win #nephmadness. M Rosner sadly blows his bracket with "Let’s get cerebral salt wasting out of this bracket and just admit that this condition may not even exist."

— David S Goldfarb, MD (@weddellite) March 18, 2018

3/What distinguishes these cases from SIAD is the persistently high fractional excretion of urate that persists after correction of the hyponatremia, which is not true of SIAD. The molecular basis for that uricosuria is likely to be identified soon.

— David S Goldfarb, MD (@weddellite) March 18, 2018

5/The physiological implications of a new mechanism of stimulating ruricosuria, causing natriuresis and hypouricemia may have similar significance as SGLT2 inhibition and certainly would be potentially druggable. Hope #blueribbonfail has been doing their homework.

— David S Goldfarb, MD (@weddellite) March 18, 2018

7/ But one thing that Dr. Rosner and I completely agree on: "Enough about glomerulonephritis and let’s get down to the really important stuff, the material that made us all want to be nephrologists." Yes, the tubule is where it's at!

— David S Goldfarb, MD (@weddellite) March 18, 2018

The Hyponatremia region is a natural place for impassioned opinion as it really addresses a topic that engenders confusion, and that’s just among nephrologists. Having just finished teaching NYU medical students about sodium and water balance and disorders of sodium and water balance, I am acutely aware of how interesting and challenging the field is. That the existence of cerebral salt wasting or renal salt wasting (CSW/RSW) is controversial is pretty astounding in this era of molecular and genetic sophistication.

I have closely followed the careful work of my fellow New Yorker, Dr. John Maesaka of NYU Winthrop Hospital, and come to think that there is indeed an unusual entity that can be distinguished from SIADH or SIAD. A distinguishing characteristic, that could lead to less uncertainty about which patients actually have this problem, is the uricosuria which persists after correction of effective arterial blood volume. That is not a feature of other cases of hyponatremia and SIAD.

Maybe it’s premature to choose CSW/RSW as the eventual winner of NephMadness 2018 but as a NY Mets fan, I NEVER root for the favorite…

– Post by David S. Goldfarb

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