#NephMadness 2022: The Saturated Sixteen

The first round results from NephMadness 2022 are in! Who’s up? Who’s down? Who’s in? Who’s out? Which team was your bracket buster? Where did the Blue Ribbon Panel go wrong? Tweet your reactions with hashtag: #Saturated16 (and #BlueRibbonFail if you’re feeling salty!)

We present the Saturated Sixteen:

Current Standings Match Results#NephMadness

And before we start, huge thanks to Omar Taco @ErrantNephron for the scoreboard graphics!

Lupus Region

Voclosporin kept it close till the last 5 minutes until they got into foul trouble. Team Belimumab with the easy win from the free throw line here.

Belimumab wins 12-9

Comments from the BRP:

Voclosporin is the youngest of the CNI siblings to appear on the stage, and may have the best skill set to dominate the game for the next generation.”

“Not just another CNI.”

“We don’t have a defined standard and the data needed are voclo versus tac. The cost is also ridiculous and B cell therapy seems to be the way to go here.”

“Tough decision here, these are both a big deal for lupus nephritis (or are they)? Voclosporin is an CNI and belimumab a biologic. The trials differ, induction (B) vs an add on to maintenance (V). The Bliss-LN trial has more baggage than my aunt going to NYC for a weekend. But its mechanism is more exciting and costs 1/3 the price of voclosporin (a marketing sales faux pas?). Superficial me chooses belimumab because a biologic is sexier.”

“Both are compelling but expensive therapies. I am swayed by the dual effect of the calcineurin inhibitors — immunosuppressive plus direct podocyte effects. Calcineurin inhibitor therapy has been marred by recurrence data and, of course, nephrotoxicity. Voclosporin seems to have less nephrotoxicity. Recurrence data?”

“Decision based on value for money, which favors Voclosporin.”

“The cost difference almost pushed me to Voclo but the novelty of Belimumab won the day.”

“Fighting B cells never wins. Need a broad attack in lupus.”

“Anything that ends with Mab is superior.

Pregnancy in Lupus Nephritis was no match for Family Planning in LN. Easy win for the latter!

Family Planning in Lupus Nephritis wins 14-7

Comments from the BRP:

Pregnancy and family planning are deeply personal decisions that weigh a variety of life factors. It must be pursued with broad information and thoughtful guidance. Family-planning wins the day.”

“Great discussion of patient management that is impactful.”

“Flip a coin here, they actually overlap a lot, but I like dealing with the risk as opposed to minimizing the risk: getting a lupus patient through pregnancy is very rewarding.”

“Individuals of child-bearing age are going to get pregnant, no matter what. AND, for many women, having a child is a critical aspect of being who they are. Family planning is very important…but dealing with the reality of the drive to have sex and have children is more important.”

“Far better to have good and helpful advice in advance, to make a shared decision on pregnancy. And not enough people get this sort of advice.”

“Absolutely, without a doubt, the toughest cases I have ever had have been pregnant women with lupus flare.”

“Definitely was helpful to me on how I can counsel patients about risks so they can make informed decisions regarding family planning. With the advent of many joint rheumatology-nephrology clinics, this can now be done in a true multidisciplinary manner and not assuming the other provider is counseling the patient.”

“A failure to plan is a plan to fail.


Animal House Region

Giraffe’s height proved to be a major benefit over Whale’s lack of legs. Giraffe walks into the next round with the easy ‘W.’

Giraffe wins 14-7

Comments from the BRP:

Giraffe physiology provides nice insight into underlying mechanisms of human hypertension.”

“Are you kidding? A giraffe would dunk on a whale any day. Not sure how he would do with taking a charge, though. And the crazy hemodynamics of the giraffe have a ton to teach us.”

“While neither as 1/10th as cool nephrologically as eg the camel, or pee shark, or even the slime fish, the whale with its baby human-sized kidneys doesn’t compare to the king of autoregulation, the giraffe.”

“This was a hard one. Too bad we didn’t learn about animal physiology much in undergrad or postgrad school because once you start learning about it, you can’t stop. it’s too fascinating. Contemplating regulation of vasculature simultaneously up the neck and in the kidneys of the giraffe is mind-boggling.”

“Fascinating and fabulous section – but the whale wins out.”

“A baby-sized kidney!”

“Very very difficult decision here. I’ve fed giraffes at the zoo so I went with my own personal experiences.”

“Anything ‘under water’ cannot win.”

“Tough category. Both with amazing physiology. Giraffe just inched out the whale.”

“You had me at kidney ‘g-suit’!

Team Bear ate Team Lungfish for dinner.  A slam dunk for Team Bear

Bear wins 15-6

Comments from the BRP:

“This was the hardest one – but the ability to turn urea into protein is really amazing.”

“Lungfish can play at home and on the road. They know how to persevere, and outlast their competitors. Lungfish were mastering the crossover dribble while bears were still twinkling in their parents’ eyes.”

“The hibernation aspect is most interesting.”

“As much as I love Homer Smith, who devoted a book to the lungfish (in which also he opined about the presence or not of god), the bear and its ability to get all its water needs for hibernation in the winter from metabolizing fat, and taking his urea and making amino acids out of it, is just too cool. Seven months without urinating or defecating…c’mon, that is just ridiculous.”

“Again, these were both amazingly cool. But what incredible kidney plasticity is exhibited by the lungfish! That can’t be beat.”

“The bear, for its extraordinary efficiency.”

“The seemingly everyday black bear has remarkable kidneys and a magic bladder to match.”

“Anything “under water” cannot win.”

“Since NephMadness began – we have been waiting for the BEAR!!!”

“Cheers to the metabolic magicians!”


Hemodialysis Region

Despite passing out from frequent bouts of low blood pressure, Intradialytic Hypotension managed to pull off the win over Intradialytic Hypertension with a series of nothing but net 3 pointers at the end. 

Intradialytic Hypotension wins 12-9

Comments from the BRP:

Intradialytic hypertension is an under-recognized and misunderstood complication of dialysis.”

“Intradialytic hypotension has moves that have confounded the playing field for generations, but newer approaches may be catching up.”

“Between these two, hypotension is one of the greater challenges, and those on midodrine have poorer outcomes post-transplant.”

“Close one here, but a low BP can stop HD, while a high BP rarely does. I look at intradialytic hypotension as yet one of those proofs that ESRD has a pernicious effect on the body and that RRT while keeping us alive doesn’t even begin to approach health (I believe it is a uremic symptom).”

“Ostensibly at least, intradialytic hypotension is understandable. Intradialytic hypertension? It is so counterintuitive.”

“Both common and dangerous and while there has been historic focus on hypertension, I am going with hypotension to bump up attention to the need for more advice for patients who may experience both extremes on their dialysis journey.”

“I think the intradialytic hypotension is more difficult to treat.”

“They’re both bad.

Yawn. This game was over at half time. Middle Molecules trounces Small Molecules

Middle Molecules wins 13-8

Comments from the BRP:

“It is time to broaden our thinking about all the kidneys do to keep us going. Middle molecules have come to play.

“I think we have had too much focus on small molecules.”

“I found each of these arguments to argue for the other side as much as for their own side so I will vote on my bias. The glomerulus is a convective organ; dialysis is diffusive. Convection better mimics the kidney. Why is residual renal function so important? Because it provides convective clearance of molecules that are not cleared with similar urea clearance on HD. Hemodiafiltration (1/2 convective) has so many positive signals. Urea’s days are numbered. Middle molecules will reign in my lifetime.”

“This is another hard one. Urea may have its drawbacks but it has endured challenges by any number of other molecules and still comes out as good a marker of adequacy as any other!”

“The symptoms of inadequate dialysis are truly horrible – huge need for targeted clearance to improve overall outcomes for patients receiving dialysis.”

“The future of dialysis is all about the middle molecules.”

“URR > 70% is clearly meaningless.”


Inequities Region

Governmental Policies got off to an early lead right out of the gate and despite a strong finish with a full court press, Institutional Initiatives couldn’t close the gap. 

Governmental Policy wins 13-8

Comments from the BRP:

Better policies can have MAJOR impacts on healthcare outcomes.”

“Important to have public policies, laws, and incentives to support institutional initiatives.”

“Governmental Policies have ruled the day for many years, but are showing their weakness and ineffectiveness. It is time to allow Institutional Initiatives to step up and take the last shot.”

“I think the intervention has to be more universal than individual initiatives to make change but it is also the more challenging.”

“The United States is so heterogeneous. Local efforts are far more likely to be successfully implemented than broad, vague, federal policies in attacking inequities in health care.”

“Yet another close call but without government support and determination we are pushing against a closed door to move towards systems which will enable those with kidney disease to receive choices and treatments.”

“Government policies can only go so far in a country without any public health infrastructure.”

“I am lucky to practice in a state that provides routine HD care for undocumented immigrants. Trainees who have never been outside California are dumbfounded when I describe to them the delivery of dialysis care (or lack thereof) in many other states.”

“Start local, then go global.

Environmental Determinants of Health played a strong defense but in the end Social Determinants of Health‘s offense and inability to miss a free throw led to a close win. 

Social Determinants of Health wins 12-9

Comments from the BRP:

“While Environmental factors are critical, they are deeply rooted in the generations of Social factors. To win this game, you have to address the root causes.”

“Tough call here as both are important. I leaned to environment although you could argue that it is a result of social inequalities.”

“This is a difficult and somewhat artificial distinction because the two sets of determinants overlap significantly. My choice is a bit arbitrary.”

“Highlighting systemic discrimination and inequities – some of this is not intractable.”

“Social determinants of health – no brainer here.”


Parasites Region

Leishmaniasis‘ defense forgot to show up to the game. Malaria hit 3-pointer after 3-pointer. Easy win for Malaria

Malaria wins 19-2

Comments from the BRP:

“Malaria in a blow-out. This is a cool diagnosis, from pathophysiology to diagnosis to treatment to outcomes.”

“Malaria is incredibly impactful in terms of death rates across the world, still.”

“I was once taught that malaria was one of the most common causes of nephrotic syndrome in the world, not at all true: ‘Only two of the malaria parasites, namely, P. malariae (quartan malaria) and P. falciparum (falciparum malaria), are clearly associated with renal disease, and this occurs only in a small percentage of patients.’ GN appears to be more common in Leishmaniasis. [Source]

“Black water fever” is a great name for the hemolysis and hemoglobinuria associated with Plasmodium falciparum, but kala-azar is a much cooler name – Leishmaniasis wins on that alone.”

“Parasites are scary. Malaria is my choice because it is the subject of stories, historical victories and defeats, and such a deadly worldwide killer. Blackwater fever.”

“More common, although all are nasty, harmful, and affect primarily those least equipped to deal with them.”

“Very difficult choice – based my choice on historical and population burden.”

“Another tough category. I have seen one case of malaria-related renal disease and one case related to leishmaniasis. Both fascinating. The entire parasite bracket demonstrates how much can be prevented by public health measures.

Strong defense led to an easy win for Schistosomiasis over Filariasis.

Schistosomiasis wins 17-4

Comments from the BRP:

Filariasis can cause chyluria! Hard not to respect that.”

“Schistosomiasis has a much deeper bench (of affected individuals).”

“Worm parasites give me the heebie-jeebies! I tossed a coin here.”

“These parasites are even scarier. My choice is schistosomiasis because anything that can crawl through the diaphragm, into the lung, and out through the nose is the stuff of sci-fi.”

“Filariasis! The image of the microfilaria in the glomerular capillary lumen together with ‘filariasis dance’ sign on ultrasound won it for me.


Cardiorenal Region

Diuretic Resistance Mechanisms came in as the higher seed but Diuretic Resistance Treatments proved they were the Cinderella of this tournament with a resounding win. 

Diuretic Resistance Treatments Wins 16-5

Comments from the BRP:

“Mechanisms is the freshman team – a critical element to building sustained dominance. But Treatments will win the day by improving patient outcomes.

“Understanding how an individual’s kidneys can become so resistant to diuretics is beyond my comprehension. Considering all of the compensatory mechanisms that the kidney has to prevent extremes of responses, I find it amazing that kidneys can get to the point where they say ‘I’m keeping it all.'”

“Though both mechanisms and treatment are important, this is certainly a situation where if you truly understand the physiology you will understand how to treat.”

“In the end it does not matter, you just need to treat the patient.”

“The physiology of diuretic resistance is much more interesting than simply increasing doses and adding other diuretics etc.”

“We know the mechanisms, let’s deal with the treatments.”

“Great topics but I think learning the treatment strategies is most meaningful.”

Cardiac Biomarkers in CKD barely showed up to this game and probably should have stayed at home given how hot Kidney Biomarkers in CHF was from the 3-point line.

Kidney Biomarkers in CHF wins 16-5

Comments from the BRP:

“Cardiac Biomarkers just keeps turning the ball over at critical junctures. Kidney Biomarkers is also a flawed team, but with good coaching can win the game.”

“I guarantee that permissive hypercreatininemia will be in my notes tomorrow!”

“I think this is a severe untapped reservoir and may lead to the development of better understanding of the mechanisms of the kidney response to CHF and the treatment of cardiorenal syndrome.”

“Permissive Hypercreatininemia – I wish I had coined that euphemism for diuretic-induced AKI in cardiorenal syndrome.”

“It’s all about the kidneys, but please don’t ask for a renal troponin.”

“There is more challenge in managing AKI in CHF than the interpretation of cardiac biomarkers with CKD.”


Neonatal Region

Novel Therapies in Neonatal AKI should have taken some of their own medicine (caffeine); they came out flat-footed and Novel Devices for Neonatal HD dunked over them for the easy win!

Novel Devices wins 13-8

Comments from the BRP:

“Looking for some new Diaper Dandies, and some promising therapies are emerging.”

“I like the idea of using current therapies to achieve better outcomes for different diseases than they were originally designed for.”

“Loved this entire bracket. I learned a great deal.”

“Truly incredible advancements.”

Neonatal AKI and CKD could not keep up with Nephron Number and CKD’s fast-paced offense and strong defense. Easy win for Nephron Number and CKD!

Nephron Number and CKD wins 15-6

Comments from the BRP:

“Neonatal AKI is mimicking the winning program Nephron Number has built over the years.”

“I know that nephron number and CKD is not a new topic, but it seems that we keep learning more and more about nephron development, holding out the potential for stimulating additional nephrogenesis, especially in very premature infants.”

“I have always embraced the concept of reduced nephron number but very rarely take a birth history. I will now incorporate that into my history taking.”

“Nephron number basis of all disease-if you have a lot of nephrons, your kidneys can withstand a lot of injury.”

“I still think the Brenner hypothesis remains one of the most important concepts of clinical nephrology. Do you know your birth weight?”

“Social determinants and environmental determinants come together right here.


Nephropath Region

PLA2R could not keep up with Other Membranous Antigens. Easy win for Other Membranous Antigens!

Other Membranous Antigens wins 12-9

Comments from the BRP:

“PLA2R is the powerhouse – it has shown us the way and taught us how to move forward.”

“Going to go with the current favorite.”

“All of these “new” antigens that are associated with the pathology-finding of membranous GN just keep reminding us that the pathology is a pattern of injury, not a mechanism of disease. I will admit that the more we learn about PLA2R, the more ways we are finding to use it to interpret and prognosticate on the disease.”

“Demonstrates the heterogeneity of kidney disease and what makes nephrology so challenging.”

“PLA2R is still king. A great model for biomarker-driven study of disease pathogenesis, clinical outcomes, and treatment algorithms.”

“Nobody loves the MGN story more than me and it all started with PLA2R, but it had its day in the sun already with NephMadness glory in 2017. Time for the up-and-coming other antigens.”

“PLA2R is SOOOOO old at this point”

“The ongoing challenges of MGN and the investigations – I thought this topic was interesting with the opportunity to better define the disease to lead to more effective treatments.”

DNAJB9 and IgG4 played a close game going into double overtime. But in the end, IgG4 won with a last second layup.

IgG4-Related Disease wins 13-8

Comments from the BRP:

Toughest match-up of the 1st round. Two evenly-matched, underappreciated dark horses. Where DNAJB9 plays a great game and has exciting promise, its impact is limited. IgG4 though is tricky, and the playbook is still being written.”

“Both rare disease targets so a close decision, but some good news on IgG4.”

“This is a hard one because I have so little experience with either (and I still have to look up what size fibrils are associated with all of those diseases). I think we are going to find out that IgG4 is actually something else entirely!”

“Heat shock protein? Amyloid negative congo red-philic? Huh? IgG4-related disease can be devastating but responds so well to steroids and rituximab.”

“IgG4 is clearly underappreciated.”

“Tough choice here, I don’t see either getting very far.

Current Standings  |  #NephMadness | @NephMadness | #SaturatedSixteen


US-based physicians can earn 1.0 CME credit and 1.0 MOC per region through NKF PERC (detailed instructions here). The CME and MOC activity will expire on June 1, 2022.

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