Management of Hypertension in Diabetic Kidney Disease.

Hypertension is a critical component of cardiovascular disease progression in patients with chronic kidney disease, and specifically diabetic kidney disease (DKD). Causation versus correlation remains up for debate, but what has been confirmed is the delay of DKD progression when hypertension is controlled or moved to guideline drive ranges. Many medications have been studied and used in real world experience for best outcomes, and we discuss below the proven winners thus far making up the renin angiotensin aldosterone system. As well, we discuss guideline changing medications including sodium-glucose cotransporter 2 inhibitors and newer generation mineralocorticoid receptor antagonists. With the growing prevalence of diabetes and DKD in the population, newer agents are emerging in multiple drug class and will be highlighted below. Clinicians continue to search for the optimal care plans for this challenging patient population.

Empagliflozin in Adults with Chronic Kidney Disease (CKD): Current Evidence and Place in Therapy.

Chronic kidney disease guidelines and disease modifying therapy have seen a dramatic shift in the last 5 years. The SGLT2 inhibitor class of medications has been catapulted from hyperglycemia management medications, to cardiovascular and kidney disease improvement therapies. Multiple trials looking at dedicated cardiovascular and kidney endpoints have resulted in favorable results. This review will target empagliflozin and the exciting journey that it has taken along this path. Empagliflozin has been studied for hyperglycemia, cardiovascular, and kidney hard outcome endpoints. Both patients with diabetes and without have been rigorously studied and shown surprising results. The major implications for patients on empagliflozin will be shown. Future studies and directions are highly anticipated to add to the growing knowledge of the SGLT2 inhibitor class, as well as discover possibilities for new disease states to benefit from empagliflozin.

Clinical Efficacy, Safety, Tolerability, and Real-World Data of Patiromer for the Treatment of Hyperkalemia.

Hyperkalemia remains one of the most difficult consequences of disease state and treatment for patients with chronic kidney disease, heart failure, and diabetes. Controlling hyperkalemia can be difficult, but has become easier with the introduction of novel oral potassium binders. Patiromer was approved in 2015 for the treatment of hyperkalemia by the FDA in the United States. Several pivotal trials proved its efficacy, safety, and improved tolerability compared with previous hyperkalemia treatments. Additionally, many real-world publications and trials have given deeper insights into the capabilities of patiromer. We discuss improved disease state outcomes with combining patiromer with RAASi. This paper will also highlight new trials forthcoming that are highly anticipated to expand the possibilities in using patiromer to improve outcomes and populations.

COVID-19-associated atypical hemolytic uremic syndrome and use of Eculizumab therapy.

There is a high incidence of acute kidney injury with COVID-19 infections. The etiologies of acute kidney injury could be ischemic acute tubular necrosis or a complex process of complement activation leading to thrombotic microangiopathy. We present a case of 32-year-old Hispanic male with a history of heart transplant, admitted with COVID-19 and atypical hemolytic uremic syndrome, which was successfully treated with Eculizumab.

Angiotensin II: A Review of Current Literature.

Up to one-third of all patients admitted to intensive care units carry a diagnosis of shock. The use of angiotensin II is becoming widespread in all forms of shock, including cardiogenic, after the U.S. Food and Drug Administration's (FDA's) initial approval for vasoplegic shock in 2017. Here, the authors review the literature on angiotensin II's mechanism of action, benefits, and future therapeutic opportunities.

Update and review of contrast-associated acute kidney injury.

Contrast associated acute kidney injury (CA-AKI) is a controversial subject in the field of nephrology, cardiology, radiology and hospital medicine. Much has been written and published concerning the causes, risk factors, outcomes, and potential treatments to avoid the ultimate outcome of complete kidney failure requiring dialysis. Over the decades many proposed preventative strategies and treatments have failed to produce a reliable outcome. Additionally, there is now a growing discussion of the severity and sincerity of CA-AKI being a major entity to worry about for patients. We discuss the present state of CA-AKI and highlight potential risk factors and possible therapeutic interventions to minimize any impact a contrast procedure may have on a patient in order to maximize the medical care.

Clinical Management of Hyperkalemia.

Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.

Nephrotic Syndrome.

Nephrotic syndrome is one cause of end-stage kidney disease. Because edema is a common presenting feature and hypertension and dyslipidemia are often present in nephrotic syndrome, it is important for the primary care physician to suspect this entity. Common causes in adults include diabetic nephropathy, focal segmental glomerulosclerosis, and membranous nephropathy. In adults, many primary causes are due to an underlying disease. A cause of the nephrotic syndrome should be established with serologic workup and renal consultation. Renal biopsy is necessary in those with an unknown cause to or classify disease. Treatment focuses on symptoms, complications, and the primary cause.

COVID-19 Extrapulmonary illness - The Impact of COVID-19 on Nephrology care.

Coronavirus disease-2019 (COVID-19) has caused a pandemic that has affected millions of people worldwide. COVID-19 is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and is spread by close contact and by respiratory droplets. It has also impacted different aspects of caring for people with kidney disease, including those with acute kidney injury (AKI), chronic kidney disease (CKD), those requiring kidney replacement therapy (KRT), and those with a kidney transplant. All of these patients are considered high risk. The lessons learned from the COVID-19 pandemic will hopefully serve to protect patients with kidney disease in a similar situation in the future.

Patiromer for the treatment of hyperkalemia.

INTRODUCTION: Hyperkalemia is a chronic and life-threatening electrolyte disorder that affects millions of patients around the world with decreased kidney function, hypertension, and heart failure. Recently newer oral potassium-binding agents have been approved for clinical use, as an alternative to the decades long use of sodium polystyrene sulfonate. This review will focus on the patiromer and its use in reducing hyperkalemia. AREAS COVERED: Pubmed was used to search from 1960 to 2020 on free subject terms: Hyperkalemia, Potassium, Patiromer, Veltassa, Kayexalate, Sodium polystyrene sulfonate, and Sodium Zirconium cyclosilicate. The authors have reviewed the literature and summarized the most salient elements in regards to patiromer. EXPERT OPINION: Patiromer has been available on the US market since 2015 when approved by the FDA for clinical use. Clinical trials monitoring patient use for up to 1 year have shown clinically meaningful potassium reductions, sustained normokalemia, high tolerability, and without major serious adverse events. Patiromer is available to all patients experiencing hyperkalemia, no matter the disease state leading to the condition. It is likely this newer oral potassium-binding agent will help change how patients with hyperkalemia are treated in regards to sudden and chronic medical conditions.

Newsletters in Medical Education.

Medical online newsletters are an important component of communication between learners and educators. The ease of creation and distribution has broadened the appeal and growth of online formats. This manuscript details the history of the modern newsletter as it relates to the nephrology community. From historical listservs to content-rich emails and blogs, the creative newsletter formats are changing to meet the demands of readers. With continued expansion of online education and access, this communication format can continue to meet the needs of virtually focused world.

Change in the Pattern of Posttransplantation Anemia in Kidney Receptors: Sex Role in Recipients and Type of Donor.

OBJECTIVE: Posttransplant anemia (PTA) in kidney recipients is a complication that has repercussions mainly of cardiovascular consequence. The objective of this study is to determine the prevalence of anemia, as well as the relationship between kidney recipient and donor sex, in the presence or absence of anemia at 12 months after kidney transplant (KT). MATERIAL AND METHODS: Observational, longitudinal study of KTs made over a 5-year period, from 2013 to 2017, in a renal transplant unit from La Raza National Health Care Medical Center. Three hundred twenty-eight records were analyzed. Hemoglobin (Hb) and the presence or absence of anemia according to the definition by the World Health Organization were analyzed. The association between kidney recipient sex and donor type (living or deceased) was evaluated. Analysis of central tendency and dispersion were performed and the mean difference was established with χ2 test or Student t test. Significance level was set at P < .05. RESULTS: The mean Hb (standard deviation) before KT was 10.38 (2.16) g/dL; Hb at 12 months was 14.47 (2.37) g/dL with an absolute increase of 4.09 g/dL. Before KT, male kidney recipients had a mean Hb of 10.54 (2.17) g/dL. At 12 months post-KT, mean Hb was 15.33 (2.25) with a change of 4.79 g/dL. Before KT, female kidney recipients had a mean Hb of 10.16 (2.13) g/dL. At 12 months post-KT, mean Hb was 13.31 (2.01) with a change of 3.15 g/dL. The difference between both sexes was 1.64 g/dL at the end of 12 months. Sixteen out of 152 (10.5%) patients had a serum creatinine (Cr) < 1.2 mg/dL and anemia; 36 out of 176 (20.5%) patients had a Cr ≥ 1.2 mg/dL and anemia (P = .014). In the bivariate logistic regression with an odds ratio of 2.047 (95% confidence interval, 1027-4078; P = .042) for higher Cr levels and the presence of persistent anemia. CONCLUSIONS: There is a prevalence of anemia in female kidney recipients and recipients of kidneys from deceased donors. There is a higher risk of persistent anemia in the case of patients with some degree of graft failure at 12 months.

Positive and negative impact of social media in the COVID-19 era.

Social Media usage has been shown to increase in situations of natural disaster and other crises. It is crucial for the scientific community to understand how social media works in order to enhance our capabilities and make a more resilient community. Through social media communication, the scientific community can collaborate around the globe in a faster way the most important findings of a disease, with a decreased knowledge transition time to other healthcare providers (HCPs). This is greatly important to coordinate research and knowledge during a time of uncertainty and protentional fake news. During the 2020 global pandemic, social media has become an ally but also a potential threat. High volumes of information compressed into a short period can result in overwhelmed HCPs trying to discern fact from noise. A major limitation of social media currently is the ability to quickly disseminate false information which can confuse and distract. Society relies on educated scientists and physicians to be leaders in delivering fact-based information to the public. For this reason, in times of crises it is important to be leaders in the conversation of social media to guide correct and helpful information and knowledge to the masses looking for answers.

Utility of telemedicine in the COVID-19 era.

Previously it has been demonstrated that telehealth (TH) could help cover the gaps in health attention in remote locations. Today the expanded capabilities have transformed TH delivery, and from the beginning of the coronavirus pandemic, it has remained one of our biggest allies. Telehealth has become a central piece in patient healthcare delivery during COVID-19 pandemic era. Telehealth allows health care services to reach patients in their homes, keeping other patients safe through social distancing and maintaining self-quarantine. Within this administration of health, TH allows health care providers to focus more resources to pandemic usage and at the same time continue caring for the health of non COVID-19 patients. During this time, clinicians are expanding knowledge about TH capabilities, such as application of forward triage as a tool to avoid patient contact in emergency departments. While previously TH was mainly used for primary care needs, specialized and urgent care health is now being utilized more than ever before. These advantages comes with limitations, some of them include a limited physical exam, lack of access to diagnostic testing or imaging, and many other pitfalls and persistent unmet needs. The 2020 pandemic has led to significant improvements leading into the next generation of telemedicine.

Potassium Homeostasis, Chronic Kidney Disease, and the Plant-Enriched Diets.

There are data demonstrating that ingestion of potassium-rich foods reduces the incidence of stroke, hypertension, nephrolithiasis, and osteoporosis. Dietary-consumption data indicate Westernized diets are high in processed foods, high in sodium content, and low in potassium. In fact, there are data suggesting individuals are not consuming enough potassium in their diet. Although consumption of diets high in plant proteins, fruits, and vegetables-which are excellent sources of potassium-is recognized as healthy and beneficial, individuals with decrements in their kidney function have been advised to avoid these foods. In reviewing the literature that provides the rationale for potassium restriction in patients with reductions in kidney function, it appears there is little direct evidence to support the levels of restriction which are now prescribed. Additionally, there are two new potassium-binding agents which are well tolerated and have been documented to be effective in controlling serum potassium. Therefore, with the new binding agents and the lack of empirical evidence supporting the stringent dietary potassium restrictions, the authors conclude by indicating the pressing need for further research focusing on dietary liberalization of potassium in patients with reductions in kidney function to enhance overall health and well being, to provide them cardiovascular benefits, and to reduce overall risk of mortality through the incorporation of potassium-enriched foods.

Update and review of adult polycystic kidney disease.

Autosomal dominant polycystic kidney disease is a common cause of end stage kidney disease. It is a progressive and unfortunately incurable condition that can lead to significant morbidity and kidney failure. Many more patients are diagnosed with this disease without any symptoms as the population is increasingly undergoing imaging for other problems and diagnostic workup. Our understanding of the genetic variants has increased in recent years as research continues to improve. As well, therapeutic options have developed with the FDA approval of a new treatment medication, with many others underway. This review updates the clinician on the pathophysiology, clinical aspects, and therapeutic options for patients the is form of kidney disease.

Sagliker syndrome in a patient with end-stage renal disease with secondary hyperparathyroidism.

Sagliker syndrome (SS), also known as an "uglifying human face syndrome," is one of the severe manifestations of chronic kidney disease in patients with uncontrolled secondary hyperparathyroidism. Patients with SS develop short stature, maxillary and mandibular bone overgrowth, nasal bone and cartilage destruction, widely spaced teeth with anterior positioning, soft tissue tumors in the oral cavity, auditory loss, and neurological and psychological features. SS can possibly be prevented with proper treatment of secondary hyperparathyroidism using disease-modifying medication and surgical therapies. We report a case of SS in a patient in the USA with end-stage renal disease achieving adequate hemodialysis.

Euvolemia-A critical target in the management of acute kidney injury.

It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician's best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient's response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.

The Social Media Revolution in Nephrology Education.

The past decade has been marked by the increasing use of social media platforms, often on mobile devices. In the nephrology community, this has resulted in the organic and continued growth of individuals interested in using these platforms for education and professional development. Here, we review several social media educational resources used in nephrology education and tools including Twitter, videos, blogs, and visual abstracts. We will also review how these tools are used together in the form of games (NephMadness), online journal clubs (NephJC), interactive learning (GlomCon), and digital mentorship (Nephrology Social Media Collective [NSMC] Internship) to build unique educational experiences that are available globally 24 hours per day. Throughout this discussion, we focus on specific examples of free open-access medical education (FOAMed) tools that provide education and professional growth at minimal or no cost to the user. In addition, we discuss inclusion of FOAMed resource development in the promotion and tenure process, along with potential pitfalls and future directions.