Tales from the Tubules

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Nyi Min Han's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Sadia Jahan's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Saumya Vishnoi's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Brammah R. Thangarajah's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Vishnu Reddy's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Sherry Wang's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Api Chewcharat's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Kavitha Ramaswamy's audio essay. Subscribe

In today's podcast, the team discusses a pregnant patient's clinical course highlighting normal physiology of pregnancy, common issues you may encounter, and how you can tackle them.Team:Priya YenebereChristel Wekon-KemeniPriya JohnEditing by:Mo IbrahimNormal Physiology of PregnancyVisual Abstract: Physiological Changes in PregnancyBlog: (Zac's blog)Sources:CJASN - “Obstetric nephrology: renal hemodynamic and metabolic physiology in normal pregnancy”Chronic vs. Gestational HypertensionVisual Abstract: Pregnancy and HypertensionBlog: (Priya and Anoushka's blog)Sources:CDC - “High Blood Pressure During Pregnancy”Obstetrics and Gynecology - “Hypertension in Pregnancy”Circulation (AHA) - “Chronic Hypertension in Pregnancy”Advances in Chronic Kidney Disease (ACKD) - “The Management of Hypertension in Pregnancy”AHA - “Hypertension in Pregnancy”Preeclampsia and EclampsiaVisual Abstract: Preeclamptic Glomerular InjuryBlog: (Christina's PEC blog)Sources:NIH - “About Preeclampsia and Eclampsia”Preeclampsia Foundation - ‘What is preeclampsia?”BMC Pregnancy and Childbirth: “Epidemiological trends of maternal HTN disorders of pregnancy at the global, regional, and national levels: a population-based study”BMJ - “Management of preeclampsia”

NephJC summary: Control-Salt-Delete by Bilal Sheikh of pod 2Tweetorial: by RachelTweetorial:Members of the podcast:Anand ChellapanParamveer SinghRachael Kermond

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Momen Abbasi's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Priya Yenebere's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Anoushka Krishnan's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Cristina Popa's audio essay. Subscribe

Cast:Anoushka KrishnanCristina PopaPriya JohnMomen AbbasiReferencesT. Alp Ikizler,Jerrilynn D. Burrowes,Laura D. Byham-Gray,Daniel Teta,Angela Yee-Moon Wang,Lilian Cuppari KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update September 2020 AJKD/NKFRosman J.B., Langer K., Brandl M., Piers-Becht T.P., van der Hem G.K., ter Wee P.M., Donker A.J. Protein-restricted diets in chronic renal failure: A four year follow-up shows limited indications. Kidney Int. Suppl. 1989;27:96–102.Cianciaruso B., Pota A., Bellizzi V., Di Giuseppe D., Di Micco L., Minutolo R., Pisani A., Sabbatini M., Ravani P. Effect of a low- versus moderate-protein diet on progression of CKD: Follow-up of a randomized controlled trial. Am. J. Kidney Dis. 2009;54:1052–1061. Locatelli F., Del Vecchio L., Aicardi V. Nutritional Issues with Incremental Dialysis: The Role of Low-Protein Diets. Semin. Dial. 2017;30:246–250. Lew QJ, Jafar TH, Koh HW, Jin A, Chow KY, Yuan JM, Koh WP. Red Meat Intake and Risk of ESRD. J Am Soc Nephrol. 2017 Jan;28(1):304-312. doi: 10.1681/ASN.2016030248.S Joshi, . Plant based diets for kidney disease: a guide for clinicians. Am J Kidney Diseases, 2020; 77, 287-296Goraya N, Simoni J, Jo C, Wesson D.E. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate.Kidney Int. 2014; 86: 1031-1038Goraya N, Simoni J, Jo C, Wesson D.E. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clin J Am Soc Nephrol. 2013; 8: 371-381Goraya N, Simoni J, Jo C, Wesson D.E. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int. 2012; 81: 86-93Yusuf T, Raji YR, Lasisi TJ, Daniel A, Bamidele OT, Fasunla AJ, Lasisi AO. Predictors of Taste Dysfunction and Its Severity Among Patients With Chronic Kidney Disease. Ear Nose Throat J. 2021 Jul 19:1455613211019708. Kim TH, Kim YH, Bae NY, Kang SS, Lee JB, Kim SB. Salty taste thresholds and preference in patients with chronic kidney disease according to disease stage: A cross-sectional study. Nutr Diet. 2018 Feb;75(1):59-64McMahon EJ, Campbell KL, Bauer JD. Taste perception in kidney disease and relationship to dietary sodium intake. Appetite. 2014 Dec;83:236-241.Márquez-Herrera RM, Núñez-Murillo GK, Ruíz-Gurrola CG, Gómez-García EF, Orozco-González CN, Cortes-Sanabria L, Cueto-Manzano AM, Rojas-Campos E. Clinical Taste Perception Test for Patients With End-Stage Kidney Disease on Dialysis. J Ren Nutr. 2020 Jan;30(1):79-84.Kusaba T, Mori Y, Masami O, Hiroko N, Adachi T, Sugishita C, Sonomura K, Kimura T, Kishimoto N, Nakagawa H, Okigaki M, Hatta T, Matsubara H. Sodium restriction improves the gustatory threshold for salty taste in patients with chronic kidney disease. Kidney Int. 2009 Sep;76(6):638-43. Brennan F, Stevenson J, Brown M. The Pathophysiology and Management of Taste Changes in Chronic Kidney Disease: A Review. J Ren Nutr. 2020 Sep;30(5):368-379.Rodriguez-Benot A, Martin-Malo A, Alvarez-Lara MA, Rodriguez M, Aljama P. Mild hyperphosphatemia and mortality in hemodialysis patients. Am J Kidney Dis. 2005;46(1):68-77.Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int. 2006;70(4):771-780.Wald R, Walsh MW. In Search of the Optimal Target for Phosphate Control: Episode 1. J Am Soc Nephrol. 2021;32(3):526-528.Edmonston DL, Isakova T, Dember LM, et al. Design and Rationale of HiLo: A Pragmatic, Randomized Trial of Phosphate Management for Patients Receiving Maintenance Hemodialysis. Am J Kidney Dis. 2021;77(6):920-930.e1.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Mo Ibrahim's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Christel Wekon-Kemeni's audio essay. Subscribe

Cast:Priya YenebereZac CerraChristel Wekon-KemeniMo IbrahimReferencesCooper, DKC. “A Brief History of Cross-Species Organ Transplantation.” Proceedings - Baylor University. Medical Center 25.1 (2012): 49–57. Web. DOI:10.1080/08998280.2012.11928783Roux FA, Saï P, Deschamps JY. Xenotransfusions, past and present. Xenotransplantation. 2007;14(3):208-216. DOI:10.1111/j.1399-3089.2007.00404.xDenner J. Porcine endogenous retroviruses (PERVs) and xenotransplantation: screening for transmission in several clinical trials and in experimental models using non-human primates. Ann Transplant. 2003;8(3):39-48. https://doi.org/10.1186/s12977-018-0411-8Wijkstrom M, Iwase H, Paris W, Hara H, Ezzelarab M, Cooper DK. Renal xenotransplantation: experimental progress and clinical prospects. Kidney Int. 2017;91(4):790-796. DOI: 10.1016/j.kint.2016.08.035Soin B, Smith KG, Zaidi A, et al. Physiological aspects of pig-to-primate renal xenotransplantation. Kidney Int. 2001;60(4):1592-1597. DOI: 10.1046/j.1523-1755.2001.00973.xIwase H, Liu H, Wijkstrom M, et al. Pig kidney graft survival in a baboon for 136 days: longest life-supporting organ graft survival to date. Xenotransplantation. 2015;22(4):302-309. DOI: 10.1111/xen.12174Cooper DKC, Wijkstrom M, Hariharan S, et al. Selection of Patients for Initial Clinical Trials of Solid Organ Xenotransplantation. Transplantation. 2017;101(7):1551-1558. DOI: 10.1097/TP.0000000000001582Fishman JA. Infectious disease risks in xenotransplantation. Am J Transplant. 2018;18(8):1857-1864. DOI:10.1111/ajt.14725Rosner F. Pig organs for transplantation into humans: a Jewish view. Mt Sinai J Med. 1999;66(5-6):314-319.Mansour T. Azhar issues fatwa allowing transplant of pigs' kidneys. The New Arab. https://english.alaraby.co.uk/news/azhar-issues-fatwa-allowing-transplant-pigs-kidneys. Accessed July 3, 2022. Lu T, Yang B, Wang R, Qin C. Xenotransplantation: Current Status in Preclinical Research. Front Immunol. 2020;10:3060. Published 2020 Jan 23. DOI:10.3389/fimmu.2019.03060Carrier AN, Verma A, Mohiuddin M, et al. Xenotransplantation: A New Era. Front Immunol. 2022;13:900594. Published 2022 Jun 9. DOI:10.3389/fimmu.2022.900594

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Zachary Cerra's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Priya John's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Husam Alzayer's audio essay. Subscribe

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Srikanth Bathini's audio essay. Subscribe

Raad ChowdhuryNicole ShmidtSrikanth BathiniSharmi HaquePhysiology and pathophysiology of the calcium-sensing receptor in the kidney | American Journal of Physiology-Renal Physiology. American Journal of Physiology-Renal Physiology. Published 2020. https://dx.doi.org/10.1152%2Fajprenal.00608.2009Rondon H, Badireddy M. Hyponatremia. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK470386/Asonitis N, Kassi E, Kokkinos M, Giovanopoulos I, Petychaki F, Gogas H. Hypercalcemia of malignancy treated with cinacalcet. Endocrinology, Diabetes & Metabolism Case Reports. 2017;2017. doi:10.1530/edm-17-0118Ayus JC, Moritz ML. Misconceptions and Barriers to the Use of Hypertonic Saline to Treat Hyponatremic Encephalopathy. Frontiers in Medicine. 2019;6. doi:10.3389/fmed.2019.00047Schrier RW, Gross P, Gheorghiade M, et al. Tolvaptan, a Selective Oral Vasopressin V2-Receptor Antagonist, for Hyponatremia. New England Journal of Medicine. 2006;355(20):2099-2112. doi:10.1056/nejmoa065181Sood L, Sterns RH, Hix JK, Silver SM, Chen L. Hypertonic saline and desmopressin: a simple strategy for safe correction of severe hyponatremia. American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation. 2013;61(4):571-578. doi:10.1053/j.ajkd.2012.11.032Burton David Rose. Clinical Physiology of Acid-Base and Electrolyte Disorders. Mcgraw-Hill; 2020.LeGrand SB, Leskuski D, Zama I. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Annals of Internal Medicine. 2008;149(4):259. doi:10.7326/0003-4819-149-4-200808190-00007Campbell OM. Women in White Coats : How the First Women Doctors Changed the World of Medicine. Park Row Books; 2022.Cheungpasitporn W, Suksaranjit P, Chanprasert S. Pathophysiology of vomiting-induced hypokalemia and diagnostic approach. The American Journal of Emergency Medicine. 2012;30(2):384. doi:10.1016/j.ajem.2011.10.005

CastSusan ThanabalasingamDana LarsenMythri ShankarSandy SureshReferencesNeal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, et al. Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. New England Journal of Medicine. 2017 Aug 17;377(7):644–57.Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM, et al. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. New England Journal of Medicine. 2019 Jun 13;380(24):2295–306.Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, et al. Dapagliflozin in Patients with Chronic Kidney Disease. New England Journal of Medicine. 2020 Oct 8;383(15):1436–46.Joshi SS, Singh T, Newby DE, Singh J. Sodium-glucose co-transporter 2 inhibitor therapy: mechanisms of action in heart failure. Heart. 2021 Jul 1;107(13):1032–8.Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. New England Journal of Medicine. 2015 Nov 26;373(22):2117–28.ScriptContributors: Susan Thalabalasingam, Mythri Shankar, Dana Larsen, Sandhya SureshHost (Susan):Hey everyone! Welcome to our episode of 2 truths and a lie, an NSMC podcast.Let's go over the ground rules.One at a time each member of our elite education panel will state two truths and one lie about Nephrology.This episode will focus specifically on SGLT2 inhibitors. The other panelist will then discuss which statement they think is The Lie.Our presenter will then educate us all on which statement is incorrect and why.So let's warm up our lie detectors.Let's meet our four players for today.I'm your host Susan Thanabalasingam and I'm a first year internal medicine resident at Queen's University in Kingston, Ontario, Canada. I'm really excited to be your host today and to have an amazing discussion with these wonderful women today! Our second panelist is Dr. Mythri Shankar from India. Hi Dr. Mythri, can you please introduce yourself?Mythri: Hello everyone. I am Dr. Mythri Shankar, Assistant Professor in Nephrology from Institute of Nephro-urology, Bengaluru, India.I am also the Associate Program Director of the NSMC. Glad to be here and I have no conflicts of interest to declare.Our third Panelist Dr. Dana Larsen from the United States of America! Hi Dr. Larsen, can you please introduce yourself? Dana: Hi all! I am Dana Larsen, a second year nephrology fellow at University of California, San Francisco and so grateful to get to be on this podcast with this great group today. I have no conflicts of interest in today's topics. Our fourth Panelist is Dr. Sandhya Suresh from India. Hi Dr. Suresh, can you please introduce yourself?Sandhya: Hi to all my fellow members of the 4th Pod, the Distal convoluted Pod and also… Hi to everyone listening to this podcast. I am Dr. Sandhya Suresh and I'm an early career nephrologist working in a medical college in Southern India. My only declaration here is that I am a flozinator who is continually amazed by everything that the SGLT inhibitors can do. Susan: Great, so let me start, I'll give you 3 statements. My statements all focus on the use of SGLT2i in the non-diabetic CKD setting, which is a cohort that merits special attention when discussing the benefits of SGLT2i use (Susan)SGLT-2 inhibitors are nephroprotective in diabetic and non-diabetic CKD (TRUE)SGLT2 inhibitors decrease proteinuria in non-diabetic CKD (TRUE)SGLT2 inhibitors are indicated for all etiologies of non-diabetic CKD (FALSE) Explanation for 1 → Statement 1 is TRUE. SGLT-2 inhibitors are in fact nephroprotective in BOTH diabetic and non-diabetic CKD. The CREDENCE trial was the first to specifically examine kidney outcomes in patients with diabetic, proteinuric CKD, and it demonstrated significant decrease in risk for kidney failure and cardiovascular events in patients treated with canagliflozin (Perkovic et al, 2019). As the effects were independent of glucose lowering effects, further studies have been conducted in the non-diabetic CKD setting. DAPA-CKD included patients with both diabetic and non-diabetic CKD and found that the use of dapagliflozin was associated with decreased risk of >= 50% decline in eGFR, ESKD or death from renal or cardiovascular causes (Heerspink et al, 2020). Explanation for 2 → Statement 2 is ALSO TRUE. We do in fact have compelling data that proteinuria is reduced with the use of SGLT2i in non-diabetic kidney disease. Pre-specified analyses from the DAPA-CKD trial demonstrated that dapagliflozin significantly reduced proteinuria in both diabetic and non-diabetic CKD, although the effect was larger in the diabetic subset. Because clinical outcomes were similar with dapagliflozin initiation between diabetic and non-diabetic patients, despite this difference in effect size on proteinuria, it has been postulated that the observed nephroprotection may not actually be related to reduction in proteinuria. Explanation for 3 → Statement 3 was the FALSE statement. In DAPA-CKD, included etiologies of non diabetic CKD were FSGS, minimal change disease, chronic pyelonephritis, chronic interstitial nephritis and hypertensive, IgA, membranous, and obstructive nephropathies. However, patients with lupus nephritis, polycystic kidney disease and vasculitis were excluded. The results of EMPA-Kidney are highly anticipated, in part as it includes a larger number of participants without diabetes, in particular those with glomerular disease, which will hopefully give us more answers about whether these patients will also benefit from SGLT2i initiation. EMPA-Kidney does however also exclude patients with PKD (The EMPA-KIDNEY Collaborative Group, 2022). That was fun, I can't wait to hear more from the rest of our panelists. Moving on to Dr. Mythri now, can you please give us your 2 truths and a lie?Mythri:SGLT2i are the initial therapy for T2DM (FALSE)SGLT2i are beneficial in heart failure with reduced ejection fraction as it reduces both preload and afterload (TRUE)SGLT2i are analogs of Phlorizin (TRUE)Explanation for 1. SGLT2i are not the initial therapy. Initial therapy consists of lifestyle modifications, diet and exercise (American diabetes association guidelines 2021).Explanation for 2. SGLT2 inhibitors promote osmotic diuresis and natriuresis in patients with and without diabetes, and thus may reduce preload. SGLT2 inhibitors may also have vascular effects (including improving endothelial function) that promote vasodilation and thus may also reduce afterload. It has also been postulated that SGLT2 inhibitors may improve myocardial metabolism and thus improve cardiac efficiency. SGLT2 inhibitors promote osmotic diuresis and natriuresis in patients with and without diabetes, and thus may reduce preload (Joshi et al, 2021).Explanation for 3:A natural compound, phlorizin, was isolated from apple trees in the early 1800s and for decades played an important role in diabetes and renal physiology research. The compound is poorly absorbed from the gastrointestinal tract and inhibits both SGLT1 (primarily found in the gastrointestinal tract) and SGLT2. Analogs of phlorizin have been developed that circumvent these two problems. These are the current SGLT2i (Atanasov et al, 2016).Susan: That was great Dr. Mythri, thank you, I feel like I learned so much! Moving on to Dr. Dana, can you give us your 2 truths and a lie?Dana:Awesome, thank you Susan! Alright, please identify the lie from among these statements all concerning potential SGLT2 side effects:SGLT2 inhibitors definitively increase the risk of vulvovaginal candidiasis and may increase the risk of urinary tract infections. (TRUE)SGLT2 inhibitors do not definitively increase risk of bladder cancers. (TRUE)SGLT2 inhibitors definitively increase risk for limb amputations. (FALSE)Do you think you have the answer!?! Let's take a closer look…My first statement, SGLT2 inhibitors definitely increase the risk of urinary tract infections and vulvovaginal candidiasis is TRUE. Multiple studies on SGLT2 inhibitors including a 2018 canagliflozin RCT and a 2013 dapagliflozin RCT have shown 2-4 fold increase in vulvovaginal candidiasis in 10-15% of patients on SGLT2 inhibitors compared with placebo (Neal et al, 2017). A 2019 meta-analysis of over 100 RCTs with SGLT2s compared with other anti-diabetic agents or placebo did NOT show an increase in risk of UTIs for SGLT2s as a group, though there was a signal for increased risk of UTIs specifically for dapagliflozin, mechanistically it is unclear why this would be the case (Donnan et al, 2019). At this time, where there is definitive increased risk of vulvovaginal candidiasis, increased risk of UTI is likely not something you need to counsel your patients on.Alright, moving on, our second statement, SGLT2 inhibitors do not definitely increase risk of bladder cancers is also TRUE. While few cases of bladder cancers have been diagnosed in patients taking dapagliflozin, half of these occurred within the first 6 months, which is thought to be too soon for tumorigenesis promotion by dapagliflozin itself. EMPA-REG trial did not find increased incidence of bladder cancer once event rates that occured within the first 6mo of drug therapy were removed (Kohler et al, 2017). Currently, the FDA recommends ongoing postmarketing surveillance And finally, moving on to our final statement which must be FALSE given the name of the game, the statement says SGLT2 inhibitors definitively increase risk for limb amputations. While the CANVAS program found that in the over 10,000 combined patients from their two major trials there was an increased risk of amputations 6.3 vs 3.4 per 1000 participants with hazard ratio 1.97, these amputations were primarily at the level of the toe or metatarsal, not the limb (Neal et al, 2017). Furthermore, there is ongoing discussion over true risk of amputation attributed to SGLT2 inhibitors as post hoc analysis of empa-reg and CREDENCE, the renal outcomes trial for canagliflozin, no association for increased risk of lower extremity amputation was found (Perkovic et al, 2019). While further investigation into the topic is warranted, we can rest assured that this is our FALSE statement on side effects of SGLT2-inhibitors. Susan: Wow Dana, thanks so much for those very important lessons on SGLT2i side effects, I certainly have a lot of take home points from your discussion! Perfect, now we'll move on to Dr. Sandhya. Please join me in welcoming her to give us our final set of 2 truths and a lie today.Sandhya:Thank you Susan. So here, I will be focussing my 2 truths and a lie on the cardioprotective effects of SGLT2 inhibitors. Without further ado, here are my 3 statements:Statement 1: Increased ketone body production is postulated as one of the mechanisms for the cardioprotective effects of SGLT2 inhibitors (TRUE)Statement 2: Glucose lowering effect and cardiovascular benefits both decline at lower GFRs (FALSE)Statement 3: Sotagliflozin in a combined SGLT2 and SGLT1 inhibitor which has demonstrated cardioprotective benefits (TRUE)Explanations for the above statements: Let me go through the explanation for each statement one by one.Statement 1 is true. The cardioprotective effects of SGLT2 inhibitors may be multifactorial. While they target the traditional cardiovascular risk factors through their glycosuric and natriuretic effects, it is also postulated that SGLT2 inhibitors improve the cardiac metabolism and bioenergetics. 90-95% of cardiac energy is derived from mitochondrial oxidative metabolism for which the predominant fuel is free fatty acids. In a diabetic heart, the metabolic flexibility in terms of substrate utilization is impaired and the myocardium becomes more dependent on free fatty acids as fuel leading to build up of free fatty acid intermediates which lead to lipotoxicity and myocardial dysfunction. SGLT2 inhibitors produce a starvation simulation with reduced insulin and higher glucagon levels which promotes lipolysis and ketogenesis. They also reduce the excretion of ketone bodies by reducing the GFR. These ketone bodies like beta hydroxybutyrate serve as an alternate super fuel for myocardial cells producing ATP more efficiently and help to preserve the mitochondrial integrity and these factors lead to improved cardiac efficiency (Joshi et al, 2021).Now coming to statement 2. The glucose lowering effect of SGLT2 inhibitors does decrease with declining GFRs because the magnitude of glucose excretion and consequently the HbA1c reduction is dependent on the filtered glucose load. This filtered glucose load is high in diabetic patients with normal GFR and reduced in patients with renal impairment thereby leading to reduction in the glucose lowering effect of SGLT2 inhibitors (Kelly et al, 2018). Conversely, the cardioprotective effects of this class of drugs seems to be remarkably preserved at lower GFRs as has been demonstrated in several trials. For example, in the EMPAREG OUTCOME trial, analysis of a subgroup of patients with prevalent kidney disease was done which included type 2 diabetic patients with established cardiovascular disease and an estimated GFR between 30-60 . There was significant reduction in the cardiovascular and all-cause mortality as well as hospitalization for heart failure in this subgroup and this effect was consistent across different categories of GFR (Wanner et al, 2017). So statement 2 is false.So by that logic statement 3 has to be a truth. We often talk about the 4 traditional flozins so I just wanted to throw in a statement about this new subclass within this class of agents. Sotagliflozin is an SGLT2 inhibitor which also inhibits the intestinal SGLT1 transporters. It was originally targeted for use in patients with type 1 diabetes mellitus with the hope that SGLT1 inhibition in the intestine could reduce postprandial hyperglycemia and improve overall glycemic control in these patients. Studies have also shown excellent efficacy for this purpose. However they also showed a higher incidence of Diabetic ketoacidosis episodes. 2 cardiovascular trials were conducted, both of which unfortunately, ended early as they lost funding sometime during the COVID pandemic. The SCORED trial included CKD patients and the SOLOIST-WHF trial included patients who had recently recovered from an episode of decompensated heart failure. I won't go into the strengths and limitations of these trials but they did show benefit in terms of cardiovascular endpoints in the sotagliflozin group compared to placebo (Bhatt et al, 2021; Bhat et al, 2021). The drug isn't commercially available as of now and is not FDA approved yet but it remains as a novel agent within the SGLT2i landscape.Susan (Conclusion by host):Amazing, thank you so much Dr. Sandhya! That was an enlightening discussion on cardioprotection with SGLT2i use. And this has been so much fun! I hope you've all found our conversation really helpful and informative - I certainly know that I have learned a lot from my colleagues today. I can't thank them enough for sharing their time and expertise with us. Be sure to tune in next time for more FOAMed nephrology education.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Susan Thanabalasingam's audio essay.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Nicole Schmidt's audio essay.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Dana Larsen's audio essay.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Raad Chowdhury's audio essay.

The first assignment in the Podcast rotation is to record a short essay on why the NSMC Intern chose nephrology (or pediatrics, or nursing, or medical school, etc…). The intern then uses this recording to practice editing, adding music and finally publishing a podcast (if they want to). Here is Sandhya Suresh's audio essay.

Cast:Mythri ShankarCarlo TrinidadBrian RifkinReferencesPerl J, Fuller DS, Bieber BA, Boudville N, Kanjanabuch T, Ito Y,et al . Peritoneal Dialysis-Related Infection Rates and Outcomes: Results From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Am J Kidney Dis. 2020 Jul;76(1):42-53. doi: 10.1053/j.ajkd.2019.09.016. Epub 2020 Jan 10. PMID: 31932094.Miller LM, Clark E, Dipchand C, Hiremath S, Kappel J, Kiaii M,et al; Canadian Society of Nephrology Vascular Access Work Group. Hemodialysis Tunneled Catheter-Related Infections. Can J Kidney Health Dis. 2016 Sep 27;3:2054358116669129. doi: 10.1177/2054358116669129. PMID: 28270921; PMCID: PMC5332080.Sun CY, Sung JM, Wang JD, Li CY, Kuo YT, Lee CC, Wu JL, Chang YT. A comparison of the risk of congestive heart failure-related hospitalizations in patients receiving hemodialysis and peritoneal dialysis - A retrospective propensity score-matched study. PLoS One. 2019 Oct 1;14(10):e0223336. doi: 10.1371/journal.pone.0223336. PMID: 31574134; PMCID: PMC6773217.Zazzeroni L, Pasquinelli G, Nanni E, Cremonini V, Rubbi I. Comparison of Quality of Life in Patients Undergoing Hemodialysis and Peritoneal Dialysis: a Systematic Review and Meta-Analysis. Kidney Blood Press Res. 2017;42(4):717-727. doi: 10.1159/000484115. Epub 2017 Oct 19. PMID: 29049991.ScriptHello and welcome to our second episode of 2 truths and a lie, an NSMC podcast.Let's go over the ground rules.One at a time each member of our elite education panel will state two truths and one lie about Nephrology.This episode will focus specifically on peritoneal dialysis.The other panelist will then discuss which statement they think is The Lie.Our presenter will then educate us all on which statement is incorrect and why.So let's warm up our lie detectors.Let's meet our three players for today.I'm your host Dr.Mythri Shankar, Assistant Professor in Nephrology from Institute of Nephro-urology, Bengaluru, India.And here is our second Panelist Dr.Carlo from the Philippines! Hi Dr.Carlo, can you please introduce yourself? Our third Panelist is Dr.Brian Rifkin from the United states of America. Hello Dr.Brian, …..please introduce yourself?Great, so let me start, I will give you 3 statements…Number 1.Peritoneal Dialysis is a good option for patients with Diabetes mellitus. (True)The concern for diabetic patients undergoing PD is over the absorption of dextrose from the PD fluid which would cause hyperglycemia. But studies comparing HD and PD in daibetic population has not shown that one is superior over the other. European Renal Best Practice Diabetes Guideline Development Group conducted a systematic review of 25 observational studies on the type of dialysis and mortality and found no mortality differences across the subpopulations. There were some limitations with respect to study designs. In the absence of clear evidence of superiority of one modality over the other, PD should not be denied to diabetic patients. The modality of dialysis should be according to patient preference. High dextrose solutions should be avoided as much as possible. Multidisciplinary team approach should be used for blood glucose management.Number 2.The adequacy of Peritoneal dialysis (Kt/v) in obese patients is falsely low. (True)Traditional exit sites cannot to used in obese patients which is a barrier for PD catheter insertion. In motivated obese patients, presternal exit site is a good option. There are no studies showing superiority of one catheter type over the other due to technical issues.Also, it is thought that adequacy of dialysis is lesser in obese patients. This is because Kt/V can not be applied to obese patients. The watson equation assesses total body water using age, sex, height and weight which cannot be applied in obese patients.It give false high volume of distribution and hence, less kt/v. Alternatively, creatinine clearance can be calculated instead of kt/V.Another retrospective study, showed that obese pts had longer survival on PD compared to low BMI pts even after adjustment for transplant and modality failure.Number 3. Infectious complications are very frequent in Peritoneal Dialysis patients (False)Peritonitis, the most common infection among PD patients, is actually quite rare. A large multicenter study by Perl et al published in the year 2020 demonstrated that among 7000 patients across 209 facilities in 7 countries, there were 2272 peritonitis episodes during 7876 follow-up years. This translates to a crude rate of only 0.28 episodes per patient year . In comparison, catheter related bloodstream infections associated with hemodialysis tunneled catheters were much more common at 1.1 to 5.5 episodes per 1000 catheter days (Miller et al. 2016). The risk of peritonitis can be reduced with proper training and handwashing techniques. Mythri : (“You got me”, or “Nope, I fooled you”). (Then give a paragraph explanation of why it is a lie, or similar knowledge to explain why other statements are true.) OK, that was fun. Moving on to Dr.Carlo, can you give us your 2 truths and a lie.Person #2:A. Patients on PD have a lower risk of developing heart failure compared to their HD counterparts (True)In a large retrospective cohort study involving 4754 matched pairs of HD and PD patients, PD patients had a significantly lower incidence of CHF (19.71 per 1000 patient years versus 25.98 per 1000 patient years) (Sun et al. 2019). PD provides gentle ultrafiltration, resulting in lesser hemodynamic fluctuations, neurohormonal activation and myocardial ischemia. Unlike in HD, PD is not associated with myocardial stunning (Selby and McIntyre, 2011), an important process in the progression of heart failure.B. PD is a better dialysis modality than haemodialysis (false)There are numerous studies comparing PD to HD in terms of mortality and quality of life Zazzeroni L et al, 2017. Quality of life has been shown to be a useful outcome measure in patients with kidney failure Tannor et al, 2018. There is no difference between PD and HD with respect to survival and quality of life Gokal et al, 1999. PD and HD have been shown to be rather complementary and should be chosen based on availability and patient preference and be worked up for kidney transplantation which has rather been shown to be better than PD and HD in terms of cost, quality of life and survival Kawanishi H et al, 2008.C. Peritoneal dialysis is more expensive than Haemodialysis in low and lower-middle income countries. (True)Peritoneal dialysis has been suggested as less expensive than Haemodialysis in most developed countries as it is assumed to be operational without expensive machines. But there is evidence to suggest that this may not be the case in low and low-middle income countries as the cost is comparable to that of HD or even more expensive as there is no local production of PD fluid and the import duties on PD fluid and equipment are expensive. Karopadi AN, 2013OK, that was fun. Moving on to Dr.Brian, can you give us your 2 truths and a lie.Person #3:Doing Peritoneal Dialysis exchanges are time consuming (FALSE)PD may allow you more time to spend with family and friends, at work, or to simply do what you love most because you can perform dialysis outside of a dialysis center. Additionally, if you choose continuous cycling peritoneal dialysis (CCPD), you will dialyze while you sleep and spend an average of three hours per week setting up and cleaning equipment.Peritoneal dialysis is not complicated and can be done by very elderly people and people with disabilities. (TRUE)Although PD may be more challenging for people with certain disabilities (blindness, deafness, amputation, etc.), this treatment may still be an option. With the help of a care partner and/or special equipment it can often be done. Training and safety programs are available to educate patients on how to perform safe and effective treatments.There are no age limits for this treatment option. Elderly people as well as children may be able to perform PD with assistance. Care partners can make it easier to perform treatments, which may help patients feel more confident and comfortable dialyzing at home.Peritoneal dialysis patients can own pets (TRUE)Pets cannot be in the room while you are performing PD, but you can still have them. Be sure to keep your home and designated treatment area clean. Also catheters are not toys. Women with a cat ended up with pasterella infection when cat bit the catheter.Conclusion by host:Well, that was really helpful and informative. I would like to thank our panelists for participating today. Be sure to tune in next time for more FOAMed nephrology education.

The patient has nephrotic syndrome, what could be the cause?Your lupus nephritis patient is doing great and then she gets pregnant. What can you do? What should you do?