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The authors began a curriculum reform project to improve the experience in a Renal Physiology course for first-year medical students. Taking into account both the variety of learning preferences among students and the benefits of student autonomy, the authors hypothesized that adding digital chalk-talk videos to lecture notes and live lectures would improve student knowledge, course satisfaction, and engagement. The authors measured performance on the renal physiology exam before (the traditional curriculum) and for 2 yr after implementation of the new curriculum. During the traditional and subsequent years, students took a Q-sort survey before and after the Renal Physiology course. Satisfaction was assessed based on ranked statements in the Q sort, as well as through qualitative analysis of student commentary. Compared with the traditional curriculum, mean scores on the renal physiology final exam were higher after implementation of the new curriculum: 65.3 vs. 74.4 ( P < 0.001) with year 1 and 65.3 vs. 79.4 ( P < 0.001) in the second year. After the new curriculum, students were more likely to agree with the statement, “I wish other courses were taught like this one.” Qualitative analysis revealed how the video-based curriculum improved student engagement and satisfaction. Adding digital chalk-talk videos to a traditional Renal Physiology course that included active learning led to improved exam performance and high levels of student satisfaction. Other preclinical courses in medical school may benefit from such an intervention.

Introduction Because there are now roughly 500,000 patients undergoing chronic hemodialysis (HD) in the United States, medical residents will certainly care for chronic HD patients no matter what field of medicine they enter. However, many residents report a lack of understanding of the dialysis procedure. The purpose of this resource is to help the learner understand the scientific underpinnings of dialysis, the differences between conventional HD and continuous renal replacement therapy (CRRT), and the limitations of renal replacement therapy. Methods This resource served as a supplement to a lecture, Hemodialysis Basics, for nephrology fellows, and as a supplement to a whiteboard and magic marker talk during an elective course, Fluids and Electrolytes, for third- and fourth-year medical students at our institution. The resource includes an electronic blackboard-style video for instruction and a quiz to assess medical knowledge related to concepts discussed in the video. Results All nephrology fellows found it to be helpful. One fellow remarked, “I thought the video was excellent. I give it a 10 [out of 10].” Similarly, from the evaluations of our third- and fourth-year medical student course, 100% of the respondents (11 of 26 students) ranked the video as high quality. Discussion We believe that this a succinct but excellent educational resource for not only renal fellows but all medical students and physicians who care for chronic HD patients or those with acute renal failure undergoing conventional HD or CRRT.

The arteriovenous graft (AVG) is most often used in hemodialysis patients when an autogenous fistula is not feasible. The optimal location (forearm or upper arm) and configuration (loop or straight) of AVGs are not known. To evaluate relationships of AVG location and configuration with patency, we conducted a secondary analysis using data from a randomized, placebo-controlled trial of dipyridamole plus aspirin for newly placed AVG.Participants of the Dialysis Access Consortium (DAC) Graft Study with newly placed upper extremity prosthetic grafts involving the brachial artery were studied. Multivariable analyses adjusting for trial treatment group, center, gender, race, body mass index, diabetes, current treatment with chronic dialysis, and prior arteriovenous vascular access or central venous catheter were performed to compare outcomes of forearm (fAVG) and upper arm (uAVG) grafts, including loss of primary unassisted patency (LPUP) and cumulative primary graft failure (CGF). Subgroup analyses of graft configuration and outflow vein used were also conducted.A total of 508 of the 649 participants (78%) enrolled in the trial had an upper extremity brachial artery graft placed, 255 with fAVG and 253 with uAVG. Participants with fAVG were less often male (33% vs 43%; P = .03), African American (62% vs 78%; P .001), and receiving dialysis at the time of surgery (62% vs 80%; P .001). Participants with fAVG had a higher mean body mass index (33 vs 29; P .001). The LPUP (fAVG 70% vs uAVG 78%; P = .07) and CGF (33% vs 36%; P = .91) were similar between fAVG and uAVG at 1-year follow-up. In multivariable analysis, AVG location (uAVG vs fAVG) was not associated with LPUP (hazard ratio, 1.21; 95% confidence interval, 0.90-1.63; P = .20) or CGF (hazard ratio, 1.36; 95% confidence interval, 0.94-1.97; P = .10). LPUP did not differ significantly between fAVG and uAVG among subgroups based on AVG configuration (P = 1.00) or outflow vein used (P = .16).Patency was comparable between fAVG and uAVG despite the larger caliber veins often encountered in the upper arm in carefully selected patients. Our findings support the traditional view that, in order to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.

Cardiac diseases in maintenance hemodialysis patients: Results of the HEMO Study.BackgroundCardiac disease is a common cause of death in chronic hemodialysis patients. A subanalysis of the data on cardiac diseases in the Hemodialysis (HEMO) Study was performed. The specific objectives were: (1) to analyze the prevalence of cardiac disease at baseline; (2) to characterize the incidence of various types of cardiac events during follow-up; (3) to examine the association of cardiac events during follow-up with baseline cardiac diseases; and (4) to examine the effect of dose and flux interventions on various types of cardiac events.MethodsThe HEMO Study is a randomized multi-center trial on 1846 chronic hemodialysis patients at 15 clinical centers comprising 72 dialysis units. The scheduled maximum follow-up duration was 0.9 to 6.6 years, with the mean actual follow-up of 2.84 years. The interventions were standard-dose versus high-dose and low-flux versus high-flux hemodialysis in a 2 × 2 factorial design.ResultsAt baseline, 80% of patients had cardiac diseases, including ischemic heart disease (IHD) (39%), congestive heart failure (40%), arrhythmia (31%), and other heart diseases (63%). There were a total of 1685 cardiac hospitalizations, with angina and acute myocardial infarction accounting for 42.7% of these hospitalizations. There were 343 cardiac deaths during follow-up, accounting for 39.4% of all deaths. IHD was implicated in 61.5% of the cardiac deaths. Any cardiac disease at baseline was highly predictive of cardiac death during follow-up [relative risk (RR) 2.57; 95% CI 1.73–3.83]. There were no significant effects of dose or flux assignments on the primary outcome of all-cause mortality or the main secondary cardiac composite outcome of first cardiac hospitalization or all-cause mortality. Assignment to high-flux dialysis was, however, associated with decreased cardiac mortality and the composite outcome of first cardiac hospitalization or death from cardiac causes.ConclusionThe HEMO Study identified IHD to be a major cause of cardiac hospitalizations and cardiac deaths. Future strategies for the prevention of cardiac diseases in the maintenance hemodialysis population should focus on this entity. Although high-flux dialysis did not reduce all-cause mortality, it might improve cardiac outcomes. This hypothesis needs to be further examined.

Early referral of the patient with chronic renal failure will give the nephrologist time to fit the treatment to the patient. Planning for dialysis and transplantation should be undertaken concurrently. If the patient is not of advanced age and is not afflicted with severe comorbid illness, renal transplantation is the preferred form of renal replacement therapy. Living donor transplantation is preferred to cadaveric transplantation. For the patient who awaits or who cannot undergo transplantation, either peritoneal dialysis or hemodialysis may be chosen. Although the mortality rate for peritoneal dialysis appears to be higher than that for hemodialysis, especially among elderly diabetic patients, peritoneal dialysis remains an acceptable therapy for the highly motivated patient. In the United States, the mortality rate for chronic dialysis patients is high. We expect mortality rates for both peritoneal dialysis and hemodialysis to fall, however, as we strive to achieve optimal solute clearance and to more effectively treat comorbid illness.

Several laboratories, including ours, have reported that receptors for 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] are decreased in parathyroid glands of uremic animals and patients. To elucidate the factors involved in receptor regulation in this tissue, we have characterized the receptor in primary cultures of bovine parathyroid cells. Extracts from these cells contain a single binding component that binds 1,25-(OH)2D3 with a Kd of 58 pM and sediments in sucrose density gradients at 3.4S, indicating the continued expression of the vitamin D receptor in these cells. Labeling of the intact parathyroid cells with tritiated 1,25-(OH)2D3 was maximal by 2 h, and binding affinity by this method was estimated to be 22 pM. Longer incubation of the cells with tritiated 1,25-(OH)2D3 resulted in a loss of specific binding to 10% maximal by 12 h. The decrease in binding correlated temporally with degradation of 1,25-(OH)2D3 in the medium. This metabolic activity was absent in vitamin D-deficient cells and was first detectable 3-4 h after the addition of 1,25-(OH)2D3, indicating that 1,25-(OH)2D3 induces its own metabolism in parathyroid cells. Replenishment of the cultures after 12 h with fresh tritiated 1,25-(OH)2D3 restored maximal binding, demonstrating that the loss of binding was not due to down-regulation of receptor. Inclusion of the cytochrome P450 inhibitor ketoconazole did not alter maximal binding at 2 h, but blocked both the metabolism of 1,25-(OH)2D3 and the decrease in binding after 3 h. In contrast to other cell types, such as osteosarcoma cells, no homologous up-regulation was seen in cultured parathyroid cells even after 12 h in the presence of 0.5 nM 1,25-(OH)2D3. Furthermore, receptor levels in preparations from cells treated for 20 h with unlabeled 1,25-(OH)2D3 at concentrations of 0.1, 1.0, and 10 nM were not different from controls. Thus, it appears that the vitamin D receptors in parathyroid cell cultures are not up-regulated by their ligand.

Patients with approaching end-stage renal disease often must choose between hemodialysis or peritoneal dialysis as the initial form of renal replacement therapy. Should nephrologists recommend one form of dialysis as superior to the other? This review focuses on studies that compared patient mortality for these two dialysis techniques. Explanations for the disparate findings of these studies will be put forth. Finally, suggestions regarding what we can recommend to patients are made.

The objective of this study was to investigate factors that might increase the risk of epidural abscesses in hemodialysis patients. The charts of all hemodialysis patients presenting with an epidural abscess over a period of 5 yr at Duke University Hospital and the Durham Veterans Administration Medical Center were reviewed for patient demographics, months on dialysis, vascular access, recently treated infections, signs and symptoms at presentation, and results of any surgical intervention. Ten patients developed an epidural abscess during a 5-yr period. Severe, debilitating back pain was the only consistent initial complaint. Eight patients had dual-lumen intravenous catheters for hemodialysis access, and five patients had or were receiving parenteral antibiotics for catheter salvage. There were no consistent physical, clinical, or laboratory findings. Surgical drainage of the abscess with removal of the hemodialysis catheters and parenteral antibiotics were required for cure in six patients. It was concluded that attempts at catheter salvage with parenteral antibiotics has significant risks for complications. Hemodialysis patients with recently treated or ongoing bacteremia who complain about severe and debilitating back pain with or without neurologic findings should raise the suspicion of an occult epidural abscess.

Medullary sponge kidney is a developmental disorder characterized by ectatic and cystic malformation of the collecting ducts and tubules. Clinical manifestations include urinary tract infections, renal stones, and hematuria. It can be associated with other developmental disorders. A case of medullary sponge kidney associated with congenital hemihypertrophy, complicated by nephrocalcinosis and nephrolithiasis, is reported here.