#NephMadness Round 1: Who Moves On?

Mar 22 2013 Published by under [Medicine&Pharma]

The first round results came in, and my bracket included the big upset. Yes, I chose PD First over Fistula First. As a pediatric nephrologist, we routinely choose PD First. Apparently a lot of participants also believe in this order of things. I also chose the big 14 - 3 seed upset in the Big Dance, not because I love Harvard. No, my father was a faculty member at Missouri State during their years with Alford. I will always cheer on whoever plays his team.

Of the 32 first round picks, I scored 27 correctly. Here are my misses:

  • Epigenetics (8) over Whole Exome Sequencing (9): I picked the sequencing because I have actually seen the diagnosis made via this technology. While epigenetics is exciting and holds a lot of promise, I believed it was not yet strong enough to take on sequencing. 
  • HIVAN (13) over MPGN Reclassification (4): I went with the favorite since the reclassification seems to be putting MPGN into classes based more on cause or function than structure, which should prove more therapeutically useful over time.
  • Tolvaptan (10) over Cyclosporin (7): I agree that Tolvaptan shows great promise in PKD, but I considered Cyclosporin as a representative of its class. Where would we be without calcineurin inhibitors for transplantation and treatment of nephrotic syndrome? I only have 1 kid on Tolvaptan; everyone seems to be on tacrolimus.
  • Winter's Formula (5) over TTKG (12): I had to look up what Winter's Formula was because I just do not use this one. That may be my pediatric bias; I suspect we see fewer mixed acid-base disorders than our adult colleagues. 
  • Citrate Anticoagulation (11) over Heparin Anticoagulation (6); Heparin has been a long-term champion. While citrate shows a great deal of promise, especially for continuous therapy, I just did not feel it would take down the defending royalty yet. 

Now for my second round picks and reasoning:

Glomerulus

  • Medicare ESRD Benefit (1) vs PD First (14): Without the benefit, the rest of this stuff would not happen. Our neighbors to the north may have guaranteed healthcare for everything, but inclusion of end-stage care in Medicare makes nephrology unique.
  • KDIGO (5) vs USRDS (7): I have the underdog here. National databases like the USRDS provide the sort of data that we used to generate all those recommendations. No USRDS, no KDIGO…USRDS wins.
  • Epigenetics (8) vs Propensity Scoring (6): Lucky for me, I picked Propensity Scoring. Given the complexity of renal patients, this sort of statistical adjustment allows us to make some sense of our clinical data.
  • Real Time PCR (4) vs Randomized Clinical Trial (2): Sorry, PCR, the RCT is the gold standard. It will take you down…

Proximal Tubule

  • HEMO Trial (1) vs TREAT Trial (3): A randomized clinical trial that informs our practice today vs a negative study of darbopoeitin pre-dialysis that led one oncology colleague to suggest that ESAs would go off the market. I have the favorite here…"HEMO, HEMO, HEMO!"
  • ALLHAT Trial (5) vs IDEAL Trial (7): ALLHAT showed an inexpensive generic drug beating a bunch of newer antihypertensive agents for cardiovascular endpoints. Not especially applicable to my pediatric population, but a really important trial. I thought about picking the IDEAL trial which showed no advantage to starting dialysis before patients feel bad, since I use this information in my practice. However, given the number of hypertensive adults vs the number of chronic kidney disease patients approaching dialysis, I went with the favorite.
  • FGF23 (8) vs Anti-PLA(2)R (6): In this battle, I went with the phosphatonin over the cause of membranous nephropathy. Call it intuition, I just feel that way.
  • HIVAN (13) vs APOL1 (2): The gene responsible for excess chronic kidney disease among African Americans wins hands down. I did not pick HIVAN in the first round, so I surely do not have it now.

Loop of Henle

  • Captopril (1) vs Mycophenolate Mofetil (3): We find another use for MMF every day, but I write more prescriptions for ACE inhibitors than any other class of drug. 
  • Eculizumab (5) vs Tolvaptan (10): Eculizumab has turned a fatal chronic disease into an annoyance. Inhibition of C5 complement may be useful in transplantation and for classic childhood HUS. Expensive, but revolutionary, and some things are worth the money.
  • Renal Fellow Network (9) vs UpToDate (6): Sorry kids, UTD is now the first place doctors look for information. It wins.
  • ASN Kidney Week (4) vs NephSAP (2): While NephSAP provides useful updates, I will pick Kidney Week. I like hearing about original research in its early stages. It is also more fun to go to convention cities and meet up with my nephrology buddies than it is to read a review article.

Collecting Tubule

  • MDRD eGFR Equation (1) vs 24-hour Cr Cl (3): I have the 24-hour collection upsetting MDRD in this match-up. In pediatrics we use a different formula for eGFR, and these estimates all seem to become less useful with repeated study. When push comes to shove, we get a timed collection and measure creatinine clearance.
  • Winter's Formula (5) vs FeNa (7): Since Winter's Formula no longer appears in my bracket, I have FeNa winning this round. Differentiating pre-renal and acute tubular necrosis frequently precipitates nephrology consults, and FeNa often helps when these kids get IV fluids. 
  • Kidney Biopsy (8) vs Citrate Anticoagulation (11): Kidney Biopsy tells us what the patient has when all other testing fails. 
  • Scribner Shunt (4) vs Kidney Transplant (2): Without transplant, I don't know if I could face treating end-stage failure. The promise of a new kidney makes the pain of dialysis worthwhile in a pediatric population. Transplant for the win.

Those are my picks and reasoning (or what passes for reasoning in my life). Be sure and help pick the match-ups over at eAJKD.

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