Did it fully reverse both times?
I’m curious about these cases and I think we should discuss them more.
However, when it’s not easy to check or it causes inertia, requiring that check is harmful. (I think)
Requiring a test 2-3 weeks after starting an SGLT2i and then dealing with the (expected yet surprising!!) eGFR drop
-> underprescription and unnecessary discontinuation.
Checking should be limited (high risk eg vol issues or if symptoms).
What guidance can we give our trainees? #askrenal
Do you check labs after starting SGLT2i in CKD patients?
What % of pts drop eGFR >30% after starting SGLT2i?
What are the usual causes if that happens?
Do you know of any studies that specifically looked at that?
@askrenal.bsky.social #flozinators
- y do u want to put me on januvia after my pcp stopped it?
- It'll slow down ur dis.. (explaining and discussing)
- yeah, but my pcp stopped it because of my kidney numbers.
- Yes, and I'm ur kidney specialist (another round of explaining).
- but my pcp said it was bad for my kidneys..
Me: 😭
Patient was told to reduce his work hours so his lower income qualifies him for savings on health insurance.
Ends up with more money if he works less.
How ironic!
Not a US-only problem. Seen it in Europe too.
Gosh that will be painful!
Only want the info available at the visit to assess the rate of decline of kidney fx.
In this era, however, electronic systems should provide patients with far more individualized, meaningful info - not just numbers. I bet this wish is coming soon.
I always struggle with how to judge GFR decline in individual patients.
If I had a wish, it would be to have weekly measurements between clinic visits. Without needles. And without lab trips.
Does that still count as one wish?!
#NephroWishList
Guidance: Be comfortable with short-term eGFR swings.
Act only on *sustained* changes. Otherwise you are treating biological variability, not disease.
*And always correlate with the clinical picture *
At Cr = 2.0, a 5% CV = ±0.10 mg/dL noise.
That normal scatter alone produces Cr 1.8–2.2, exactly the range creating our 42 - 33 eGFR swing.
This small creatinine noise becomes a 7–9 mL/min eGFR illusion of progression or recovery.
This study measured short-term variability in stable CKD.
Most patients had within-person creatinine CV ~3–7% over <4 weeks.
pmc.ncbi.nlm.nih.gov/articles/PMC...
Using CKD-EPI 2021:
Cr 1.8 → eGFR 42
Cr 2.0 → 37
Cr 2.2 → 33
So a trivial 0.2 mg/dL creatinine change shifts eGFR by ~5 mL/min.
Noise or signal?
eGFR fluctuating from 42 - 33 mL/min over a few weeks in a *stable* 57-yo man (Cr ~2.0):
biological noise or reason to worry? 🧵⬇️
Can’t get more surprising!
Me leaving the clinic with all notes completed and signed- thanks to AI scribe:
Sing it brother!
Humans:
- Taking my job?
----- I hate AI!😡
- Helping me get rid of another human when doing something?
----- I love AI!🥰
We are doomed!!
www.msn.com/en-us/health...
The recipe includes: trust, incentives, visible early adopters, and leadership.
Innovation only starts at invention. Adoption is the next main component.
How many clever solutions do you know that need a push towards adoption?
Here is the JAMA article again: pubmed.ncbi.nlm.nih.gov/12697800/
The lesson? Discovery is only half the battle.
Without systems that support diffusion, life-saving interventions stay stuck in labs and journals instead of reaching patients.
In healthcare today, effective interventions (drugs, vaccines, care models) take DECADES to become routine.
Innovation diffuses slowly even when the benefits seem obvious.
"To introduce any new article of food among seamen... requires both the EXAMPLES and the authority of a Commander."
- Captain James Cook.
LEADERSHIP DRIVES DIFFUSION!
EVIDENCE ALONE IS NOT ENOUGH!
Adoption required authority, leadership, and culture change.
Cook saw this and he benefited from the immediate application for himself and his crews.
However, it wasn't until 1865 - 264 yrs after Lancaster, that the British Board of Trade required merchant ships to follow suit.
Two and a half centuries from proof to policy!!! So why so slow?? 😵💫
It took 48 more years for the British Navy to officially issue citrus rations.
Scurvy nearly disappeared from its fleets.
Year: 1747 (146 years later!)
James Lind repeated the test aboard HMS Salisbury.
Again, citrus worked!! Now, there should be immediate adoption, right? Again, not even close!!😢
Year: 1601. Nobody knows about vitamin C at that time.
Captain James Lancaster tested lemon juice at sea.
👉 His sailors remained healthy. 🎉💪
👉 All while almost HALF the crews on other ships died of scurvy.💀
You'd expect immediate adoption? Not even close. The Navy ignored it.
A fascinating story about prevention of scurvy shows how it can take CENTURIES between discovery and practice.
Meanwhile, there will be winners and losers.
Here is the story and some valuable lessons. A thread 🧵 below.
doi.org/10.1001/jama...
15 L interdialytic wt gain.
Record?
Pt was trying to beat nausea with chips and water.
How are our patients dealing with these tremendous costs?
Do you have ppl in ur clinic to help pts obtain these medicines at an affordable cost?
Source: Primer on Diabetes Management www.vumedi.com/video/primer...
In case you missed it on the #AJKDBlog:
AJKDBlog Interviews Editor Timothy Yau caught up with Dr. Subhash Chander to discuss if urea is effective for managing SIADH-induced hyponatremia.
bit.ly/ChanderBlog25 (FREE)
Do u have a local policy for picc- and mid-lines for pts with renal impairment?
🧭 Any simple algorithm that can be shared with other specialties?
⛔️ “Has to be discussed with nephrology” is a battle- we r the bad people who r inconsiderate of realities of the pt’s (immediate) care!
#askrenal
