Go Twins

I've got tickets tomorrow (courtesy of my main man Dave P.) to see my first-ever live Fenway Park baseball game. To make matters even more juicy, I get to watch them play my hometown Minnesota Twins and root for the Boston Red Sox to continue their late-season choke job which will hopefully continue into this year's playoffs.

I can't completely explain why I root for the Red Sox to lose, but a good example for my disdain against Boston baseball was demonstrated last week while flipping channels. I came across the top of the 9th inning of a Boston Red Sox-Tampa Bay Devil Rays baseball game TAKING PLACE IN TAMPA BAY which featured a dramatic come-from-behind victory by the Red Sox. The thing which struck me was that the crowd, a significant majority of which was sporting annoying pink Red Sox paraphenalia, was cheering like wild for the away team! Now, I couldn't name more than 2 players who are current Tampa Bay Devil Rays players, and I have nothing against their team, but in my opinion it's criminal for any home crowd to be cheering for the away team in any circumstance. It makes my blood boil. It also proves the point that the Bosox don't need any more members of Red Sox Nation, and as a result I shall be pulling for the Yankees from here on out.

HIV-Positive Kidney Transplants

I went to an interesting talk yesterday regarding performing kidney transplants in patients with HIV infection.

As most people know, HIV disease is associated with a high rate of infections. In addition, it's also associated with kidney disease, especially in African-American patients. So the question comes up: can you give a patient with HIV disease a kidney transplant?

Traditionally the answer has been no. The major reason for this is that the medications required for a normal kidney transplant are immunosuppressants, which are taken to minimize the chance of a kidney rejection. It's thought that if HIV patients (who are already immunosuppressed) were given these meds, this "double hit" on the immune system would render them extremely prone to infection.

Things have changed in recent years, however. For one thing, the immunosuppresant medications are better and rejection is becoming less common. More importantly for HIV patients, the introduction of new HIV meds in the early 90s has led to a dramatic increase in survival and immune system recovery. So there are some transplant centers--ours at Harvard is not yet one of them--who have done kidney transplants in highly selected and motivated HIV patients. The results as they were presented at this recent meeting were pretty encouraging, and it seemed that HIV+ patients with kidney transplants did about as well as HIV- patients with kidney transplants.

However, these patients have to take a mind-boggling number of pills. They typically have to take 2-3 pills to keep their HIV in check, typically three different immunosuppressants for their transplant, at least two medications to prophylax against pneumocystis pneumonia and CMV disease (common diseases in the transplant patient), and likely will have to take medications to control their diabetes, high blood pressure, and high cholesterol levels that that both the HIV meds and the immunosuppressant meds have as side effects. In a sense, it's kind of like trading in one disease for another, though I think most patients would say that the trade is worth it.

Sophie's Video Debut!

Okay, so I finally figured out how to post videos on my blog. Although this one is a little dated (taken about 3 weeks ago) it features the vocal stylings of little Sophie Hellman (with a little prompting from her mom). Enjoy!

Like A Kidney Stone...

Found this amusing "kidney stone" themed cartoon while surfing, so I guess today's topic will be kidney stones.

Lots of great chemistry to learn with nephrolithiasis (the medical term for kidney stones). Basically, your pee is filled with all sorts of minerals and ions. When the concentration of certain minerals gets too high, there will actually be crystallization of these molecules which form a solid kidney stone. I hope I never have one, because I can just imagine how painful a stone moving through the ureter and urethra would be...

The cool thing for us nephrologists is that occasionally, if you're lucky, you can determine the identity of the crystallized mineral forming the kidney stone just by looking under the microscope at the urine and looking at the shape of the crystals. For instance, calcium oxalate crystals (which are quite common) look like tiny envelopes (left). A genetic disease called cystinuria results in highly stereotypic hexagonal crystals in the urine (right). And struvite stones, which form exclusively in the urine of patients with infection, often look like a "coffin-lids".

A suggestion to the medical community...

If I could change just one thing about the medical establishment in the United States....and believe me, there is a lot more than just one thing I would change...it would be our system of record-keeping. It's outrageous. Just about every hospital has their own informatics system, each with their own bewildering array of buttons and commands in order to accomplish just about the same thing. Once a physician stays at the same hospital for a period of time, they can obviously learn to master the system and use it efficiently. However, a physician working at multiple hospitals (which is more and more often the case these days) will have to contend with multiple computer systems. The even bigger problem than physician convenience, however, is the difficulty in communication between hospitals. It's sometimes nearly impossible to figure out exactly what happened to a patient when they are hospitalized at a different hospital, even with faxed records--a large inconvenience even in the best of situations--this involves having the patient sign a release form, calling the other hospital's records department, faxing them the form, hoping that the records person is going to take the job seriously, and then hoping the relevant information makes its way over.

In my mind, this could largely be fixed in one fell swoop: do what the VA Health System does. Every hospital in the U.S. should be required to use the same interconnected health information system. This is how it works at the VA. They developed a computer system in the early 90s which despite its sometimes archaic features, is surprisingly versatile and extremely reliable. Every single thing that happens to a patient in the health system--from cardiac catheterizations to rehab stays to nursing homes to visits with the hospital chaplain, even--goes into that computer system. Having this degree of detail available would, in my opinion, be the single-best thing our health system could do in order to improve patient health care. I also suspect that it would in the long run save money, as it would probably cut down on redundant tests that are performed.

Other news: our camera is on the fritz so unfortunately there may be a lull in Sophie photos . Here are some from the archives.

Time to start bundling up for the cooler fall weather.
Still smiling a lot!

Sophie's mobile kind of reminds of either the scary "Feed Me, Seymour" plant from Little Shop of Horrors or something out of the "Alien" movie series. Hopefully she won't be traumatized by it...

Ribs and Asparagus

There is an enormous (and growing) discrepancy between the number of people who WANT kidney transplants and the number of people who are able to get them. The waiting time varies by region, but in Massachusetts the wait time is between 3-5 years on average (a sobering statistic especially considering the crappy mortality rates on dialysis I quoted in my last post). Another interesting strategy for increasing the pool of kidneys available are "kidney exchange programs."

Here's how it works: say that Mr. Ribs has end-stage kidney disease and his wife, Mrs. Ribs, is willing to donate. The first thing to do in this instance is see if Mrs. Ribs is a "match" for her husband. This takes into account several factors, the most important being the blood type (A, B, or O) and the identity of MHC genes (which are involved in your immune system). If the kidney is a good "match" Mrs. Ribs could then likely proceed with the kidney donation. However, if there's NOT a match--for instance, if Mrs. Ribs had blood group A and Mr. Ribs blood group B--you would likely see an immune attack of the donor organ within minutes of transplant (in cases where this has happened in the past, the surgeons can actually see the transplanted kidney swelling up and turning black before their eyes)--obviously Mrs. Ribs couldn't donate her kidney to her husband.

But she could donate her kidney to a stranger who has type A blood. Say that there's a second couple, Mr. Asparagus (blood type A) who needs a kidney and his wife Mrs. Asparagus (blood type B), who wants to donate to her husband but can't for the same reasons. What kidney exchange programs (like NEPKE, the New England Program for Kidney Exchange) seek to do is match up different incompatible pairs so that Mrs. Asparagus would donate her kidney to Mr. Ribs and Mrs. Ribs would donate her kidney to Mr. Asparagus. The transplants are typically carried out on the same day (likely in part to make sure that both sides follow through with the deal). Mmmm, ribs and asparagus. It's a win-win situation.

In other news, I saw a very interesting case of Sjogren's Syndrome-associated cryoglobulinemic membranoproliferative glomerulonephritis the other day.

The Wacky World of Kidney Transplant

I'm starting to really enjoy the world of kidney transplants.

For one thing, it's simply the lesser of two evils. When your kidneys stop working, you see, you have one of two options. The first is to go onto dialysis, the kidney machine. Patients tend to dislike this, because it involves having to get hooked up to a machine for about 4 hours, three times a week. The second is to get a kidney transplant. The NIDDK (National Institute of Diabetes, Digestive, and Kidney Diseases) website publishes statistics on the overall survival of each option:

Dialysis survival (probability of patients surviving, from day 91 onwards):
at 1 year: 77.7% survival
at 2 years: 62.6% survival
at 5 years: 31.9% survival
at 10 years: 10.0% survival.

Patient survival following living-donor kidney transplant:
at 1 year: 98.2% survival
at 2 years: 95.8% survival
at 5 years: 95.5% survival
at 10 years: 70.6% survival

Patient survival following deceased-donor transplant:
at year: 94.3% survival
at 2 years: 91.1% survival
at 5 years: 81.2% survival
at 10 years: 59.4% survival.

You'll notice that the survival rate for patients on dialysis is pretty dismal: well over half are dead by 5 years! In contrast, patients who receive a living kidney transplant (say, if your brother or sister donates a kidney to you) have the best survival rate (nearly 96% by 5 years) whereas patients who receive a deceased-donor transplant (for example, somebody died in a car crash and is an organ donor) still have a not-too-shabby 81% survival rate. These numbers are perhaps a bit misleading, since in general it's the healthier patients who are chosen to get transplants and the sicker patients who often have no choice but dialysis--but in general the data is sufficiently convincing that kidney transplant is far, far superior to getting dialysis.

P.S. Happy 2nd Wedding Anniversary to myself and Claire!

Arnold Arboretum

A glorious weekend off:

Yesterday (Saturday) Claire, Sophie and I went to check out the Arnold Arboretum. The day started out rainy but ended with sunshine, which was welcome because it's actually started to get a little chilly out.

Then today (Sunday) I attended a Nephrology Boards Review course, which consisted of me listening to lectures on kidney disease from 8am until 7pm. My head is swimming in formulae to calculate free water clearance and transtubular potassium gradients. I'm a little shell-shocked after a full day of lectures, but it is an efficient way to learn.

Yo MTV Cribs

After having slept in a small, portable plastic crib for her first few weeks in the United States, Sophie has now graduated on to a much larger and official-looking wooden crib. Mom managed to convince Dad that pink was the right color for the job, as you can tell by the pictures. Special thanks to members of the Antignac lab and also my Uncle Joe for the crib!

Other news: Claire received her green card in the mail the other day! The only thing that I found a bit of a let-down was that the card itself is not actually green. Don't you think they should make it green?

Date Night & Paris Nostalgia

Claire and I refuse to be parents who say things like, "We don't have time to go to the movies anymore ever since our kid was born." Of course, we won't be going every weekend, and will have to be more selective in terms of what movies we see (for example, I think I will have to wait for "Balls of Fury" to come out on video tape). But we can see the occasional movie when the stars are aligned correctly.

Tonight, for instance, I was not on-call, nor was my Urology resident friend Heidi, who graciously offered her baby-sitting duties for la petite Sophie. As a result, Claire and I got to see the movie "Paris, Je T'Aime", which I truly enjoyed. It's a series of 18 different short films, each by a different director, which has as its theme falling in love in Paris. Some are sad, some are silly, some are charming & romantic, some are bizarrely incomprehensible in an artsy way. I do recommend it. The highlights for us were recognizing all the familiar landmarks in our adopted city--including a lovely scene of the Parc Montsouris where I used to play basketball which left me wishing I was still living in Paris--as well as a great Coen Brothers short starring Steve Buscemi which takes place entirely at one particular Paris Metro stop.

Below: Sophie staring at her favorite toy thus far, a very colorful caterpillar (French: "une chenille") with different noises and textures that we strap onto her little chair. It's usually good for about 10 minutes or so of distracting her when she starts to act up...

What's going on?

What's going on? Not much. Here are some the highlights (or lowlights, as the case may be).

1. I lost my keys while jogging last week, a major pain-in-the-ass. My sisters always make fun of me for running with my keys in hand. It's become such a habit that when I've done road races in the past I carry my keys along with, not because I need to but just because I like holding on to something when I run. Well, about 3/4 through my run along the Cleveland Circle reservoir, I looked down at my hands and realized they were completely devoid of keys. WTF? I guess they must've just slipped out as I was running and I didn't realize it. This is only the second time in my life that I've lost my keys, the first being the infamous time I accidentally dropped them down into a pile of boulders on the shores of Lake Superior. They're probably still there.

2. The weather in Boston over the past day or so has been, in my opinion, the perfect September weather. Sunny, just cool enough to recognize that fall is coming but not yet jacket weather.

3. The VA Spa. I've actually been pleased with the West Roxbury VA (photo on right). For one thing, it's much nicer as a building than the other two VA's at which I've worked (the Philadelphia VA and the St. Louis VA, which I will always remember because I had my license plates stolen from their parking twice during the same week when I was a medical student).
And it's generally fun taking care of the veterans as well.

4. Happy Rosh Hashonah (Jewish New Year), everyone (even if it means that I can't park my car in front of the synagogue down the street as usual for the next two days...)

NFL Sunday

It's Sunday, my day covering the renal service at the VA has been ridiculously easy, and, for the first time since the 2005-06 season, I have the opportunity to watch some regular season NFL football on TV (I managed to catch the Super Bowl while living in France last year, but other than that, the only football I saw on TV was of the European variety). So far the highlight for me has been cackling with glee as New England Patriots WR Randy Moss, who I nabbed in the 4th round of my Fantasy Football League draft, hauled down 9 passes for 183 yards and a TD. This year's starting lineup for The Duluth Dominators looks like the following:

QB Payton Manning (Colts)
RB Clinton Portis (Redskins)
RB Marion Barber III (Cowboys)
WR Randy Moss (Patriots)
WR Bernard Berrian (Bears)
TE Alge Crumpler (Falcons)
D Jacksonville Jaguars
K Steven Gostkowski (Patriots)
RB/WR Julius Jones (Cowboys)

Go, Dominators! In other news, Claire got her green card in the mail today!! We were disappointed to find out that it's not even green. What's up with that? Anyways, I'll throw in a few recent Sophie photos to keep the parents happy. Have a good weekend, all.

One MRI please, hold the gadolinium

One of the recurring nephrology consults that I am asked to see in the hospital revolves around the use of contrast dye that is used in a variety of medical imaging studies. In both CT scans and MRI scans--a way of obtaining very nice images of the living body and crucial for a variety of diagnoses)--the use of contrast is often needed in order to get a high-quality image. Unfortunately, however, these contrast dyes can be toxic to the kidneys, particularly in people who already have some underlying kidney damage.

The hottest topic in this field is the use of gadolinium in MRI images, such as the one showed here giving a nice look at the kidneys and the renal arteries which supply them with blood. (The big long vessel running vertically on the image is the aorta; the two vessels coming off the aorta which lead to the kidneys are the left and right renal arteries). Gadolinium was once considered perfectly safe for the kidneys. In just the past year, however, there has been a growing concern that gadolinium, while not extremely toxic to the kidneys, can be responsible for a terrible skin condition called nephrogenic systemic fibrosis, or NSF. I won't go into details as to what NSF is, but suffice it to say, you don't want to get it: your skin experiences an extreme tightening, which can be so severe that it can cause muscle contractures and can event prevent walking. Not surprisingly, the decision has been made at most major hospitals to not give gadolinium to patients with end-stage kidney failure.

Not surprisingly, the legal community has been quick to respond to this news. In fact, when I google "nephrogenic systemic fibrosis", the first web sites to pop up are not in fact medical sites but rather lawfirms advertising free consultations for individuals who might be afflicted with NSF. Apparently there has been a big push to file lawsuits against the companies which manufacture the contrast agent, saying that the companies did not adequately determine the safety of their product before it was released into clinical practice. Gadolinium has been used for several decades now and it's only been recently that enough cases of NSF have occurred in order to determine the association between renal failure and NSF, and even now due to the rarity of the condition this is still considered somewhat controversial.

Mmmm, Fish Oils

Random quick Nephrology Fact o' the Day:

The disease IgA Nephropathy is the most common cause of glomerulonephritis (a type of kidney inflammation, it sometimes results in complete loss of kidney function) in the world. One of the medications that can be used to treat it are FISH OILS. They come in gel-like capsules full of purified fish omega fatty acids.

How do they know it works? There was a clinical trial comparing individuals with IgA Nephropathy who received fish oils capsules compared to those who received placebo capsules with just olive oil inside. Patients who received fish oil capsules had improved kidney function.

One of the side effects listed for people taking fish oils is that it "may cause fishy odor."

Famous Dead Americans

Last year in Paris I saw my fair share of famous dead people's tombstones (see Pere Lachaise Cemetiere as well as Cemetiere Montparnasse), so I guess it's fitting that this year I pay homage to some of the famous American patriots who are buried in my new city. On Sunday during our "Freedom Walk" we went to visit the tiny Granary Burial Ground which, at least by American standards, is quite old, with tombstones dating back to the 1600s. Perhaps the funniest one is shown on the left, a strikingly phallic tombstone marking the grave of the aptly-named John Hancock.

"Now here's a little story I've got to tell about three bad brothers you know so well..." Hopefully, you get the reference...if not, here's the grave of famous Bostonian Paul Revere.


Sam Adams was so influential they named a local Boston beer after him.
All the martyrs of the Boston Massacre are buried in the same area. Interestingly, John Adams , a lawyer and signer of the Declaration of Independence, acted as the public defender of the British soldiers who had fired into the crowd because nobody else wanted to do it at the time. And this grave I thought just looked kind of cool.

Some Boston History

I'm not sure exactly when, if ever, Boston will start feeling like "home." I definitely feel like an outsider thus far, but taking steps to remedy the situation. Everytime I meet a new patient I ask them what city or neighborhood they are from and then ask them to describe it to me so that I can slowly become informed on New England geography. In addition, we're familiarizing ourselves with the Beantown tourist areas: last Sunday, for instance, Susie and Andrew went with us to finish the Freedom Walk walking trail, which begins at the Boston Common, crosses the Charles River, and ends at the Battle of Bunker Hill Memorial. Some pics, beginning on the right with the Old North Church (the church where the "one if by land, two if by sea" lanterns were hanging).

Next up: the U.S.S. Constitution, built in 1797 and used during the War of 1812, is the oldest active navy boat in the world.
Claire and Sophie amidst some colorful merchandise at Faneuil Hall, a large public marketplace downtown.

The obelisk-shaped Battle of Bunker Hill Monument, commemorating one of the earliest battles of the Revolutionary War. Here's a bit of useless trivia: the Battle of Bunker Hill did not, in fact, take place on Bunker Hill. Most of the fighting was carried out at nearby Breed's Hill. Also, I didn't realize this, but apparently the British won the Battle of Bunker (though at a high cost, which is why the lost battle is nonetheless a celebrated one). Finally, the phrase, "don't fire until you see the whites of their eyes" allegedly came from this battle.

Walking up the 297 steps of the Bunker Hill Monument yields a nice view of the Zakim Bunker Hill Bridge, constructed in 2002 as part of the legendary Big Dig construction project which modernized much of the highway system in Boston.
Finally, we just had to stop and take this picture of Claire flipping the bird to an unenlightened shopowner whose store along the Freedom Trail features a "France Sucks!" T-shirt prominently featured in the display window. Doesn't he know that the French were allies with the U.S. during the very Revolutionary War which his store is celebrating?

Aunt Susie and Eggo Wristwatches

This weekend Sophie met, for the first time, her Aunt Susie. She and her boyfriend Andy (below) drove up from the Big Apple and it's been a wonderful and relaxing weekend for me. I have a ton of photos from our trek around Boston and plan to post them later in the week.

Congrats to Susie for being hired for her latest 5-month gig at Palm Beach (Florida) Opera Company starting in November! And kudos also to Andy for his big New York City Opera debut coming up this fall!

Other exciting news: Susie and Andy bought me as a gift this sweet, retro Eggo waffle wristwatch. I'm still not entirely sure why, but I like the way it looks. Ah, the wonders of E-Bay.

Dialysis Monkeys

Every medical subspecialty, no matter how interesting, has its share of repetitiveness. In Endocrinology (the study and treatment of diseases related to hormone problems), roughly 90% of business is related to managing sugars of diabetic patients. While there are a ton of interesting diagnoses and fascinating physiology in the field of Cardiology, most cardiologists' practices are dominated by coronary artery disease, the biggest killer in the Western world. And in Nephrology, a field to which many are attracted based on its intellectual and mathematical approach to electrolytes, homeostasis and physiology, a huge percentage of one's time is spent dealing with dialysis, the artificial kidney machine to which people in kidney failure must be attached to in order to survive. Of course, there are interesting aspects to dialysis (and since I'm just starting out, I haven't yet earned the right to speak of dialysis as boring and routine....indeed there is still a part of me that will always be fascinated that the function of such a complicated organ can be partially replaced by a machine, like something out of a science fiction movie)--but even after a few weeks of this business I can appreciate to some extent the viewpoint that dialysis can become quite repetitive if that is all that one is doing throughout the course of the day.

In other news, Sophie is very much looking forward to meeting her Aunt Susie, who will be visiting from NYC sometime this weekend!