Chronic Kidney Failure and bicarbonate supplementation

The goal in caring for a patient with chronic kidney failure is to retard the progression of renal function deterioration. In a study published in the Journal of American Society of Nephrology, it was shown that daily supplementation with sodium bicarbonate was effective in slowing the progression of kidney failure. The study focused on people who are in stage 4 and 5 chronic kidney disease which is defined by their creatinine clearance. Creatinine clearance is a way to measure kidney function or glomerular filtration rate (GFR). Stage 4 is a GFR of 15 to 29 ml/min and stage 5 is <15 ml/min. Usually when people reach stage 4, they are already preparing to get dialysis. People that reach stage 5 have end stage kidney disease and dialysis is needed for life.

The study followed these patient for 2 years and noticed that patients who received the sodium bicarbonate supplementation had slower deterioration of the GFR in comparison to patients who did not receive the sodium bicarbonate supplementation (5.93 vs 1.88 ml/min.) Although the amount seems small (roughly deter 2ml/min/yr), to patient who are nearing end stage renal disease, those 2ml/min/yr could mean being put on dialysis a year or two later. This effect was also shown in the comparison of people reaching end stage renal disease (6.5 versus 33%).

Social commentary: sodium bicarbonate is the chemical name for the every day baking soda. The patients in these studies basically received baking soda compressed into a pill form. Baking soda is not patented and costs next to nothing. A jar of 1000 sodium bicarbonate pill costs 10 dollars. In comparison, a year of dialysis will costs upward of $30,000 according to American Association of Kidney patients. In 2007, Medicare spent about $8.6 billion on patients who need dialysis. If we can just push back their need for dialysis by 2 years, we essentially save 60,000 dollars off of every patient who will need dialysis assuming their lifespan stays the same. With 350,000 Americans on dialysis, we would have saved $10.5 billion on their treatment if they start dialysis one year later or $21billion if two years later. There is another study that looked at if sodium bicarbonate treatment has an effect in patients who are at earlier stages of renal disease and it does. It was also effective in retarding renal function deterioration in patients that are in stage 2 and 3 renal failure. If we start patients earlier on this treatment, we can potentially push off the need for dialysis till much much later. The quality of life for the patient is much better without dialysis. Also, the financial incentive for the failure American health system is also huge.

Of course more research is needed in order to make sodium bicarbonate a standardized therapy for patients with end stage renal disease. Currently there are multiple clinical trials underway to further substantiate the results of the study quoted earlier. If successful, it will be another tool in our arsenal in treating chronic kidney disease and our overburdened health system.

CPK level in psychiatric patient

Recently we had a psychiatric patient that was transferred to us due to high creatinin phosphokinase (CPK) level in the blood stream. Generally CPK level is higher in psychiotic patient due to the medications that they are taking. There are various studies published in the 70's about the effect of typical anti-psychotic (neuroleptic) drugs on CPK level. Namely it causes a benign rise in CPK level that can often be confused with underlying pathology. However, in certain instances, the rise in CPK level can be due to pathological process.

In patient that's taking neuroleptic, we're worried about neuroleptic malignant syndrome (NMS) which is characterized by muscle rigidity, fever (>106F), and cognitive changes such as delirium. Mainstay of treatment for this syndrome is to discontinue the medication (classic anti-psychotic) and supportive care. The msucle rigidity causes rhabdomyolysis and thus high CPK level. In instances when the patient has severely elevated CPK level (>15000) or underlying renal problems or risk factors for renal damage, the patient will receive intra-venous fluid (IVF) to help clear out CPK and preserve renal function. This is done because CPK is mainly cleared from the body by the kidneys and high levels of it will kill the kidney. This brings us to why the patient previously mentioned wind up in our care.

The patient was transferred to us because of elevated CPK level and the psych ward decided the patient needed IVF to protect the patient's renal function. However, the patient has no predisposing factors nor prior renal pathology. In addition, the patient's CPK level was high, but not THAT high (~6000.)

In a study published on exertional rhabdomyolysis, healthy patient can reach level as high as 10,000 without any symptoms. Other more recent case report on elevated CPK and psych patient showed two cases where level of around 10,000 was treated with oral fluid and did fine clinically without any sequelae (future pathological process associated with this instance.)

In managing the patient, the CPK serum level should be drawn to monitor progress. Generally, the patient's CPK serum level should decrease by 40% each day provided that all insults were removed and patient is resting. The most dramatic decrease should be within the first 6 to 8 hours.

In summary:

-admit patient if

-CPK >15,000 (if otherwise healthy)

-has predisposing renal risk (sickle cell, PCKD, transplanted kidney)

-has renal failure

-the patient is a lawyer

Augmentin - How does it work?

Augmentin is a combination of amoxicillin and clavulanate.

Amoxicillin is a beta lactam antibiotics which binds to and inhibits penicillin binding protein (PBP). PBP is what makes the cell wall of the bacteria and, by inhibiting it, amoxicillin prevents new synthesis and replicating capacity of the bacteria.

The above image is a picture of the beta-lactam ring that binds to PBP.

However, bacteria are smart and they evolve at a rapid pace to overcome the antibiotics. One of the way that bacteria do this is to produce what's called the beta-lactamase which breaks the beta-lactam ring. The arrow on the picture shows where the beta-lactamse acts on to break the 4 carbon ring structure.

In order to deal with beta-lactamase, we added clavulanate to the mixture. Clavulanate is a beta-lactamase inhibitor. Thus it stops the activity of the enzyme to break down the antibiotics and let amoxicillin does what it is supposed to do.

Some of the side effect of this drug is nausea and vomiting that generally is better if taken with milk or food. Other side effects that are particularly higher with augmentin is diarrhea which is said to be up to 30% higher incidence than other antibiotics. Recently the FDA approved a higher dosage of amoxicillin combine with the same dose of clavulanate which seems to have less incidence of diarrhea than the older formulation.

Other more uncommon but dreaded complications are C. Diff colitis and steven-johnson syndrome. C. Diff pseudomembranous colitis can be treated with oral vancomycin or metronidazole (flagyl). If the disease evolved into toxic megacolon then surgical solution is required. In the case of steven-johnson syndrome, it's an autoimmune mediated response triggered by the penicillin-like medications. This syndrome is where the patient's skin sloughs off in patches leading to severe-burn like symptoms. Most of these patients are sent to the burn unit to be treated with mortality ranging from 3 to 90% depending on the severity of the disease. Treatment for steven-johnson is mostly supportive and discontinuing the offending agent (in this case the antibiotics.)

Teaching post

I've decided to start posting at least once a week on a medical topic that I have either learned or have presented. I think this will be mostly beneficial for me as a learning tool and also as a reference for me later on.

Back from almost 2 year hiatus

so to update on everything that has happened since my interview...

I got accepted! although it was a pretty late acceptance, all that matters is I am going to medical school. when i received the acceptance letter, i felt that at least i have a future now.

I'm currently in my 2nd year at medical school and i'm currently writing on this blog in order to procrastinate on my step 1 study. all my excitement since getting into medical school has mostly faded and i'm just left with frustration and stress. my study schedule involves me waking up at 8am and start studying by first reading first aid (USMLE bible essentially). this would take almost the entire morning. Like the good book, first aid is very dense and requires immense amount of time and concentration just to finish a couple pages. Just last friday, it took me 3 hours to read/memorize 6 pages. that's 1 page every 30 mins....

The morning session is followed by a quick lunch then continue reading first aid to finish what i couldn't in the morning. afterwards, it's on to doing USMLE World (Question bank). Uworld is basically a bunch of questions that are meant to simulate the actual test. it's very discouraging when i do them. currently, i'm consistently scoring 50% on every practice test. that's not even enough to pass... i keep telling myself that at least i'm learning more with every question that i get wrong by reading the explanation. however, i expected to at least see some improvements by now.

k enough procrastination, time to study.

The dread when you come back from an interview

Blah... to borrow a phrase from the family guy " you know what grinds my groin" when I come back from my medical school interview? it's when people keep asking the question, how did your interview go... i must have said the same thing over and over five or six times. it became so rehearsed that it made me think i should have practiced my interview with these people before i went. i could spew out the same thing on the spot and if i feel like it, i can switch it up a little and add new flares to my answer. oh well... back to research

Just got back from my interview

I just made my journey back to California and back to my job. god it's so boring.... i never knew a job can be so incredibly mind numbing. The interview was not at all what i had expected. it was very casual and we barely talked about why i want to be a doctor. This makes me think that they already know who they are going to accept based on what they see on paper. the trip is only for you to find out more about the school and the surrounding area. it's also for them to see whether you're crazy or not. However, i think the process is so nerve wrecking that it should be amended somehow. it's not right for people who wants to heal to get discouraged because of the damn application process. everyone that i've talked to, even doctors in their late 50s or 60s said the process can be compared to a rite of passage. it's torturous so that you know you really want to be a doctor. i think that's ridiculous as there's no one out there, saved for a very select few, that knows exactly what they want to do. it's not like we get to try to be a doctor for a month and test it out. since this profession requires such a stringent set of skill that it's impossible for anyone without medical training to try out the profession. now some people might argue that you can volunteer at a clinic or go shadow a doctor. I'm gonna make the argument that volunteering and shadowing is not the same as actually doing the job. when you volunteer, the clinic usually gives the volunteer the most boring, labor intensive, and mind numbing job ever. that's because they don't trust you to make the right judgement or more so they can't afford any screw up since you have no accountability as you are just a volunteer. As a result, people's skill set are way underuse. you have college students attending the front desk and etc. comon...i don't understand why after spending 3 or 4 years in college getting a BS, you're still a drone. now i think the above statement is going to receive a lot of flame, but it's somewhat of a rant. The application system is broken, but it has served us so well with many generations of doctors in the making. What I am saying is there's much more to be improved with the system so as to not make the process so stressful for the people that only want to improve the community and care for the weak.

More Ranting

so i read over what i wrote last time and really it's just a bunch of ranting about life in general. who knew life can be so hard?

anyways, so i have my interview coming up for medschool. blah, it's my first and only interview. Kinda nervous about the whole ordeal since if i don't get in to this school, it means that i would have to retake my mcat and apply all over again. i don't know if i can take this whole process again. it's driving me insane...

Although i know that i want to be a doctor, I'm still having a hard time verbalizing the reasons coherently. i think it's just my inability to express myself.

So I'm going to bronx, ny. I've never been to ny before so i don't know what to bring since i heard it's quite cold there. I started asking my coworker about the area and the more they talk about the place, the more I'm scared of it. I know there're crimes in NY but wow... the way they described it, i feel like this will be my last trip since i'll either get shot, mugged, or raped. They're probably just trying to scare me, but comon... not helping guys. I'm already frustrated enough with the interview already, I don't need to know that i'm gonna get shot while walking on the street and die not of loss of blood, but rather the hypothermia that will set in as the homeless people strip my clothes away and leave me to die in the snow.

life sucks....

The continuation of the rat race

Hi all,

A little about myself. I recently graduated from college and is now applying for medical school. For all of those that went through the process and are in medical school, you should know what I feel like right now. If your answer is not in the range of total dispair then you are not welcome to continue to read this blog. to continue, when I graduated from highschool, I thought everthing was going to be a breeze that life was going to be a breeze. I cruise through highschool while playing hours of videogames. Mind you, my highschool was one of the top ranked highschool. I graduated with high honor and got accepted into UC Berkeley. Life was great. However, little did I know that my life would start falling apart as I enter college.

The phrase big fish in a little pond fits my situation to a T. When I entered college, I thought I can cruise through another 4 years and get a job. Even when I got my first midterm back, I thought I was doing fine. Minimal study and still two standard deviation above. However, I was in for a big surprise when second round of midterms come around. While I was taking the midterms, I knew I was in deep trouble. It the feeling of complete helplessness as I stare blankly at the test before me. Then comes the denial. "The other students must be shocked at how hard the test is... yes that must be it." Deep down, you know you're just fooling yourself. In a class of 600+ students, the bell curve usually applies. There will be champions that emerge on top of a pile of bodies and there is me right at the bottom getting piled on. I remember the feeling, even to this day, when I got back my exam. 2.5 standard deviations below the mean. To all those who are not familiar with how standard deviations work, assuming normal distribution in the class, 2.5 standard deviations below the average means that I am at the bottom 10% of the class. To those who think that this is just for one class.... nope. I got 2.5 standard deviations in all my classes during my 2nd round of midterms. The only class that I didn't get 2.5 standard deviations below was in my writing class where there's no numerical score and the grade there wasn't pretty either. As I continue down my journey through undergraduate, I started coping with my situation and made the most out of it. i started studying much harder and was able to pull my grade out of the shithole into the land of mediocracy.

all of this time, the desire to go to medical school was never there...

The only reason that i decided to try to go to medical school was because my mom thought I like biology so much that being a doctor would be a good profession. BTW, I like biology just as much as my other subjects which is not very much. Although I must say, i like biology much more than spanish since for some reason language just doesn't come natural to me. This would suggest that the other subjects come naturally to me so i should rephrase... It's a miracle that I learn how to speak English. My elementary teacher thought I was retarded because I had trouble with basic grammatical structure which to this day I still have trouble with.

blah... to be continued... I have to get back to work at my mediocre job. Med school.... where art thou?