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Although medical schools across the United States have updated their curricula to incorporate active learning techniques, there has been little discussion on the nature of the content presented to students. Here, we share detailed examples of our experience in using original experiments to lay the groundwork for foundational concepts in renal physiology and pathophysiology. We believe that this approach offers distinct advantages over standard case-based teaching by (1) starting with simple concepts, (2) analyzing memorable visuals, (3) increasing graphical literacy, (4) translating observations to "rules," (5) encouraging critical thinking, and (6) providing historical perspective to the study of medicine. Although we developed this content for medical students, we have found that many of these lessons are also appropriate as foundational concepts for residents and fellows and serve as an excellent springboard for increasingly complex discussions of clinical applications of physiology. The use of original experiments for teaching and learning in renal physiology harnesses skills in critical thinking and provides a solid foundation that will help learners with subsequent case-based learning in the preclerkship curriculum and in the clinical arena.

Background Many programs designed to improve feedback to students focus on faculty's ability to provide a safe learning environment, and specific, actionable suggestions for improvement. Little attention has been paid to improving students' attitudes and skills in accepting and responding to feedback effectively. Effective "real-time" feedback in the clinical setting is dependent on both the skill of the teacher and the learner's ability to receive the feedback. Medical students entering their clinical clerkships are not formally trained in receiving feedback, despite the significant amount of feedback received during this time. Methods We developed and implemented a one-hour workshop to teach medical students strategies for effectively receiving and responding to "real-time" (formative) feedback in the clinical environment. Subjective confidence and skill in receiving real-time feedback were assessed in pre- and post-workshop surveys. Objective performance of receiving feedback was evaluated before and after the workshop using a simulated feedback encounter designed to re-create common clinical and cognitive pitfalls for medical students, called an objective structured teaching exercise (OSTE). Results After a single workshop, students self-reported increased confidence (mean 6.0 to 7.4 out of 10, P

Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.

Andrew Matthews, 1 Jeffrey H William 2 1Department of Medicine, Clinical Fellow in Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania Health Systems, Philadelphia, PA, USA; 2Division of Nephrology, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USACorrespondence: Jeffrey H WilliamHarvard Medical School, Beth Israel Deaconess Medical Center, Division of Nephrology, Department of Medicine, Boston, MA, USAEmail jhwillia@bidmc.harvard.edu In Response to Oliveira et al:While we agree that self-reflection is vitally important in applying feedback, ourworkshop focused on the ability to appropriately receive feedback in the moment(or in “real-time”). The skills taught in the live session were geared toward thisclinical environment—when feedback provided may be brief and less formal thanstandard feedback sessions. View the original paper by Matthews and colleagues This is in response to the Letter to the Editor

Background Secondary hyperparathyroidism (SHPT) commonly occurs in end-stage renal disease (ESRD), leading to vascular calcification and increased mortality. For SHPT refractory to medical management, parathyroidectomy improves symptoms and decreases mortality. Medical management has changed with the release of new guidelines and advent of novel medications. We investigate recent national trends in parathyroidectomy for SHPT. Materials and methods We used the National/Nationwide Inpatient Sample from 2004 to 2016 to identify hospitalizations including parathyroidectomy for SHPT and calculated parathyroidectomy rates utilizing data from the United States Renal Data System. Subgroup analysis was conducted by race. Risk factors for in-hospital mortality were identified with purposeful selection and multivariable logistic regression. Results From 2004 to 2016, the rate of parathyroidectomies for SHPT per 1000 ESRD patients decreased from 6.07 (95% CI: 4.83-7.32) to 3.67 (95% CI: 3.33-4.00). Black patients underwent parathyroidectomy for SHPT at a 1.8-fold higher rate than white and Hispanic patients (5.59 versus 3.04 and 3.07). Almost all tracked comorbidities increased in prevalence. In-hospital mortality trended lower (1.5% to 0.8%, P = 0.051). Risk factors for in-hospital mortality included weight loss (OR 4.19, 95% CI: 2.00-8.78) and cardiac arrhythmia (OR 3.38, 95% CI: 1.66-6.91), while additional calendar year (OR = 0.87, 95% CI: 0.80-0.95) was protective. Conclusions The etiology of the declining parathyroidectomy rate for SHPT is unclear; possible factors include changing guidelines emphasizing medical management, widespread availability of cinacalcet, changing practice patterns, and inadequate surgical referral.

Background Many programs designed to improve feedback to students focus on faculty’s ability to provide a safe learning environment, and specific, actionable suggestions for improvement. Little attention has been paid to improving students’ attitudes and skills in accepting and responding to feedback effectively. Effective “real-time” feedback in the clinical setting is dependent on both the skill of the teacher and the learner’s ability to receive the feedback. Medical students entering their clinical clerkships are not formally trained in receiving feedback, despite the significant amount of feedback received during this time. Methods We developed and implemented a one-hour workshop to teach medical students strategies for effectively receiving and responding to “real-time” (formative) feedback in the clinical environment. Subjective confidence and skill in receiving real-time feedback were assessed in pre- and post-workshop surveys. Objective performance of receiving feedback was evaluated before and after the workshop using a simulated feedback encounter designed to re-create common clinical and cognitive pitfalls for medical students, called an objective structured teaching exercise (OSTE). Results After a single workshop, students self-reported increased confidence (mean 6.0 to 7.4 out of 10, P

As with other electrolytes, magnesium homeostasis depends on the balance between gastrointestinal absorption and kidney excretion. Certain drugs used commonly in patients with CKD can decrease gastrointestinal ingestion and kidney reclamation, and potentially cause hypomagnesemia. Other magnesium-containing drugs such as laxatives and cathartics can induce hypermagnesemia, particularly in those with impaired glomerular filtration and magnesium excretion. In this review, we will discuss the potential magnesium complications associated with a range of commonly encountered drugs in the care of CKD patients, discuss the potential mechanisms, and provide basic clinical recommendations.

Rhabdomyolysis is characterized by skeletal muscle cell damage leading to the release of toxic intracellular material into the blood circulation. Its major causes include trauma, significant exertion, hypoxia, drugs, toxins, infections, and metabolic disorders. Acute kidney injury is a common complication of rhabdomyolysis, with an incidence ranging from 13% to approximately 50%, representing about 7% to 10% of all cases of acute kidney injury in the United States.1 Rhabdomyolysis secondary to sauna burns is rare, but could be life-threatening and requires multidisciplinary expertise to address subsequent multi-organ dysfunction.

Educational innovations in nephrology have focused largely on attracting trainees to the field, but few efforts have influenced the career development of nephrology fellows. We investigated the impact of an annual, week-long summer course titled “Origins of Renal Physiology” on academic career development by conducting a survey study of course participants and a control group of renal fellows who did not participate in the course. The survey elicited reasons for course attendance, perceptions of the course, and current career paths of respondents. We compared career trajectories and academic productivity between course participants and non-participants. Fellows attended the course primarily to review physiology in a novel educational setting and to gain long-term understanding of concepts in renal physiology. Course participants reported significantly higher current engagement in research than non-participants, especially in basic science. Analysis of free-text responses about the course’s most positive attributes identified four themes: interactions/networking, hands-on laboratory experience, mentorship, and unique learning environment. The course appears to have offered an innovative learning opportunity that fostered mentorship and peer-to-peer networking in a scientific, relaxed, and supportive learning environment. Emphasizing the role of basic science research and its application to clinical care through such courses may stimulate the interests of fellows into research and academic careers.

The pathophysiology of nephrolithiasis has been elucidated over time through the epidemiologic study of this complex disease process. The prevalence of kidney stones has increased throughout the late twentieth and into the twenty-first century, potentially attributable to a variety of factors including environmental changes, alterations in dietary intake, and the increased prevalence of the metabolic syndrome and its associated comorbidities. With the increased recognition and burden of stone disease, the costs to our healthcare system have also risen. In-depth analyses of large observational cohorts have been instrumental in our current understanding of how demographics, dietary intake, genetic and environmental factors, and chronic medical conditions all influence the risk of nephrolithiasis occurrence and recurrence.

The association of proton-pump inhibitor (PPI) use and hypomagnesemia has garnered much attention over the last 5 years. A large body of observational data has linked chronic PPI use with hypomagnesemia, presumably due to decreased intestinal absorption and consequent magnesium deficiency. However, despite the increasing prevalence of this highly popular class of medicine, and despite potential significant risks associated with magnesium depletion, including cardiac arrhythmias and seizures, there are no well-designed studies to delineate the nature of this observed association. Consequently, providers must use best judgment to inform clinical decision making. This review summarizes the current body of evidence linking PPI use with hypomagnesemia, acknowledges the possibility of significant residual confounding in the observational data, explains potential physiologic mechanisms, and offers clinical recommendations.

Aims Although multiple recent studies have confirmed an association between chronic proton-pump inhibitor (PPI) use and hypomagnesaemia, the physiologic explanation for this association remains uncertain. To address this, we investigated the association of PPI use with urinary magnesium excretion. Methods We measured 24-hour urine magnesium excretion in collections performed for nephrolithiasis evaluation in 278 consecutive ambulatory patients and determined PPI use from contemporaneous medical records. Results There were 50 (18%) PPI users at the time of urine collection. The mean daily urinary magnesium was 84.6 ± 42.8 mg in PPI users, compared with 101.2 ± 41.1 mg in non-PPI users (P = 0.01). In adjusted analyses, PPI use was associated with 10.54 ± 5.30 mg/day lower daily urinary magnesium excretion (P = 0.05). Diuretic use did not significantly modify the effect of PPI on urinary magnesium. As a control, PPI use was not associated with other urinary indicators of nutritional intake. Conclusions Our findings suggest that PPI use is associated with lower 24-hour urine magnesium excretion. Whether this reflects decreased intestinal uptake due to PPI exposure, or residual confounding due to decreased magnesium intake, requires further study.

Novel educational tools, such as case-based learning in a web-based module format, are an effective approach to teaching clinical concepts to medical trainees, especially if the situations are clinically relevant and the intervention is delivered at the point-of-care. Though studies have evaluated the effectiveness of point-of-care reference materials, limited literature addresses active web-based interventions designed for completion at the point-of-care.By taking advantage of existing technological resources and integrating an effective learning modality into the clinical environment, we can increase trainee understanding of high-yield topics in clinical nephrology.We designed interactive, case-based computer-based modules in Principles of Dialysis, Hyponatremia, and Acid-Base abnormalities, with interwoven multiple-choice and free text questions with immediate feedback, supplemental practice questions, and enrichment material to be completed in the clinical environment. All medicine trainees at an urban, academic institution were invited to participate in a needs assessment, pre and post knowledge tests, and module completion.Most trainees believed the modules were "very" or "extremely helpful" in understanding the selected topic and that they would likely change their clinical practice. Those who completed the modules performed better on a post-intervention knowledge assessment. Free-text feedback was overwhelmingly supportive of the modules.Our findings confirmed that a novel, simplified approach to renal content by making it readily applicable to a clinical context and available at the point-of-care improves trainee understanding of high-yield topics in nephrology.

Since the early reports nearly a decade ago, proton-pump inhibitor-induced hypomagnesemia (PPIH) has become a well-recognized phenomenon. While many observational studies in the inpatient and outpatient populations have confirmed the association of PPI exposure and serum magnesium concentrations, there are no prospective, controlled studies to support causation. Molecular mechanisms of magnesium transporters, including the pH-dependent regulation of transient receptor potential melastatin-6 transporters in the colonic enterocyte, have been proposed to explain the effect of PPIs on magnesium reabsorption, but may be a small part of a more complicated interplay of molecular biology, pharmacology, and genetic predisposition. This review explores the current state of research in the field of PPIH and the proposed mechanisms of this effect.

To gain some insight into how various behavioral (lifestyle) factors influence sleep duration, by investigation of the relationship of sleep time to waking activities using the American Time Use Survey (ATUS).Cross-sectional data from ATUS, an annual telephone survey of a population sample of US citizens who are interviewed regarding how they spent their time during a 24-hour period between 04:00 on the previous day and 04:00 on the interview day.Data were pooled from the 2003, 2004, and 2005 ATUS databases involving N=47,731 respondents older than 14 years of age.N/A.Adjusted multiple linear regression models showed that the largest reciprocal relationship to sleep was found for work time, followed by travel time, which included commute time. Only shorter than average sleepers (7.5 h) spent more time socializing, relaxing, and engaging in leisure activities, while both short (5.5 h) and long sleepers (or =8.5 h) watched more TV than the average sleeper. The extent to which sleep time was exchanged for waking activities was also shown to depend on age and gender. Sleep time was minimal while work time was maximal in the age group 45-54 yr, and sleep time increased both with lower and higher age.Work time, travel time, and time for socializing, relaxing, and leisure are the primary activities reciprocally related to sleep time among Americans. These activities may be confounding the frequently observed association between short and long sleep on one hand and morbidity and mortality on the other hand and should be controlled for in future studies.

Intraocular hypertension is common during hemodialysis. Dialysis disequilibrium syndrome and intraocular hypertension occur via similar pathophysiologic mechanisms. These mechanisms may contribute to the development of glaucoma and cataracts in a patient population already at high risk for ocular abnormalities, given the common risk factors for chronic kidney disease and impaired aqueous humor outflow. We describe a patient with complicated diabetes mellitus, end-stage renal disease, and recent cataract surgery who developed severe intraocular hypertension during hemodialysis. We recommend increased awareness of the symptoms of intraocular hypertension and subsequent ophthalmologic surveillance in order to prevent long-term visual complications.

Although case reports link proton-pump inhibitor (PPI) use and hypomagnesemia, no large-scale studies have been conducted. Here we examined the serum magnesium concentration and the likelihood of hypomagnesemia ( < 1.6 mg/dl) with a history of PPI or histamine-2 receptor antagonist used to reduce gastric acid, or use of neither among 11,490 consecutive adult admissions to an intensive care unit of a tertiary medical center. Of these, 2632 patients reported PPI use prior to admission, while 657 patients were using a histamine-2 receptor antagon ist. PPI use was associated with 0.012 mg/dl lower adjusted serum magnesium concentration compared to users of no acid-suppressive medications, but this effect was restricted to those patients taking diuretics. Among the 3286 patients concurrently on diuretics, PPI use was associated with a significant increase of hypomagnesemia (odds ratio 1.54) and 0.028 mg/dl lower serum magnesium concentration. Among those not using diuretics, PPI use was not associated with serum magnesium levels. Histamine-2 receptor antagonist use was not significantly associated with magnesium concentration without or with diuretic use. The use of PPI was not associated with serum phosphate concentration regardless of diuretic use. Thus, we verify case reports of the association between PPI use and hypomagnesemia in those concurrently taking diuretics. Hence, serum magnesium concentrations should be followed in susceptible individuals on chronic PPI therapy., National Institute of Biomedical Imaging and Bioengineering (U.S.) (Grant 2R01 EB001659)