𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
This is one of the funniest things to me. I will often ask someone who tells me that they’re dry. How is it that they got that way and then there’s usually a little bit of silence, a mumble about insensible losses, a limited PO intake, despite the 3 L that have been given in the last 48 hours, lol. The reality is that unless you were getting aggressive diuretic therapy or you have severe G.I. losses, your so-called intravascular dry patient likely has a main systemic filling pressure problem and you don’t wanna miss the septic source because you thought they were dry.
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Totally agree, @VincentRK! Center availability for PLEX can vary quite a bit. We’re fortunate to have PLEX available right away here, and it helps lower FLC levels while we wait for plasma cell-directed therapy to reach its maximum effect. Individualized medicine is key!
Replying to @ShrutiGkidney
Thanks. Yes and I understand the dilemma. But it’s a package. One doesn’t work well without the other based on pathogenesis and how these treatments work. Even a quad like Dara VCd takes a couple weeks to work. So if I have cast nephropathy with a creat of 6, I’d be quite worried if we are willing to wait 2 weeks to reduce the light chains and give my kidneys a chance a good chance at recovery when there is a way to reduce light chains on day 1. And similarly if we just plex for 5 days and not institute highly effective therapy to shut off the tap we cannot expect plex to change outcomes.
I appreciate this is an area that for a number of years I’ve been going outside of the evidence. But all studies I have seen so far run huge risks of type II error. And the consequences to patients are so huge that I feel compelled to recommend based on the non randomized data we have at Mayo and the pathophysiologic rationale.
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Replying to @VincentRK
Thanks for your comments. However, I would like to highlight that there are very few patients in practice that receive both Dara and plex - mayo is unique that way.
The target trials were separate and were intended to look at each treatment individually, not together.
👑
Replying to @ross_prager
Being "intravascularly dry" is often suspected when:
1. Furosemide monotherapy for diuresis is used, which produces metabolic alkalosis and hypernatremia irrespective of someone's true volume status.
2. Low MSFP shock due to vasoplegia in conditions like sepsis. The issue isn't about volume, but rather the pressure driving venous return.
3. Oliguria in the ICU. Many cases are 1) not AKI 2) not fluid responsive and 3) congestive
4. The patient has intracavitary gradients or dynamic LVOTo. These patients behave "super dry" . Preload helps temporarily, but afterload, beta blockade etc. accomplishes same goal in more durable fashion.
5. Pancreatitis patients. These patients have third spacing, sure, but actually are often more distributive. They require some fluids, but routine use of 100+ml/hr IV fluids in the absence of objective markers of low stroke volume and fluid responsiveness leads to many of the iatrogenic complications of pancreatitis we see!
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Being "intravascularly dry" in the ICU is way rarer than most clinicians think.
Most of the time its mistaking other conditions/circumstances 👇
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Plasma Exchange and Daratumumab for Myeloma Cast Nephropathy
-In a multicenter cohort study, neither PLEX nor daratumumab was associated with kidney recovery at 90 days #mmsm #bmtsm @cshincovich @ShrutiGkidney
onlinelibrary.wiley.com/doi/…
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Replying to @spjuraschek
I agree. Adina Turcu has an excellent paper pubmed.ncbi.nlm.nih.gov/3817… on factors that may better predict surgical success. Lots to do in this area but it’s the minority of cases for sure. I agree that with more screening we need to be address this as a field.
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Why do we keep doing this dumb study?
In mechanically ventilated adults with #AcuteHypoxemicRespiratoryFailure, an inhaled sedation strategy using isoflurane with intravenous adjuncts as needed did not reduce hospital mortality vs intravenous sedation. Ventilator-free days, intensive care unit–free days, hospital-free days, and 3-month quality-of-life and disability scores were also similar between groups.
ja.ma/3TKDpfY
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Pregnancy-Associated TMA: Bringing the Right Experts Together When Every Hour Counts
Masterclass discussion with Cristina Popa
kireportscommunity.org/post/…
@ISNkidneycare #TMA #pregnancy
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Well, we won't spoil all the details, but the primary outcome was similar to both CVVH and IDH; the so-called superiority is just a secondary outcome- trial was not powered for it and was interrupted earlier... lots to comment on in a future #nephjc
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
We will have a @Rush_Nephrology live renal biopsy conference tomorrow Thursday 10/15 at 1 PM CST. All I can say is this is some bad pathology. Please join us. #RushRenalRules
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
ASN Kidney News Oct-Nov 2026 Intravenous Bicarbonate for Metabolic Acidosis in the ICU: Improving Outcomes or Just Fixing Numbers?
J. Pedro Teixeira, Lenar Yessayan @luck_urine
@asnpublications
kidneynews.org/view/journals…
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
ASN Kidney News Oct-Nov 2026 Nephrology Educator to Make the Case for Dialysis Access Curriculum Changes @Nephro_Sparks kidneynews.org/view/journals… @asnpublications
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Thanks Kenar. Very honored and humble to receive this award. Thanks to everyone who has supported me along the way, including all of the current and past fellows at Duke and all of my mentors from Duke and all over. I appreciate the support and can’t wait to see everyone
ASN Kidney News Oct-Nov 2026 Nephrology Educator to Make the Case for Dialysis Access Curriculum Changes @Nephro_Sparks kidneynews.org/view/journals… @asnpublications
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Congratulations to you Sasha @staruschenko on this well-deserved recognition, the Donald Seldin Award Lecture, @AHAScience @CouncilonHTN
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
A critical appraisal of guidelines and recommendations for the management of ANCA-associated vasculitis
doi.org/10.1093/ckj/sfag317
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Replying to @IM_Crit_
I hate that “being uncomfortable” is now viewed by some as an indication to use a scarce ICU bed.
It’s not about physician “comfort” it’s about patient needs. A stable persons who has gotten a transfusion doesn’t automatically need ICU level care.
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
Sometimes, a drug’s metabolite is more potent than its parent molecule, yet loses one of its most interesting pharmacological properties. Losartan is a fascinating example.
Following administration, losartan undergoes hepatic metabolism, primarily through CYP2C9 and CYP3A4, generating its active metabolite EXP3174.
This oxidation converts a hydroxymethyl group into a carboxylic acid, producing a molecule with substantially greater affinity for the angiotensin II type 1 receptor (AT₁R). Consequently, EXP3174 contributes significantly to losartan’s sustained antihypertensive activity by preventing angiotensin II-mediated Gq/11 signalling, phospholipase C activation and intracellular Ca²⁺ mobilisation.
But here comes the interesting part.
The parent molecule possesses a pharmacological activity that its more potent metabolite largely lacks: the ability to promote uric acid excretion.
In the kidney, URAT1 (SLC22A12), located on the apical membrane of proximal tubular epithelial cells, normally reabsorbs filtered urate through exchange with intracellular organic anions.
Losartan directly inhibits URAT1, reducing urate reabsorption and increasing its urinary excretion. This uricosuric effect lowers circulating urate concentrations.
Interestingly, the structural modification that enhances EXP3174's affinity for AT₁R markedly diminishes its ability to inhibit URAT1.
This demonstrates that losartan's uricosuric activity is mechanistically independent of AT₁R blockade and is primarily attributable to the parent drug.
Although other angiotensin receptor blockers may interact with urate transporters experimentally, losartan stands out for its consistently demonstrated clinical uricosuric activity.
One drug, two molecular targets, two distinct pharmacological effects. And a reminder that greater potency at one receptor does not necessarily mean broader biological activity.
𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇 retweeted
#Eicosanoids as Biomarkers of #Hyperfiltration-Mediated Injury in #CKD
#VisualAbstract by @assad_sm
kireports.org/article/S2468-…































