Wei Ling Lau, MD – Page 2 – The Early Career Voice

How To Conference Like A Rock Star: Tips For First-time Conference Attendees.

November 29, 2017 Wei Ling Lau, MD

Approach a large national meeting like it’s a Target run. You know the scenario – you go into Target to get just one thing and leave with 10 items you didn’t know you needed. Likewise, you can go to a scientific meeting thinking your priority is to get CME, or to network, or to share your research. But really it’s all of this and more. Below are my 2-cents on how to get the most out of professional meetings.

…Ready for it?
Do a bit of prep work before the conference starts. Download the mobile App since this will have the most up-to-date session details. Pick out the sessions that are most relevant to your career or research interests; 2-3 per day would be reasonable. Plenary and late-breaking clinical trials sessions are usually worth attending. Then schedule in the miscellaneous which are just as important: Early Career networking, class reunions, meetings with mentors, sponsored dinners, etc.

Shake it off.
The national AHA meeting can seem terribly overwhelming. There’s 6-8 talks going on at the same time, vendors and poster abstracts spread out over an area equivalent to a football field, council meetings and sponsored lunches/dinners in adjacent hotel venues. My first whoop-de-do was an American Society of Nephrology conference (back when it was still called Renal Week) and I recall feeling lost and worrying whether I was making the right choices about how I was spending my time. Such anxiety is pointless – just breathe, do a bit of preparation (see above) and steer away from fear-of-missing-out mentality.

Talk to people.
It’s easy to hang back and blend into the masses – there’s nothing wrong with that, but you will gain more if you are actively engaged. Introduce yourself to leaders in the field, whether to ask a question or to just let them know you’re a fan of their work. Share ideas with other early career colleagues. Chat with reps at the vendor booths (a good way to learn about new devices and drugs on the market, since pharma representation is tightly restricted at academic centers). Most folks are happy to talk and will appreciate your interest.

Taking breaks is okay.
You are not obligated to sit in talks for 8 hours straight. Have a coffee, tea, or smoothie break. Grab lunch to reconnect with friends or colleagues. Browse the vendor booths and play a spin-the-wheel game. Relax at the Early Career lounge; post a tweet or two. At a meeting in Atlanta I joined a tour of the Coca Cola museum then went back to sit in on an evening research abstracts session. The break cleared my mind and allowed me to re-focus.

Blank space.
For Early Career peeps with a young family: This is your professional development time. Probably best not to bring your dependents. It is much harder to focus on the new hypertension guidelines if you’re wondering whether your kids ate a good breakfast and whether they’re doing okay at the hotel pool. Just saying.

End game.
Keep an open mind and you’ll find a learning opportunity at every turn. While it’s normal to initially feel a little intimidated, after the first day you’ll be navigating scientific meetings like a pro. And definitely take advantage of the awesome Early Career events and resources at AHA meetings!

(How many Taylor Swift song titles did you spot?)

Wei Ling Lau, MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.

Back To Square One: Normal Saline For Prevention Of Contrast-Associated Kidney Injury

November 14, 2017 Wei Ling Lau, MD

I was in medical school when the JAMA paper came out that reported superiority with sodium bicarbonate IV fluids over normal saline in preventing contrast-induced acute kidney injury. This was a Big Deal. Kidney injury is associated with prolonged hospital stays and increased risk of death. I recall carefully making a note of the exact sodium bicarb formulation and pre- and post-contrast infusion rates, carrying this index card around in my coat pocket. Later during residency, I would diligently order the sodium bicarb fluids for high-risk patients pending contrast procedures and spell out the protocol in my chart notes.

A barrage of studies followed the JAMA report but the robust benefit in preventing kidney injury was not replicated. While some investigators were able to detect a modest benefit with sodium bicarb fluids (for urine alkalinization) or oral N-acetylcysteine (NAC, for scavenging of reactive oxygen species) other groups reported no difference, and small cohort sizes with low outcome rates was a prevailing limiting factor.

The PRESERVE trial (Prevention of Serious Adverse Events Following Angiography) definitively lays to rest all the uncertainties surrounding sodium bicarb and NAC. In a very anti-climactic fashion. Sodium bicarb was no better than normal saline, and NAC was no better than placebo. The study was funded by the Veterans Affairs Cooperative Studies Program and included about 5,000 high-risk patients with stage 3-4 chronic kidney disease (80% were diabetic) from 53 medical centers in the US, Australia, New Zealand and Malaysia. (I was born and raised in Malaysia, and am simultaneously impressed and bemused that Malaysia was the only Asian country involved in PRESERVE.) Rates of acute kidney injury were ~9% and death by 90 days ~2.5% across all treatment groups. PRESERVE trial findings were published in NEJM to coincide with Dr. Weisbord’s presentation at the #AHA17 late-breaking clinical trials session.

I chatted with Dr. Pastor-Soler, a nephrologist from University of Southern California who was the discussant at the media briefing session, expressing my disappointment that we don’t have more effective prevention strategies for contrast-induced kidney injury. In pragmatic fashion, she pointed out that the PRESERVE trial is important since sodium bicarb fluids often have to be prepared to-order by hospital pharmacies, and there are intermittent shortages plus increased cost. Based on the PRESERVE trial findings, we can confidently proceed with normal saline which is readily available, with more efficient patient care. (I’ll make a plug here for Women In Nephrology (WIN) where Dr. Pastor-Soler is President-Elect… if you’re a female in the field of nephrology, consider joining!)

So how much normal saline should we give? The PRESERVE investigators allowed a great deal of flexibility to participating medical centers: “1 to 3 ml per kilogram of body weight per hour during a period of 1 to 12 hours for a total volume of 3 to 12 ml per kilogram before angiography, 1 to 1.5 ml per kilogram per hour during angiography, and 1 to 3 ml per kilogram per hour during a period of 2 to 12 hours for a total volume of 6 to 12 ml per kilogram after angiography… In patients with a BMI of more than 30, we capped fluid-administration rates on the basis of a weight of 125 kg.” It sounds like if you give some NS before, during and after, you’re a winner!

To end on a sobering note, the PRESERVE statistics indicate that in high-risk stage 3-4 chronic kidney disease patients who require IV contrast procedures, about 1 in 10 will develop acute kidney injury and 1 in 40 will not survive past 90 days. Medical necessity for IV contrast should always be carefully weighed. And normal saline hydration – yes, definitely! – while keeping in mind that 1 liter of NS contains 3.5 grams of sodium and it is prudent to avoid excessive salt/water loading (volume overload being another key predictor of poor hospital outcomes).

Wei Ling Lau MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.

Anticoagulation In Dialysis Patients: Clear As Mud

November 13, 2017 Wei Ling Lau, MD

End-stage renal disease (ESRD) is a paradox of both increased ischemic and hemorrhagic stroke risk. Atrial fibrillation is prevalent in up to 27% of the ESRD population and further amplifies the stroke risk. However, while the overall ischemic stroke rate is increased 2.5-fold in ESRD as compared to the general population, the rate of hemorrhagic stroke is increased 5-fold due to a complex milieu that includes uremic platelet dysfunction and exaggerated blood pressure fluctuations on hemodialysis.

For over 50 years, warfarin was the only oral anticoagulant available for long-term stroke prevention in atrial fibrillation patients. However, while robust data from randomized controlled trials in the 1980s clearly demonstrated stroke reduction in the general population, we only have observational data in the ESRD population and the evidence here is mixed. Overall, the survival benefit is unclear, and bleeding events are augmented. Warfarin also has the notoriety for increasing the risk of adverse cardiovascular outcomes in the ESRD population. Our group recently published a retrospective analysis of our medical center’s database (spearheaded by medical student extraordinaire Mark Lin) where we noted significantly increased risk of mortality and MI in ESRD patients on warfarin.

Over the past decade we’ve seen the emergence of Direct Oral Anticoagulants (DOACs) that include the direct thrombin inhibitor dabigatran, and the factor Xa inhibitors apixaban, rivaroxaban and edoxaban. Apixaban was approved by the FDA in 2014 for use in ESRD patients, a perplexing move that was based on a single phase 1 study that involved eight hemodialysis patients who were given a single dose of the drug.

At the #AHA17 scientists and colleagues presented trends from the US Renal Data System database that highlights the remarkable spike in apixaban prescriptions for atrial fibrillation among Medicare beneficiaries on chronic dialysis (Nov 12, 2017 Abstract# 17197). About 26,000 patients were included in the final analysis. Utilization of DOACs rose from 0.16% to 29.16% between 2010-2015 with apixaban accounting for the majority of new DOAC prescriptions (see Figure).

anticoagulant graph Photo credit @JCosinSales

Post FDA approval, the observational data has been promising in that apixaban may have lower adverse bleeding rates compared to warfarin. However, a more rigorous pharmacokinetics study published this year in the Journal of the American Society of Nephrology by Mavrakanas et al. raises serious concerns about supratherapeutic blood levels if standard apixaban dosing (5 mg BID) is used in ESRD patients. Until more data is available, the investigators cautioned that apixaban 2.5 mg BID is a more appropriate dosing regimen in dialysis patients.

A randomized clinical trial in ESRD patients with atrial fibrillation is currently ongoing that will directly compare apixaban versus warfarin (RENAL-AF). However, given the lack of a placebo control arm, this trial will not address the fundamental unanswered question: Does anticoagulation, period, decrease stroke risk and improve survival in the ESRD population?

Nephrologists, who manage heparin anticoagulation during hemodialysis treatments and are most attuned to the bleeding risks in ESRD patients, need to be notified when dialysis patients are initiated on anticoagulation. In this complex and high-risk population, ongoing dialogue between the cardiologist, primary care doc and nephrologist is necessary to weigh the risks/benefits of anticoagulation on a case-by-case basis.

Wei Ling Lau MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in animal models of chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.