Medical School 2020, Year 2, Week 20

From our anonymous insider…

The Saturday Friendsgiving has thinned the ranks of Monday and Tuesday lecture attendees. At least five of us, including me, are down with an upper respiratory infection.

Instead of watching the recorded lectures, I watch Pathoma and read Robbins & Cotran. Chronic kidney disease (CKD) is an irreversible loss of kidney function defined by a GFR of less than 60 milliliters per minute for more than three months. Pathoma explains the process of hyperfiltration, where loss of one group of nephron units, from e.g., infection, inflammation, hypoperfusion (low blood flow), causes the remaining functioning nephron units to increase GFR.

I return Wednesday for two hours of CKD treatment strategies by the nephrologist from last week: “What I love about nephrology is there are only four diseases that I have to know: diabetes, hypertension, pyelonephritis (kidney infection), and hereditary kidney disease. 95 percent of all CKD is caused by one of these and they are all covered in First Aid.”

He discussed some exceptions to this rule, starting with an unsolved mystery in Central America “Certain agricultural communities have up to 20 percent incidence of CKD. We do not know why.” (see “Chronic Kidney Disease Epidemic in Central America: Urgent Public Health Action Is Needed amid Causal Uncertainty”, Ordunez, et al., PLOS, 2014). He also described an outbreak of “Chinese herbal nephropathy” from a weight loss supplement that used aristolochia instead of stephania. This is the same compound that caused the 1965 Balkan Endemic Nephropathy in the Soviet Bloc. Aristolochia grows in wheat fields along Danube river Valley. This contaminated flour. “When I was in medical school, this was huge news. Now the region has 65 times the risk of getting uroepithelial cancer.”

We learned about the various types of dialysis for end-stage renal disease. “We tell our patients it is fine to travel. One of the beauties of effective government regulation is that all dialysis machines are standardized. We use the same settings for each machine. Our patients travel all over the country, and we are able to handle dialysis for visitors from anywhere in the world.”

The nephrologist concluded: “You will each briefly do a nephrology rotation. One of the things I wish you could see is the patients that are doing well. If patients do not take care of themselves there are serious consequences. You see these patients in the hospital. But if they do take care of themselves they can be healthy and productive members of society. You don’t see the patients who have jobs, families, and a good quality of life. I wish we could show you what it is like on the outpatient side. Come join us for a day!”

Our patient case: Jenny, a recently married 24-year-old manager at a fashion designer store. She was fresh out of college, had moved with her husband for new jobs, and purchased a house, all within one year. Jenny presents for one month of joint pain and an expanding rash over her face and torso. She was worked up for Lyme Disease. “I got a call a few days later by the nurse who referred me to a rheumatologist.” The earliest appointment was in two months.

“The next week I could not get out of bed because the pain was so bad.  I had to lie like a coffin. I thought I was dying. We had to cancel our honeymoon! That’s when my husband realized that the problem was more than natural laziness.” She chuckled, and continued: “I called my family friend who is a doctor. He gave me a list of tests to get. I called to get another appointment with my PCP, but I could only see a PA. I think she was insulted when I presented my long list of labs and tests.” Her labs showed abnormal urinalysis including albuminuria and red blood cells in the urine. “They now wanted me to see a nephrologist instead of the rheumatologist! I saw the nephrologist the same day.”

Her short, sarcastic 40-year-old nephrologist said that she had immediately suspected systemic lupus erythematosus (SLE or “lupus”) given Jenny’s age, sex, kidney function, and the expanding characteristic butterfly rash now covering her face. She started Jenny on several drugs, including an immunosuppressant, high dose NSAID, and steroids to bring her lupus into remission. Jenny has been in remission for almost three years since the initial flare up at age 24.

Jenny said, “My husband is a saint. Once I got the diagnosis, I immediately went to the Internet. WebMD is a dark hole of death. I thought every little ache or sniffle spelled death. After a week, My husband forbade me from looking up any information about lupus. If I was concerned about something, I told him, and he would search it.”

After roughly six months, Jenny began tapering down the powerful immunosuppressants. Her lupus is controlled now only with high dose NSAIDs. “The drugs I was on had terrible side effects, but I was just as scared about relapse. Weaning off the drugs takes months. My husband was the only reason I was able to follow the strategy. He reminded me every day, and kept track of the dosing schedules.” (Roughly half of individuals with chronic illnesses do not take their medications correctly.)

When would a nephrologist rather than a rheumatologist manage a patient with lupus? “It depends on what condition is the most urgent. If lupus is impacting the kidney, a nephrologist will manage the case until the kidneys are safe. The rheumatologist manages the day-to-day stuff, we get involved only to evaluate the kidney.”

Straight-Shooter Sally asked Jenny to summarize her care. “To be honest, I was not impressed with my PCPs. I felt like they failed me. But, I love my specialists. They know so much. Any question or concern, they have seen before and know exactly what to do.”

Surfer Saul asked Jenny if she is able to have children. Jenny’s rheumatologist does not want her to get pregnant due to the risk of a flare up from the hormone surge. Her nephrologist: “I think it is okay. I’ve had a few SLE patients get pregnant.” Mischievous Mary asked if pregnancy would stress Jenny’s kidneys because of the sudden increase in blood volume and hyperfiltration? “Oh no, pregnancy is good for your body, good for the kidney. Pregnancy is a protective risk factor for lots of cancers. I tell Jenny she can get pregnant.”

Gigolo Giorgio asked if Jenny, in light of her current knowledge of lupus, could remember pre-diagnosis flare-ups. “Yes, I got really sick in college once. Terrible. It had to be a flare up. I also remember being allergic to all these random things like yellow dye.”

A student asked the nephrologist what her patients can you eat on a renal-restricted diet? “Wonder bread and lettuce. There are no good options. Every food has things the kidney struggles to excrete. I have patients come in to me complaining of having Wonder Bread stuck to the top of their mouth.”

Our class discussed the proposed Republican tax plan at lunch. Students did not understand the changes to the mortgage interest deduction. One student believed that the new tax plan would increase the mortgage deduction limits “to benefit the wealthy in their McMansions.” Luke attempted to correct the group by stating the new tax bill would restrict and cap the mortgage interest deduction at $10,000. (This was also incorrect; it was state and local taxes that were limited to $10,000 while mortgage interest would remain deductible on loans of up to $750,000.) Socialist Sam, a 23-year-old self-described “Democratic Socialist,” responded: “Well, then, the deduction would distort the housing market. It would make it more expensive for people to move up in housing market, exacerbating racial housing discrimination.” (Decades of government subsidies to homeowners via the mortgage interest deductions apparently did not constitute a “distortion” to the housing market!)

Curiously for someone whose future paychecks will be coming from insurance companies, Gigolo Giorgio supported getting rid of the Obamacare “individual mandate” requiring citizens to purchase health insurance. “A bunch of my college friends took the $2,000 hit instead of purchasing health insurance.”

The argument continued on Facebook. Type-A Anita shared a Bustle article, “The GOP Senate Tax Bill Will Make It Much Harder To Be A Woman In America” underneath “hi warning friends only read this if ur ready to get good and depressed because IDK WHAT I EXPECTED FROM THE TITLE but wowie wow wow.” The main point of the article is that people who don’t currently pay taxes will be denied the opportunity to claim tax credits:

Millennial moms would also be impacted because the bill excludes 10 million low-income children from claiming tax credits. Because women still mainly shoulder the responsibility for child care, families in the lowest income bracket won’t receive tax benefits for their children when they’re the ones who need it the most.

[Editor: Let’s see if single moms are so discouraged by this new tax law that they turn over custody, and the child support cash that comes with custody, to the respective fathers!]

Some of our female classmates thank her for educating them (8 angry faces; 14 likes). Sample comments:

My brain cannot even comprehend the sheer cruelty of this bill


Facebook also brought news from my college classmate who decided to leave the United States for enlightened Brussels due to Trump’s election (see Year 2, Week 3). His coworker in Belgium has been “jokingly” calling him by a variety of anti-gay slurs:

I refuse. I will not be defined by your words and I will not be forced to accept them as “business as usual”.

His friends commented that Trump could be blamed for this outbreak of homophobia in Brussels.

Statistics for the week… Study: 25 hours. Sleep: 6 hours/night; Fun: none. We leave Wednesday after class for Thanksgiving break. Students complain that the administration scheduled exams for the week after Thanksgiving.


3 thoughts on “Medical School 2020, Year 2, Week 20

  1. This anonymous medical student writes so much like Phil. Could Phil be getting a degree in medicine?

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