National Kidney Conference, Bergen, Norway

I just attended the "National Kidney Conference" in Bergen. It was held in memory of Bjarne Iversen, my old mentor. Since the common denominator was that the presenters were old collaborators, the talks were very varied, or, you might say, the conference was a bit unfocused. Many did include a short presentation of how they had collaborated with Bjarne and tried to present data that in some way was connected to this, but equally many held their presentations as they would have at any other conference.

The highlights were Bill Arendshorst who talked about renal vascular function and Christos Chatziantoniou who talked about new markers and potential therapeutic targets in renal fibrosis. In addition Hans-Peter Marti presented data on markers of renal fibrosis on the genetic level. Personally, I had hoped for a wider attendance but I think the organizers wanted a more intimate meeting.

As with any meeting the important part was getting to meet some other experts in my field and discuss what we are and should be doing, and of course when and where we should meet next time to have a been and a chat. A bonus with invited lectures is that you get to aggregate your data and try to present them in a wider context. All-in-all a good meeting, although with a sad undertone as we remembered our mentor and friend who could not attend what was originally planned by him as a retirement seminar.

Not so bad in Bad Gastein

I am in Bad Gastein for my mother's birthday. It is not the best place for a vacation if you can not ski. The town is slowly turning into a ghost-town. The center, or as our concierge put it not-much-of-a-center, includes a handful of kitsch-shops and some restaurants, non of which open before after-ski. These isolated shops are surrounded by old hotels, most empty and poorly kept. Supposedly it is too expensive to renovate them, and probably equally important, it makes no difference because everyone who come here now come here to ski. On the other hand, when the rest of the family is up on the slopes, there is no one to disturb me when I blog work and the WiFi is free.

An interesting feature of Bad Gastein's are the thermal baths. High-radon steam and water spas that are, supposedly, good for you. The steam in the thermal caves in Bad Gastein clocks in at around 100 000 Bq/m3, or about 1000 times more than the suggested intervention-level for living-areas, and about the same as in the uranium-mines where radon was originally shown to cause lung-cancer. But, as the proponents of this radiation therapy are wont to say, there is no scientific data that shows that short-time or low-dose radon exposure actually is harmful. And, since it is a traditional remedy there surely must be some advantageous effect simply because it is traditional and people have been doing it for hundreds of years. There is indeed some data indicating that repair enzymes are induced by low-level radiation, and, on the epidemiological scale, higher background radiation does not correlate that well with cancer incidence. Being a liberal type, I think that those who want to bathe in radon-vapour should be allowed. If nothing else, it should speed natural selection on its way.

Crossfit

I still do not have an anterior cruciate ligament, but with the suturing of the collateral ligament and some training the knee is surprisingly stable. As anyone can understand, the idea of keeping up with the young elite judoka at our club came to nothing. For this year anyway. Instead I have two gym cards, and I who have always considered gym-training the most boring training conceivable. Even worse than running, or even swimming.

First I have the subsidized membership at the hospital gym. It is a decent gym, mostly machines and a very cramped space for free-weight lifting. On the other hand it is easy to patch on 20 minutes of lifting before or after work (important), and they have a sauna (very important).

Second, an old friend of mine has started a crossfit gym in Uppsala, surprisingly named Crossfit Uppsala. Apparently it is the new hip thing for athletes to do, and the gym is also really good as far as crossfit-gyms go. When they started, some two (or three, even four) years ago, I shot some pictures for them. To my great satisfaction they still use them on their homepage.

Björn, combining single-handed push-ups with correcting his spectacles. I do not think they use this one on their homepage.

Now they have over a hundred members and sell training-equipment to other gyms. The training is very varied and usually done in smallish groups with a leader (who may, or may not, drink coffee incessantly). If you are interested in more details about cross fit there are easily thousands of dedicated sites, just google it. Suffice to say I find it quite entertaining now that I cannot do judo for a while.

Strength-wise I am as strong as I ever was. Today we did back-squats and my new personal best is 100kg. Quite good for not having an anterior cruciate ligament. Endurance-wise I was almost back before the influenza-epidemic hit, now I have some more catch-up to do. The knee is not stable enough for full-contact judo, but as soon as I get my surgery (not counting the following six months of rehab) I will be all set.

Identity-crisis

For many years now my plan was to establish myself as a researcher and then work my way into clinical nephrology, while continuing my research. Instead, I find myself at a crossroads. The department of nephrology at my hospital has no plans for another resident for at least two years, certainly not a combined research and clinical position. At the same time I have been offered just that in anaesthesiology and intensive care.

The research in medicine and nephrology is very much risk-factor based and focused on the progression of chronic disease, while intensive care is more focused on acute, homeostasis-based physiology. My research has connections to both areas: Acute regulation of renal blood flow on the one side, and more chronic progression of renal damage on the other. I can not say that I find either more enticing than the other.

So, my experimental research is about equally applicable in the two specialities, but the role as a doctor is completely different. In Sweden anaesthesiology is a service-speciality. That is, they keep the patient alive while the surgeons do their job. Intensive care is much the same, they maintain life-support while doctors from other departments are actually responsible for the diagnosis and treatment of the patient. Not that that may not be challenging or interesting in itself. It is just not the way I have looked at myself. On the other hand, practically everything in modern health-care are collaborations, and as intensivist you are really at the center of the treatment of the most critically ill patients. Sadly, it often means that the patients are not very talkative, and may not remember you at all.

In contrast, nephrologists get to diagnose and follow their patients through an often slowly progressing chronic disease. In short, they get to know their patients. In addition, the pace is decidedly slower, more measured, and the rounds longer, much, much longer.

At the moment, everything seems to head toward anaesthesiology and intensive care for me, while my self-image, and clinical practice so far has been focused on medicine and nephrology. Thus the identity-crisis.

Hypertension course - Day 2

After a too short night's sleep we started day two at 8:45 in the morning. The morning sessions covered treatment and current guidelines. Even though I was a bit tired, I managed to remember to take some pictures (for the blog), and write an extra presentation to replace a lecturer that could not attend.

There is massive data that shows that reducing the pressure under 140/90 mmHg is the first priority. Use what ever means necessary, just get the pressure down. Then there is data to show that renin-angiotensin-system-blockers may have some additional benefit. In type 1 diabetes this is indisputable. Type 1 diabetic patients should have an ACE-inhibitor or an ARB as soon as they show microalbuminuria, no matter what their pressure is. Unless you have a specific need for a beta-blocker you should start with a RAS-inihibitor and a calcium blocker.

The afternoon focused on target organ damage and associated diseases, such as diabetes, stroke and old age. To protect the heart and kidneys, ACE-inhibitors or ARBs are the best choices. To protect against renal failure and stroke it is quite clear that lower pressure is better down to 120/70, at least. For the heart, the nadir may be around 130/80, considering that the coronary arteries are perfused in diastole, this is not surprising. After stroke, certainly ischemic and maybe hemorrhagic, the pressure should not be treated the first couple of days, with the possible exception of systolic pressures above 220mmHg.

In the elderly, pulse pressure is a much stronger predictor of mortality than systolic pressure or diastolic pressure, so that 160/110 mmHg is actually better than 160/60 mmHg. Much better.

Hypertension is therapy resistant when treated with three antihypertensives at the maximal doses, including a thiazide-diuretic. It may then be time for renal nerve ablation, or to ask the patient if they eat a lot of salt. Another under-appreciated reason for uncontrolled blood pressure is doctor's-, or even investigator's-inertia. That is, the patient has an uncontrolled blood pressure, does not have the maximal dose, have not experienced any adverse events, and still the dosage isn't increased by the doctor.

All in all, it was a very successful course. 130 attendees, and some 20 lecturers. The next one will be in two years, in 2014.

On a side-note, free wifi on the airplane home is brilliant. All airlines should provide it, on all flights.

Actually, everywhere should provide free wifi.

Course on hypertension

Finally, the first day of our hypertension course has come to an end, and I can go to a much needed repose. First I just have to finish my blogpost, and possibly check the twitter. So far it has been a very successful course. As is traditional we started with epidemiology, worked through pathophysiology and diagnosis. Treatment will come tomorrow.

Here is a brief summary of the conclusions from the first day:

Hypertension is developing better traction with the big agencies, WHO etc, as the largest modifiable risk factor for disease and death. Not only in the high-income countries, but globally.

Prehypertension (120-140 in systolic- and 70-90 in diastolic blood pressure) is an important risk factor for later hypertension and later cardiovascular morbidity and death. It should probably indicate a closer follow up and counceling about life-style, although, it is still not well studied enough to be an indication for pharmacological treatment.

Diastolic hypertension is the strongest risk factor for later cardiovascular morbidity and mortality in adolescents. In middle age systolic blood pressure takes over, and in greater ages the pulse pressure is stronger than either.

Hypertension is part of the cluster of risk factors sometimes known as the metabolic syndrome. Increased stress-hormone release may represent a common mechanism behind this syndrome.

High exercise blood pressure (>210 mmHg) in the absence of clinical hypertension may be a sign of masked hypertension.

Hypertension is both caused by, and leads to structural changes in the vasculature, which are important for the associated cardiovascular diseases and end organ damage.

Non-pharmacologic treatment, such as exercise, weight-loss and reduced salt-intake are effective components in the treatment and prevention of hypertension.

The work-up for a patient with hypertension should include ambulatory blood pressure if they are prehypertensive or if the indication for treatment is uncertain. For example, slight hypertension, no other risk factors and no target organ damage. A situation where current guidelines suggest to wait and see. A problem is that ambulatory measures are not included int the current guidelines. So, it is unclear how the results should be interpreted.

Secondary hypertension is a surprisingly common cause of hypertension, in particular hyperaldosteronism which may include 5-13% of all hypertensives.

Albuminuria is an important, independent risk-factor for cardiovascular morbidity all the way from sub-microalbuminuric levels.

In addition to these lectures we had some clinical cases and two panel discussions:

Is hypertension the most important global risk factor for disease and death?

Does living well improve your survival?

Both of these were answered with quite solid affirmative answers. Not really surprising given the audience and setting, but probably not wrong either.

ESH 2012 satellite symposium in Oslo

In connection with the CME course on hypertension in Oslo that will start tomorrow, the Norwegian society of hypertension together with the European society and the research group in Oslo have arranged a Research symposium so that some of the young researchers in Norway would have occasion to present their data. Not me. I am just here to pretend to listen while blogging. The sessions were focused on Coronary heart disease, Cardiac hypertrophy, Kidney disease and Diabetes and Atrial Fibrillation, all in more or less direct connection to hypertension, as well as hypertension as such.

After a night on call and then leaving home for my flight at 5:30 in the morning, I might have been less attentive than otherwise. But never the less, I thought I might mention some highlights:

Anabolic steroids causes heart disease (well known).

Early pressure intervention is probably bad after ischemic stroke (SCAST as reported last year). 

Long-time endurance training is associated with increased risk for atrial fibrillation (as we knew). 

Inflammation in reumatologic disease increases the development of atherosclerosis. 

Hypertension treatment in moderate aortic stenosis is probably not dangerous (needs more study). 

IL-18 plasma concentration is affected by a SNP in the 3'-UTR, which is also associated with hypertension, but not with cardiovascular disease in the studied population (The physiologist finds this interesting, the physician not so much). 

Antiviral treatment in HIV is associated with hypertension in those with more severe disease before the start of treatment. 

Blueberry extracts (anthocyanins) have no effect on blood pressure (None).

Now my brain is full and I have to get to my hotel and get something to eat before I die from undernutrition and sleep deprivation.