• Welcome

• NephJC is a Twitter Journal Club that discusses the latest developments in nephrology in an open public forum, everyone is welcome and we have had excellent input from attendings, professors, med students and patients.
• Before we go any further I want to remind anyone watching this to sign up for our once weekly e-mail newsletter, we use it to announce the next twitter chat and these Hangouts. We really appreciate each every person who signs up.
• Speaking of the twitter chat we meet every other week to open the discussion on a new topic and then conclude the discussion a week later with a Google Hangout where we  summarize the discussion and if we are lucky dig a little deeper. This week we are looking at the recently released “Clinical practice guideline on diagnosis and treatment of hyponatraemia”
• Joining me today we have

• NephJC co-founder Swapmil Hiremath
• University of Rochester Chief of Medicine Richard Sterns
• Hatim Hassan from the University of Chicago

• And before we go any further, do any of you have any conflicts of interest you would like to reveal. I was a sub-investigator on the TEMPO 3:4 trial which was done at my sight, which was an ADPKD trial that used tolvaptan a drug also used for hyponatremia, but I never was involved in any of their hyponatremia research.
• Today’s paper is a clinical practice guideline, these are not typically the subjects of journal clubs, which usually focus on the primary literature but these documents are increasingly driving the way nephrologists practice so we believe they deserve the scrutiny that journal clubs provide.

• Nephrology has played a prominent role in CPGs over the years

That said it does seem a little weird to see guidelines for electrolytes. The UK Renal Association has published hyperkalemia guidelines.

Swapnil, were you a suprised to see guidelines for this subject? What about you Dr Hassan?

Dr. Sterns, You were an author on the 2013 hyponatremia guidelines from the American Journal of Medicine. Can you comment on the role of guidelines in the field of hyponatremia?

• The guidelines, Swapnil, why don’t you give us a high level view of what the guidelines contain

• Use of the GRADE System
• hypotonic hyponatremia only
• nice summary of the pathology of hyponatremia
• section 6 the first place guidelines are provided. They focused initially on categorization:

• biochemical severity
• acuity
• symptoms

• not the classic: hypo, eu, and hypervolemic

• Section 6.3 Diagnosis
• Section 7 treatment

• 7.1 severe symptoms
• 7.2 moderate symptoms
• 7.3 acute hyponatremia without moderate or severe symptoms
• 7.4 chronic hyponatremia without moderate or severe symptoms

• Drs Stern and Hassan

• What are your views of the guidelines?
• What is your take on the anti-vaptan position?

• And what about the anti-demeclocycline position?

• The guidelines are almost entirely ungraded or D level evidence

• why is that?
• why is our knowledge so thin about this topic?
• osmotic demyelination has been reported 54 times, but hyponatremia occurs in over 10,000,000 people a year. Does this mean we are doing an excellent job managing hyponatremia or are we just lucky? Under reporting?

• The authors had this beautiful text which described all of the uncertainty in the diagnosis of hyponatremia, how difficult he physical exam is and how the urinary sodium and osmolality can be unreliable in various studies, but then they threw all of that away and created a flow chart for diagnosis. Do we do a disservice to learners with simplified flow charts that over promise with simplicity?
• Reading through the guidelines, I thought they referenced all the important papers on nephrology, did you guys notice any important omissions?
• what do each of you are thinking are the most pressing research needs in the field of hyponatremia.

• Dr Sterns?
• Dr Hassan
• Swapnil
• myself

• Thank-you everyone for a stimulating hangout. Why dont we get final thoughts on the subject.

• Dr Sterns?
• Dr Hassan
• Swapnil
• myself--sometimes CPGs get ahead of the evidence but this makes fat targets for research to benchmark, they becomes obvious end-points to test so by getting ahead of the evidence they can guide the future of research improving the field, I think to a large degree this was seen in the KDIGO CKD guideliens that were largely 100% opinion based in 2002 and have since been fleshed out with more and more data. I hope we can look forward to a similar phenomena here.

• If you guys wouldn’t mind we are going to take a moment to announce our next Twitter JC, next tuesday at 9PM we will be discussing Posiedan,

Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial (Lancet)

• This is an interesting attempt to add some intelligence to the way that we hydrate patients undergoing contrast for heart catheterization.
• It is a positive trial.
• Swapnil, do you have any initial thoughts on the trial to share?
• We will be discussing that Wed, June 25. We are pushing it back 1 day because Tuesday is my 14th anniversary.