Beginning the Application Process for DI's

To contact us Click HERE
I know it seems like it's a little early to start your DI application via DICAS, but it’s never too early to start thinking about it and planning for it. The portal opens on December 1^st so I’m trying to get everything in order to make this process as easy as possible.  I’ve been talking with people who are either in their internship right now or have been through this process recently. Here are some tips that they’ve told me:

•  Get transcript requests sent right away. It may take a while for some schools to send them, and if you’re a transfer student like me, you’ll have to make requests for multiple transcripts. Not only does DICAS need them, but you also have to input all the courses you’ve taken so that they can calculate various GPAs. You might want to do this part first since it’s the most tedious.

•  Ask people to write your recommendation letters as soon as possible. Hopefully they’ll all say that they’d love to write them for you, but you may come across some problems—they might be too busy, etc. Also ask them what they need to write the letter. You may need to send them your personal statement, past homework assignments or you may need to sit and talk with them about what your goals are.

• If you are applying to more than one internship, make sure you know what each internship’s focus is. You are going to have to write a different personal statement for each one you apply to. I believe that this is going to be the most time consuming part for me—even more so than deciding which internships I am going to apply to. Once they are written, have everyone you know read them! The more eyes that see them, the more feedback you can get before you submit your application.

• Contact the program directors. Either talk with them in person or over the phone. If there is an open house for the internship you’re interested in, GO!!! Meet the people you could be working with! When they get your application they’ll be able to put a face to the name.

•  Most importantly, be yourself. Be genuine about what your goals and interests are. 

This whole application process can be so daunting. Make it easy for yourself and DO NOT procrastinate!

By: Allison Richards

It's Not Just Meat and Potatoes: The Diversity of the Dietetics Profession

To contact us Click HERE
By: Jill Merrigan 
I am constantly asked, “What do you want to do when you finish school, and complete a dietetic internship?”  For me I am asked this weekly but find that I have a monthly response. One of the most exciting pieces of my return to school is the inspiration I have as I continue to learn about all the possible career opportunities I’ll have as a registered dietitian.
The career field for a registered dietitian offers a colorful plate, it not just meat and potatoes. From clinical dietitians, foodservice managers, research dietitians, educators, outpatient nutrition counselors, consultants. It is encouraging and motivating to remember that all my hard work in the classroom will expose me to a broad path of experiences within the dietetic profession.  When I was in the process of leaving my job in ad-sales and transitioning into my new life in Boston at Simmons College I took the time to meet with many registered dietitians, educators, and professors. One of the most important observations I took away was that in the dietetic profession we are not limited to one career path. Many times an RD will choose a position that meets their specific needs and in time branch into another position that suits them, and continue to make changes as it feels appropriate with time.  Some of the unique careers I have discovered that RDs are pursing include a RD – Food stylist, RD – Psychotherapist, RD – Medical Doctor, and RD – Farmer.
The nutrition and dietetic field is versatile, allowing diverse ways to educate and help people eat right. If you are considering a career change into nutrition and dietetics but now sure where the path will lead you then be sure to take some time, learn about the many opportunities that are available, and compare them to your own personal goals, strengths and interests and begin to see yourself living your career dream. 

Amanda's Cardiology Rotation

To contact us Click HERE
I had a great past couple weeks in my cardiology rotation.  I had the opportunity to meet and work alongside an inspirational RD who is not just a clinical dietitian but also an outstanding community leader who holds leadership roles in numerous organizations including the local dietetic association.    Of course I also learned how to plan and educate patients about heart healthy diets, make notes in the charts of patients, and do nutrition assessments on patients with CHF.

One of the main things I have learned is that nutrition care is hardly one-dimensional.   Although a patient may come into a hospital with the initial diagnosis of chest pain and shortness of breath, they may also have diabetes, renal failure, cognitive impairment, trouble chewing/swallowing; the list goes on.  When assessing a patient, it is important to look at the “big picture” and not just the diagnosis that the patient was admitted with.  This is especially important when completing a case study. 
Case studies are some of the best opportunities to learn during clinical rotations.  They give you the opportunity to apply all the information you learned in your MNT classes to a real-life scenario.  Scanning charts and comparing lab values made me feel like a detective; it was up to me to figure out where the patient was nutritionally deficient and what nutrition interventions were needed to restore their health. 
One tool that was especially helpful was my MNT book from college.  This book is filled with so much detailed information that was helpful when completing my cardiac case study.  If you are planning on completing an internship I would definitely recommend resisting the urge to sell your MNT book at the end of the year and hold onto it as it will prove to be a valuable tool during your internship.  
Question (to other past/present dietetic interns): What other resources have you found to be helpful during your dietetic internship rotations? 

Amanda's Career Goals and Reflection over 1st half of DI

To contact us Click HERE
Half Way There!
It is amazing for me to think that one year ago at this time I was putting my dietetic internship application packets together, not even sure which internships I was going to apply to.  Now I am five months into my internship, with only five months to go until I am eligible to sit for the RD exam.  The internship so far has challenged me and prepared me for a career as a dietitian in ways far beyond what I learned in the classroom.
One of the best things I have learned thus far is that I am certain that pursuing a career in school food service is the path I want to take.  The rising need for dietitians in schools and the regulatory changes facing school nutrition programs are two reasons why this career path appeals to me.  Here are a few of the benefits that working as a dietitian in a school nutrition program offers: 

• You get to work with kids!  There were so many people in my college classes who were interested in pursuing a career as a pediatric dietitian.  Rather than working with kids who are already sick, school dietitians can work with kids proactively by promoting nutrition education and nutrition integrity in the meals offered in school. 

• The variety of positions available to dietitians.  As a dietitian you can get a job as a nutrition educator, a manager of school kitchen, an area supervisor for a district or the director of food service for an entire school district.  No two school districts are alike so you can also have a variety of options in the type of school food service program you would like to work in.

• Opportunities for career advancement.  Depending on where your strengths and career goals lie, school nutrition programs can offer many opportunities for professional growth.  This is especially true if you are interested in nutrition management and business.

• Great work schedule.  Depending on the position, school dietitians may get the summer months off and for sure the holidays as wells as most weekends (nutrition conferences may take up a weekend day or two). 

If you are interested in a career as a school dietitian or would like to know more about why I think it is such an exciting career path, please feel free to reach out to me with any questions you may have!  I hope finals are wrapping up well and that the holiday break brings some much needed time for rejuvenation and relaxation.  

Hemoglobin A1C Blood Test Isn't Perfect

To contact us Click HERE

The hemoglobin A1C is a great blood test for type 2 diabetics, but not for diagnosing diabetes.

Don't misunderstand. I love the hemoglobin A1C blood test. It doesn't require fasting. It can be done in the doctor's office with a fingerstick just like your glucose monitor, and you can know the results before you leave the office. And it lets you know how your blood sugar has been doing over the past two or three months. It sounds perfect.

But it isn't. For diabetes management you and I need to know what our blood sugar is doing all the time, not just every three months. A great HGA1C reading does not mean there have been no hyperglycemic or hypoglycemic episodes over that time. So the hemoglobin A1C cannot replace daily checks with a glucose monitor and log book records.

Taken together with daily readings, the hemoglobin A1C gives an accurate picture of whether you are keeping your blood sugar in the ranges that will keep away the complications. There is more and more evidence that an HGA1C between 6.5 and 7 will do just that.

And here's an encouraging fact. If your A1C was 9 and you lower it to 8, there is a 20% reduction in risk of complications even though you aren't in the target range yet. That's good to know. You should also know that the American Diabetic Association says to get the test done every three months if your are diabetic.

Here's how it works. Hemoglobin is the medical term for red blood cells, and glycated hemoglobin is the term for red blood cells with sugar stuck to them. Over the life of a red blood cell, which is 120 days if all goes well, more and more sugar sticks to it as it travels through your bloodstream.

The amount can be measured accurately, and doctors know how much should be on each normal cell. If the level is high, that signals diabetes. The amount is reported as a percentage. That is why HGA1C numbers are so different from the readings you get from your glucose monitor.

So What's a Good Number?

This is where things get a little muddy. Depending on where you go for numbers, you'll get slightly different answers. The American Diabetes Association says a number under 7%, or 7, is a good target for a diabetic. Endocrinologists (M.D.'s who are diabetes specialists) have agreed that 6.5% is a better goal.

Non-diabetics have numbers in the range of 4-5.9%, and when the test number goes over 6.0%, some doctors tell their patients they might be diabetic. This is the danger of using the HGA1C to diagnose diabetes. Here are some reasons why.

There can be at least a half percentage point difference between two tests depending on how they are done. With home testing (a kit you can buy), the blood from a fingerstick is put on a card and mailed away to be tested.

The doctor's office test is done with a machine that gives results in 6 minutes but can be off a little because of the method. The most accurate test is done with a vial of blood at a testing facility or hospital, because they have national standards for constant recalibration, and the test is read using a more sophisticated method.

But even after an accurate test, the numbers can be read in different ways. For example, one expert says that a 6% reading means your blood sugar average for the past two or three months is 126, but another says it is 135. At 7% it might be 154 or 170. Which one is "right?"

Small discrepancies are not a problem if you know you are diabetic and are just evaluating how tight your blood sugar control is long term. But when 5.9% is normal and 6% means prediabetic according to what your doctor tells you, that tenth of a percent matters a lot for your peace of mind.

And there are other problems too. Anything that affects the life or health of red blood cells can make the hemoglobin A1C tests inaccurate for diagnosing diabetes. Any kind of anemia or illness, a change in medication, and even donating blood can affect the test. It is not used for testing gestational diabetes because of its limitations, and doctors still use the glucose tolerance test for that.

For diagnosing diabetes, the glucose tolerance test is still the best choice. Endocrinologists agree on this. So why does a family doctor use the hemoglobin A1C for diagnosing? Perhaps because he or she is not usually a diabetes specialist, and if the HGA1C is sold as the newest way to diagnose diabetes, it's going to be hard to resist.

Diabetes is probably in half of the patients over 40 in a doctor's practice, and the machine is cutting edge stuff. But the glucose tolerance test is still the best way to know if you are prediabetic, diabetic or just fine.

It takes a while but it is an accurate picture of how your body reacts to glucose. You don't have to worry. It isn't painful (unless you count fasting and a few fingersticks). So if you know someone who has been diagnosed by a hemoglobin A1C test, I hope you advise them to get the GTT test for a confirmation and to look for an endocrinologist.

I do love the A1C test, being a type 2 diabetic, because when I'm below 7 I know I'm doing well, and I have seen proof of that good blood sugar control in my own peripheral neuropathy symptoms. When the test is used for that purpose, it's fine. I love it when my doctor says, "Do you know your hemoglobin A1C?" and I say, "Yep, it's 6.8," and the doctor says, "Wow, that's great!"

Those are words I don't hear from my doctor often enough.

Martha Zimmer invites you to visit her website and learn more about type 2 diabetes, its complications and how you can deal with them, as well as great tips for eating healthy that will make living with diabetes less painful.

Go to http://www.a-diabetic-life.com and find out what you can do to avoid many of the pitfalls of this life-changing condition, like paying for cures that don't work and spending money for things you could have gotten free. Martha has made the mistakes and done the research so you don't have to.

Article Source: http://EzineArticles.com/?expert=Martha_J_Zimmer

Beginning the Application Process for DI's

To contact us Click HERE
I know it seems like it's a little early to start your DI application via DICAS, but it’s never too early to start thinking about it and planning for it. The portal opens on December 1^st so I’m trying to get everything in order to make this process as easy as possible.  I’ve been talking with people who are either in their internship right now or have been through this process recently. Here are some tips that they’ve told me:

•  Get transcript requests sent right away. It may take a while for some schools to send them, and if you’re a transfer student like me, you’ll have to make requests for multiple transcripts. Not only does DICAS need them, but you also have to input all the courses you’ve taken so that they can calculate various GPAs. You might want to do this part first since it’s the most tedious.

•  Ask people to write your recommendation letters as soon as possible. Hopefully they’ll all say that they’d love to write them for you, but you may come across some problems—they might be too busy, etc. Also ask them what they need to write the letter. You may need to send them your personal statement, past homework assignments or you may need to sit and talk with them about what your goals are.

• If you are applying to more than one internship, make sure you know what each internship’s focus is. You are going to have to write a different personal statement for each one you apply to. I believe that this is going to be the most time consuming part for me—even more so than deciding which internships I am going to apply to. Once they are written, have everyone you know read them! The more eyes that see them, the more feedback you can get before you submit your application.

• Contact the program directors. Either talk with them in person or over the phone. If there is an open house for the internship you’re interested in, GO!!! Meet the people you could be working with! When they get your application they’ll be able to put a face to the name.

•  Most importantly, be yourself. Be genuine about what your goals and interests are. 

This whole application process can be so daunting. Make it easy for yourself and DO NOT procrastinate!

By: Allison Richards

It's Not Just Meat and Potatoes: The Diversity of the Dietetics Profession

To contact us Click HERE
By: Jill Merrigan 
I am constantly asked, “What do you want to do when you finish school, and complete a dietetic internship?”  For me I am asked this weekly but find that I have a monthly response. One of the most exciting pieces of my return to school is the inspiration I have as I continue to learn about all the possible career opportunities I’ll have as a registered dietitian.
The career field for a registered dietitian offers a colorful plate, it not just meat and potatoes. From clinical dietitians, foodservice managers, research dietitians, educators, outpatient nutrition counselors, consultants. It is encouraging and motivating to remember that all my hard work in the classroom will expose me to a broad path of experiences within the dietetic profession.  When I was in the process of leaving my job in ad-sales and transitioning into my new life in Boston at Simmons College I took the time to meet with many registered dietitians, educators, and professors. One of the most important observations I took away was that in the dietetic profession we are not limited to one career path. Many times an RD will choose a position that meets their specific needs and in time branch into another position that suits them, and continue to make changes as it feels appropriate with time.  Some of the unique careers I have discovered that RDs are pursing include a RD – Food stylist, RD – Psychotherapist, RD – Medical Doctor, and RD – Farmer.
The nutrition and dietetic field is versatile, allowing diverse ways to educate and help people eat right. If you are considering a career change into nutrition and dietetics but now sure where the path will lead you then be sure to take some time, learn about the many opportunities that are available, and compare them to your own personal goals, strengths and interests and begin to see yourself living your career dream. 

Amanda's Cardiology Rotation

To contact us Click HERE
I had a great past couple weeks in my cardiology rotation.  I had the opportunity to meet and work alongside an inspirational RD who is not just a clinical dietitian but also an outstanding community leader who holds leadership roles in numerous organizations including the local dietetic association.    Of course I also learned how to plan and educate patients about heart healthy diets, make notes in the charts of patients, and do nutrition assessments on patients with CHF.

One of the main things I have learned is that nutrition care is hardly one-dimensional.   Although a patient may come into a hospital with the initial diagnosis of chest pain and shortness of breath, they may also have diabetes, renal failure, cognitive impairment, trouble chewing/swallowing; the list goes on.  When assessing a patient, it is important to look at the “big picture” and not just the diagnosis that the patient was admitted with.  This is especially important when completing a case study. 
Case studies are some of the best opportunities to learn during clinical rotations.  They give you the opportunity to apply all the information you learned in your MNT classes to a real-life scenario.  Scanning charts and comparing lab values made me feel like a detective; it was up to me to figure out where the patient was nutritionally deficient and what nutrition interventions were needed to restore their health. 
One tool that was especially helpful was my MNT book from college.  This book is filled with so much detailed information that was helpful when completing my cardiac case study.  If you are planning on completing an internship I would definitely recommend resisting the urge to sell your MNT book at the end of the year and hold onto it as it will prove to be a valuable tool during your internship.  
Question (to other past/present dietetic interns): What other resources have you found to be helpful during your dietetic internship rotations? 

Amanda's Career Goals and Reflection over 1st half of DI

To contact us Click HERE
Half Way There!
It is amazing for me to think that one year ago at this time I was putting my dietetic internship application packets together, not even sure which internships I was going to apply to.  Now I am five months into my internship, with only five months to go until I am eligible to sit for the RD exam.  The internship so far has challenged me and prepared me for a career as a dietitian in ways far beyond what I learned in the classroom.
One of the best things I have learned thus far is that I am certain that pursuing a career in school food service is the path I want to take.  The rising need for dietitians in schools and the regulatory changes facing school nutrition programs are two reasons why this career path appeals to me.  Here are a few of the benefits that working as a dietitian in a school nutrition program offers: 

• You get to work with kids!  There were so many people in my college classes who were interested in pursuing a career as a pediatric dietitian.  Rather than working with kids who are already sick, school dietitians can work with kids proactively by promoting nutrition education and nutrition integrity in the meals offered in school. 

• The variety of positions available to dietitians.  As a dietitian you can get a job as a nutrition educator, a manager of school kitchen, an area supervisor for a district or the director of food service for an entire school district.  No two school districts are alike so you can also have a variety of options in the type of school food service program you would like to work in.

• Opportunities for career advancement.  Depending on where your strengths and career goals lie, school nutrition programs can offer many opportunities for professional growth.  This is especially true if you are interested in nutrition management and business.

• Great work schedule.  Depending on the position, school dietitians may get the summer months off and for sure the holidays as wells as most weekends (nutrition conferences may take up a weekend day or two). 

If you are interested in a career as a school dietitian or would like to know more about why I think it is such an exciting career path, please feel free to reach out to me with any questions you may have!  I hope finals are wrapping up well and that the holiday break brings some much needed time for rejuvenation and relaxation.  

Hemoglobin A1C Blood Test Isn't Perfect

To contact us Click HERE

The hemoglobin A1C is a great blood test for type 2 diabetics, but not for diagnosing diabetes.

Don't misunderstand. I love the hemoglobin A1C blood test. It doesn't require fasting. It can be done in the doctor's office with a fingerstick just like your glucose monitor, and you can know the results before you leave the office. And it lets you know how your blood sugar has been doing over the past two or three months. It sounds perfect.

But it isn't. For diabetes management you and I need to know what our blood sugar is doing all the time, not just every three months. A great HGA1C reading does not mean there have been no hyperglycemic or hypoglycemic episodes over that time. So the hemoglobin A1C cannot replace daily checks with a glucose monitor and log book records.

Taken together with daily readings, the hemoglobin A1C gives an accurate picture of whether you are keeping your blood sugar in the ranges that will keep away the complications. There is more and more evidence that an HGA1C between 6.5 and 7 will do just that.

And here's an encouraging fact. If your A1C was 9 and you lower it to 8, there is a 20% reduction in risk of complications even though you aren't in the target range yet. That's good to know. You should also know that the American Diabetic Association says to get the test done every three months if your are diabetic.

Here's how it works. Hemoglobin is the medical term for red blood cells, and glycated hemoglobin is the term for red blood cells with sugar stuck to them. Over the life of a red blood cell, which is 120 days if all goes well, more and more sugar sticks to it as it travels through your bloodstream.

The amount can be measured accurately, and doctors know how much should be on each normal cell. If the level is high, that signals diabetes. The amount is reported as a percentage. That is why HGA1C numbers are so different from the readings you get from your glucose monitor.

So What's a Good Number?

This is where things get a little muddy. Depending on where you go for numbers, you'll get slightly different answers. The American Diabetes Association says a number under 7%, or 7, is a good target for a diabetic. Endocrinologists (M.D.'s who are diabetes specialists) have agreed that 6.5% is a better goal.

Non-diabetics have numbers in the range of 4-5.9%, and when the test number goes over 6.0%, some doctors tell their patients they might be diabetic. This is the danger of using the HGA1C to diagnose diabetes. Here are some reasons why.

There can be at least a half percentage point difference between two tests depending on how they are done. With home testing (a kit you can buy), the blood from a fingerstick is put on a card and mailed away to be tested.

The doctor's office test is done with a machine that gives results in 6 minutes but can be off a little because of the method. The most accurate test is done with a vial of blood at a testing facility or hospital, because they have national standards for constant recalibration, and the test is read using a more sophisticated method.

But even after an accurate test, the numbers can be read in different ways. For example, one expert says that a 6% reading means your blood sugar average for the past two or three months is 126, but another says it is 135. At 7% it might be 154 or 170. Which one is "right?"

Small discrepancies are not a problem if you know you are diabetic and are just evaluating how tight your blood sugar control is long term. But when 5.9% is normal and 6% means prediabetic according to what your doctor tells you, that tenth of a percent matters a lot for your peace of mind.

And there are other problems too. Anything that affects the life or health of red blood cells can make the hemoglobin A1C tests inaccurate for diagnosing diabetes. Any kind of anemia or illness, a change in medication, and even donating blood can affect the test. It is not used for testing gestational diabetes because of its limitations, and doctors still use the glucose tolerance test for that.

For diagnosing diabetes, the glucose tolerance test is still the best choice. Endocrinologists agree on this. So why does a family doctor use the hemoglobin A1C for diagnosing? Perhaps because he or she is not usually a diabetes specialist, and if the HGA1C is sold as the newest way to diagnose diabetes, it's going to be hard to resist.

Diabetes is probably in half of the patients over 40 in a doctor's practice, and the machine is cutting edge stuff. But the glucose tolerance test is still the best way to know if you are prediabetic, diabetic or just fine.

It takes a while but it is an accurate picture of how your body reacts to glucose. You don't have to worry. It isn't painful (unless you count fasting and a few fingersticks). So if you know someone who has been diagnosed by a hemoglobin A1C test, I hope you advise them to get the GTT test for a confirmation and to look for an endocrinologist.

I do love the A1C test, being a type 2 diabetic, because when I'm below 7 I know I'm doing well, and I have seen proof of that good blood sugar control in my own peripheral neuropathy symptoms. When the test is used for that purpose, it's fine. I love it when my doctor says, "Do you know your hemoglobin A1C?" and I say, "Yep, it's 6.8," and the doctor says, "Wow, that's great!"

Those are words I don't hear from my doctor often enough.

Martha Zimmer invites you to visit her website and learn more about type 2 diabetes, its complications and how you can deal with them, as well as great tips for eating healthy that will make living with diabetes less painful.

Go to http://www.a-diabetic-life.com and find out what you can do to avoid many of the pitfalls of this life-changing condition, like paying for cures that don't work and spending money for things you could have gotten free. Martha has made the mistakes and done the research so you don't have to.

Article Source: http://EzineArticles.com/?expert=Martha_J_Zimmer

A Quest for a Pot of Gold

To contact us Click HERE

In the quest for bettersolute clearance, two divergent paths were taken on each side of the Atlantic.The US nephrology community has concentrated more on low weight molecules. The Europeancounterpart has focused on both low and middle weight molecules.The European endeavor hasled to the evolution of the on-line hemodiafiltration (HDF), combining HF andHD. A water-permeable filter allows middle molecule removal by convection.Dialysate then supplements low molecular weight solute removal by diffusion. Production ofthe replacement fluid from dialysate in the circuit (thus called “on-line”) cuts thecost.Since Fresenius’ Online Plus™came out in 1998, on-line HDF has gained popularity in Europe and othercontinents. In the US? Not so much, but we may see it more as it was justcleared by FDA for the market this April.The idea of middle moleculeremoval sounds physiological. But is there really any advantage?It has been suggested thatthe on-line HDF may reduce intra-dialytic hypotension, improve nutritionalstatus, and decrease ESA (erythropoiesis stimulating agent) requirement. Butwhat about the hard end points (all-cause mortality and cardiovascular outcomes)?In the recent CONTRAST study, 700 patients in the Netherlands, Canada, and Norway wererandomized to on-line HDF or low-flux HD. The surprise? There was no CONTRASTbetween the two groups… The CONSOLATION was a minimal survival benefit amongthose who received top-quartile convective volume. Didthis disappoint the nephrology community? Yes, to some extent. In arecent CJASN editorial, Dr. Kuhlman from Germany pointed out  that in Europe the advantages of on-line HDFover conventional HD have been “somehow taken for granted”.Didthis put an end to on-line HDF? The answer is no. A couple of more Europeanstudies are on their way, so is the research to solve technical challenges. Thisis a never ending journey, even if it may end up with the quest for a pot ofgold at the end of the rainbow.
Posted by Tomoki Tsukahara

Medication Nonadherence in Renal Transplantation: Barriers and Consequences

To contact us Click HERE
It is surprising how high the nonadherence rates for immunosuppressants is among renal transplant recipients, ranging from 15 to 40%, despite the potential impact of nonadherence and the degree of education provided to transplant recipients.
Nonadherence to immunosuppressive medications is associated with increased incidences of allograft rejection and a seven-fold increased risk of graft failure as compared to adherent patients. Approximately 20-25% of nonadherent renal transplant recipients develop a late rejection at five years posttransplant, frequently antibody-mediated, as compared to 5-8% of adherent patients. Even a short period of nonadherence to immunosuppressive medications can initiate the rejection process.
Identifying possible barriers to adherence and intervening accordingly is necessary for improving transplant outcomes. One of the well-studied barriers is the complexity of the immunosuppressive regimen. Choosing a simpler regimen among possible effective regimens is likely to provide convenience to patients and; therefore, improve adherence. In addition, forgetfulness is one of the most common causes of missed doses. Nonadherence is more prevalent in patients with comorbidities that can cause impaired cognitive function. 
Some interventions to improve adherence include: associating medication administration times with a daily activity (such as meals, waking up, or going to bed), using pill boxes, and setting alarms or voice reminders that help patients remember to take their medications at the right times.
Ineffective communication may also increase the probability of intentional nonadherence due to a poor understanding of the benefits and risks associated with the patients’ prescribed medications. Most medications used in the transplant setting are preventive, and patients do not perceive the benefits of the medications immediately, which may facilitate nonadherence. Although fear of developing side effects can complicate patients’ nonadherence, patients are more likely to be adherent to a medication when they are aware of its possible adverse effects, which highlights the importance of educating patients. High drug costs can limit patients’ access to medications and increase nonadherence rates. Even with Medicare part B coverage, there are significant copays for patients without secondary insurance. Also, even if patients have prescription drug coverage, the high number of medications needed for some transplant patients can result in high monthly out-of-pocket expenses. This ongoing financial burden is substantial for most patients, and could act as a barrier to adherence when it is not addressed and adjusted. 
It is imperative for renal transplant recipients to adhere to medication regimens, as it can directly affect outcomes. Clinicians should assess adherence at every follow-up and keep in mind possible barriers to medication adherence, in particular, complexity of regimen, financial burden and lack of knowledge of potential consequences of nonadherence.
Miae Kim, PharmD, PGY2 Resident in Transplant Pharmacy
Steven Gabardi PharmD, FCCP, BCPS, Organ Transplant Clinical Specialist at BWH

Stress test for renal transplant candidates: select or screen all?

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We have previously discussed cardiovascular mortality after transplantation. But one controversial aspect in the evaluation of potential kidney recipients is the performance of stress tests for risk stratification. With the cost of stress tests ranging from U$2,500-5,000 and the long waiting time for a kidney transplant on the deceased donor list, this is a particular important point for financial, medical and logistical reasons. To evaluate that, De Lima et al. studied the prognostic value of myocardial scintigraphy in 892 consecutive renal transplant candidates classified into four risk groups: very high (aged ≥50 years, diabetes and CV disease), high (two factors), intermediate (one factor) and low (no factor). After a median follow up of 22 months, 181 major CV events were observed(overall incidence = 20%): 12 (6.6%) inlow-risk, 51 (28.2%) in intermediate-risk, 61(33.7%) in high-risk and 57 (31.5%) in very high-risk patients (p below 0.0001; Figure below). This simple classification was able to nicely separate the different groups according to incidence of major CV events.

The prevalence of abnormal scan increased with the degree of risk, from 12.7% in low-risk patients to 50.8% among very high-risk subjects. Interestingly, only in patients with one risk factor (either age ≥50years, diabetes or CV disease) was an altered myocardialstress test associated with an increased incidence of majorCV events [30.3 versus 10%, hazard ratio (HR) =2.37; p below 0.0001). Low-riskpatients did well regardless of stress test results, while in patients with 2 or 3risk factors, altered stress test did not add to the already increased risk forfuture CV events. The question that remains is whether an invasive intervention could lower the CV events in the high-risk groups and if coronary angiography should be considered instead of stress test, as proposed by some. The cost, invasiveness and risk of the procedure would likely be unwarranted until a randomized trial show benefits of revascularization in ESRD pts compared to medical management. It is important to remember that most clinical trials addressing this question excludes ESRD patients so we must extrapolate data from the general population, which do not support intervention in asymptomatic patients. An upcoming randomized controlled trial is addressing this question in transplantation: COST trial.Until then, we have to base our decisions on observational/restrospective data and poor evidence-based guidelines. My personal approach has been not to screen low risk patients with stress test anymore but I am still performing stress tests for the intermediate and high risk patients. The reason to do a stress test on a high risk patient is not to assess for the presence or not of CV disease, but to attempt to identify a large defect, exercise-induced hypotension or angina that might warrant intervention prior to transplantation. Among the stress tests, I usually recommend a MIBI protocol with sequential exercise followed by pharmacological (if HR goal not achieved), which allows for evaluation of patient's exercise capacity and cardiac imaging to determine the burden of CV disease. For obese patients, PET may give you better images. To provoke even more the debate, Diamond et al. supports the approach of: "test no one and treat  everyone" for asymptomatic diabetic patients compared to "screen everyone and treat only those with an abnormal test". The authors believe that optimal medical interventions such as statins/beta blocker are sometimes ignored after a normal stress test (high false negative rate), missing an important point of intervention, which could be more cost-effective than the screening strategy. Definitely lots of fuel for more debate...  

To biopsy or not to biopsy - IgA

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The topic of IgA nephropathy has been discussed in multiple posts here in the past. IgA is the commonest primary GN with a wide variety of presentations and prognoses ranging from isolated hematuria to a rapidly progressive GN. Over the last few years, my practice has been that if I see a patient with isolated hematuria, no adverse family history and minimal proteinuria, I will not biopsy them and reassure them that their chance of progression is very low. This is an approach that has also been supported by previous posters.

An article and accompanying editorial in this month's JASN would appear to support this approach. This was a retrospective review of the outcomes in 141 patients diagnosed with IgA nephropathy with minimal proteinuria (less than 0.5g) between 1975 and 2008 in 8 Spanish hospitals. During this period there was an aggressive policy in place with a very low threshold for renal biopsy. At the time of biopsy, only 16% were hypertensive while 17.7% had no detectable proteinuria. All patients had a normal eGFR at baseline.

Over a mean follow-up of 9 years, no patients were treated with immunosuppressive agents and 41% were treated with RAAS blockade. 5 patients (3.5%) had an increase of 50% from baseline creatinine while 1 patient had a doubling of creatinine (following pregnancy). 14.9% of patients developed proteinuria (more than 0.5g) while it increased above 1g in 6 patients. The only factor predicting increased proteinuria or an increased creatinine after multivariable analysis was the presence of FSGS (S1 by the Oxford Classification).

These results are very reassuring and for me reinforce the idea that we should not be routinely biopsying patients who present like with isolated hematuria. It is notable that most of the hospitals in this study have stopped this aggressive biopsy policy and it is unlikely that a similar study will be done in the future. However, there is no doubt that they should be followed long term because there is a (small) risk of progression. It should be stated that these results are not necessarily generalizable to other populations - studies in Asian populations have found a much higher rate of progression and the indication for biopsy might be different in this group. It would be interesting to know what the genetic factors underlying this difference in outcomes might be.

Less is More

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Despite the fact that thekidney ultrasound is generally obtained as one of multiple recommendations whenevaluating AKI, the benefit of kidney ultrasound is not clear. The post-renalcauses of AKI are not very common. Itadds to the cost and can subject patients to unnecessary work-ups by revealingincidentalomas. How often, then, is the ultrasound useful? In order to assess theprevalence of the post-renal AKI and determine a cost-effective use of theultrasound, a single-center case-control study was conducted.Their conclusion is that theprevalence of hydronephrosis requiring stenting or nephrostomy placement wasonly 0.4% in the low-risk group. The number to screen to find a case of urinaryobstruction was 223. At what cost? In our institution the kidney ultrasoundwithout Doppler costs $600. It costs $133,800 to find one case.Who is the low-risk grouppatient? Based on the multivariate analysis, a patient was considered low-riskif he or she did not have a history of hydronephrosis and had no more than oneof the following: 1. Recurrent UTI2. Diagnosis to suspectedobstruction (BPH, abdominal or pelvic cancer, one functional kidney,neurogenic bladder, pelvic surgery)3. Non-African American 4. Absence of:  exposure to the following medications (ASA,diuretics, ACEI or IV vancomycin), congestive heart failure, or pre-renal AKI.The study has limitations. Notall AKI patients were studied. The cases requiring non-surgical interventions werenot counted. If we would have to implement this strategy, we don’t know whatthe cost of missing some cases of obstruction would be.However, the implication isthat we should not routinely order kidney ultrasound on every patient with AKI,particularly those in the low-risk group. In this era of cost constraint on medicine,less is usually more…Or, here is what you can do.If your place has an ultrasound on the floor, with a little training you canhave a quick look at the kidneys just to rule out obstruction in low riskpatients. You acquire one more diagnostic skill, your students have one morefun on round, and your hospital saves significant amount of money!Posted by Tomoki Tsukahara

Beginning the Application Process for DI's

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I know it seems like it's a little early to start your DI application via DICAS, but it’s never too early to start thinking about it and planning for it. The portal opens on December 1^st so I’m trying to get everything in order to make this process as easy as possible.  I’ve been talking with people who are either in their internship right now or have been through this process recently. Here are some tips that they’ve told me:

•  Get transcript requests sent right away. It may take a while for some schools to send them, and if you’re a transfer student like me, you’ll have to make requests for multiple transcripts. Not only does DICAS need them, but you also have to input all the courses you’ve taken so that they can calculate various GPAs. You might want to do this part first since it’s the most tedious.

•  Ask people to write your recommendation letters as soon as possible. Hopefully they’ll all say that they’d love to write them for you, but you may come across some problems—they might be too busy, etc. Also ask them what they need to write the letter. You may need to send them your personal statement, past homework assignments or you may need to sit and talk with them about what your goals are.

• If you are applying to more than one internship, make sure you know what each internship’s focus is. You are going to have to write a different personal statement for each one you apply to. I believe that this is going to be the most time consuming part for me—even more so than deciding which internships I am going to apply to. Once they are written, have everyone you know read them! The more eyes that see them, the more feedback you can get before you submit your application.

• Contact the program directors. Either talk with them in person or over the phone. If there is an open house for the internship you’re interested in, GO!!! Meet the people you could be working with! When they get your application they’ll be able to put a face to the name.

•  Most importantly, be yourself. Be genuine about what your goals and interests are. 

This whole application process can be so daunting. Make it easy for yourself and DO NOT procrastinate!

By: Allison Richards