Chiefs’ Inquiry Corner August 5th, 2019

August 5, 2019

Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity.  In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals.  Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.


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Patients with chronic liver disease are nearly three times more likely to develop osteoporosis than matched controls. In contrast to patients with post-menopausal osteoporosis, in whom increased osteoclast activity depletes bone density, the mechanism in patients with liver disease is thought to be driven by decreased osteoblast activity. Patients with liver disease see decreases in osteoblastogenesis stimulating factors such as IGF-1 and vitamin K and increases in serum bilirubin, which directly inhibits osteoblastogenesis. It is recommended to screen the following female and male patients for hepatic osteopenia:
  • All patients with cirrhosis
  • All patients with chronic cholestasis (bilirubin >3mg/dL for 6 months)
  • All potential liver transplant candidates

An estimated 20% of COPD exacerbations are due to non-infectious causes. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends antibiotics only in moderate or severe COPD exacerbations with both increased cough and purulent sputum production. In spite of these guidelines, antibiotics are frequently prescribed in the treatment of mild COPD exacerbations. C-reactive protein (CRP), a biomarker associated with infection and severe COPD exacerbation, has been proposed as a tool guide clinicians toward appropriate antibiotic use. A large, multicenter, randomized-controlled trial recently compared outcomes in patients with acute COPD exacerbation treated with a CRP-driven antibiotic protocol and those treated with usual care. The study’s primary outcome of reported antibiotic use was significantly lower in the CRP-guided group (57.0% vs 77.4%), and antibiotic prescriptions were lower as well. Safety outcomes were no different between the two groups.   

References: CRP for COPD  
Yes! The Kidney Failure Risk Equation (KFRE) utilizes patient gender, age, eGFR, and urine albumin to creatinine ratio to predict risk of progression from CKD stage G3 (eGFR 30-60 ml/min/1.73m^2) to kidney failure requiring dialysis or transplantation at 2 and 5 years. This was initially developed in a Canadian population, then later validated using over 700,000 patients from more than 30 cohorts from around the world. There are now additional calibration factors to adjust for risk prediction in North American vs. non-North American patients. Interestingly, urine albumin to creatinine ratio is the only potentially modifiable element of the KFRE, underlying the importance of treating proteinuria with ACEi/ARB.  

References: Predict ESRD