Dr. DAVID MILLSMedical Associates of Northern New MexicoChronic kidney disease affects nearly 11 percent of Americans. Most causes of kidney injury are considered to be preventable; three-quarters of chronic kidney disease can be explained by diabetes and hypertension (high blood pressure) alone.Perhaps a more insidious cause is from non-steroidal anti-inflammatory drugs (NSAIDs).Marketed under the generic names ibuprofen and naproxen, NSAIDs are perhaps better known by their brand names Advil, Motrin and Aleve. These readily available over-the-counter drugs exist in the majority of our medicine cabinets, and few of us think twice about taking a couple for that occasional headache or muscle ache.It is common for a patient’s health care provider to be unaware of the frequency in which these medications are used by their patients. In my experience, these medications make up a disproportionate number of kidney disease cases in Los Alamos (up to a third).Kidney function can easily be measured with routine blood work. A test for serum creatinine concentration is obtained to estimate kidney function. Serum creatinine is measured in milligrams per deciliter and can have a wide variability in interpretation. Using ones age, gender, race, and creatinine, an estimated glomerular filtration rate (eGFR) is obtained. Most people have an eGFR of 90-120 (ml/min/1.73m2) in early adulthood, but will naturally decline with age. Normal renal function is defined as 60 or above in an average, healthy adult. eGFR represents the amount of aqueous serum from our blood that is passed through the filters of the kidney each day. An important determinate of eGFR is kidney blood flow which is roughly three times the eGFR. Thus, an average 18 year old male has approximately 500 liters of blood that will pass through the kidney each day (every drop of blood goes through the kidneys 100 times per day), roughly a quarter of all blood pumped by the heart. One hundred eighty liters are filtered, but more than 99 percent of that is reabsorbed during subsequent processing within the kidney. The resulting filtration (and reabsorption) of ones total blood volume 36 times a day provides more than adequate removal of water soluble waste products and toxins.NSAIDs cause a significant dose dependent reduction in kidney blood flow. This reduction occurs due to the drug-induced constriction of small arteries at the filters. This can be so profound that NSAIDs alone have served for “medical nephrectomy,” or the removal of a kidney, in extreme cases. Interestingly, this is not the most common means by which NSAID induced kidney injury occurs. Rather, this is because NSAIDs are the single most common cause for allergic interstitial nephritis (AIN), or inflammation within the kidney architecture. Allergic white blood cells lead to inflammation, decreased kidney function, and eventually scarring. AIN is also responsible for kidney disease related to over-the-counter drugs, omeprazole (Prilosec), pantoprazole (Protonix) and esomeprazole (Nexium). Fortunately, this condition can sometimes recover, but once suspected, the patient should refrain from NSAIDs indefinitely. Reduction in kidney blood flow by NSAIDs is significant nonetheless, and frequent harm can come when used during coexisting physiologic stressors. A frequent example is when a patient with vomiting and diarrhea who is volume depleted (i.e. dehydrated) takes an NSAID to lower a fever. Reduced blood volume from dehydration prevents normal blood delivery to the kidney and then is exacerbated by constriction of blood vessels from the NSAID. The injured kidneys then cease to filter as certain cells within the kidney die due to lack of oxygen. Sometimes, the kidneys can recover. High blood pressure is associated with changes in renal blood flow, whereas diabetes frequently predisposes individuals to volume depletion. Altitude also has an effect on reducing kidney blood flow, although this effect varies amongst individuals and with acclimatization to altitude. This brings us to an important question as to when or even if it is safe to take NSAIDs. While the biases of some physicians may be that NSAIDs should never have been released over-the-counter (also a major cause of peptic ulcer disease and increases risk for stroke and heart attack), the fact remains that they are readily available and will remain to be so.I feel that they should always be avoided in patients with acute dehydration, before or during vigorous exercise, and with alcohol. Avoid NSAID use when exercising for periods of two hours or more. Although used successfully to reduce muscle soreness after training, it is far safer to train appropriately and gradually to avoid sudden severe soreness from overdoing it. Remember, altitude also has an effect on kidney blood flow. There is significant increase risk for kidney damage when NSAIDs are used regularly with diuretics, blood pressure medications, or in diabetics. I never advise daily use beyond a couple of weeks, but may be suggested by your primary care provider for chronic arthritic pain. Just make sure your provider knows you are taking them, and they are checking your kidney function regularly. Finally, any patient with known chronic kidney disease should avoid NSAID use altogether.There are other options for over-the-counter pain relief. Lidocaine skin patches, analgesic balms and heat/cold therapies can be effective for temporary relief. Acetaminophen may also serve as an alternative to NSAIDs, but also have their own risks, primarily related to the liver (never take with alcohol). I recommend that patients discuss any and all over-the-counter drugs, vitamins, and natural or herbal supplements with their primary care provider. Beware that most supplements have not been evaluated for safety in kidney disease, and my general advice is to completely avoid them.
Flight CV7687 from Luxembourg to Sao Paulo Viracopos International airport was the first-ever commercial operation of a B747-8F into the country. The Brazilian authorities only recently certified Boeing’s flagship freighter to fly in its airspace. Until now, Cargolux has only been able to deploy its smaller, less fuel-efficient B747-400 freighters into Brazilian gateways. “The 747-8F will further support airfreight exports from Brazil, permitting export commodities like automotive parts, pharmaceutical products and fruits to reach their markets throughout the world in a more fuel efficient and, therefore, sustainable way,” said Pier Curci, Cargolux vice president the Americas. www.cargolux.com
It says, loudly:They believe in second-year quarterback Mason Rudolph, in what they saw in his college performances before drafting him in the 2018 third round, what they’ve seen in training since and what they observed when he took over for a little more than a half in Sunday’s loss to Seattle.They expect star QB Ben Roethlisberger to recover at a reasonable pace from elbow surgery that will cost him the remainder of the 2019 season. He’ll have two years remaining on his contract then. If Rudolph excels, they can decide how they want to address the future.They know their defense has been a wreck, particularly in the middle of the field, and Fitzpatrick has excelled in his short time in the league as a slot corner and safety.Most important, they have not surrendered on the 2019 season and believe what remains is salvageable, despite an 0-2 start and the absence of a quarterback who has seen them through 144 wins and two Super Bowl titles since 2004.MORE: Fitzpatrick trade grades for Steelers, DolphinsIt’s a declaration of intent by the Steelers that they refuse to surrender on the season, despite a horrific start in every respect: too many injuries, too many defeats, too few reasons to be optimistic. They perceive no cause at all for surrender.”We feel comfortable with the team we’ve assembled,” coach Mike Tomlin said at his weekly Tuesday press conference. “Obviously, we’ve dealt with some circumstances that will force us to adjust and play a certain style that puts us in position to win. Our level of expectations in terms of our performance will not change, and has not changed.”It is our job to keep this train rolling. … If anything, from a competitor’s standpoint, it energizes me and us. We’re excited about balling up our fists and fighting, and fighting together.”Tomlin said Fitzpatrick will immediately move into the free safety position vacated by an injury to veteran Sean Davis, who was placed on injured reserve. As Fitzpatrick gains familiarity with the Steelers’ approach, however, he also might be deployed as a slot corner, where he last season was regarded as one of the most effective in the league. Trading away a first-round pick can give off the scent of a desperate management team trying to remain relevant by selling the future. In this case, though there is no certainty the trade will be a smash, they have risked little of their future and wheedled some financial flexibility under the salary cap. Because the Dolphins paid his signing bonus, the Steelers get three years of Fitzpatrick at an average annual salary of $1.9 million. There also is an option for a fifth year, in 2022. They would have control of their 2020 pick only a smidge longer, and Fitzpatrick is a proven NFL player, not someone who might struggle with the transition from college.He might struggle with the transition to the Steelers, though, and that’s where this becomes a discussion.There are a few scenarios in which this trade becomes disastrous:1. Rudolph proves not to be a worthy successor at quarterback and Roethlisberger’s recovery does not facilitate his return to the field next September, meaning the Steelers will have blown a chance to find a QB with a high 2020 first-rounder.2. The pieces in place this autumn fail so spectacularly that the Steelers find themselves slotted into one of the prime draft positions — say top five — in 2020.3. The deficiencies in the Steelers’ defensive backfield’s schemes and/or training have the same deleterious effect on Fitzpatrick as on safeties Terrell Edmunds and Davis or an army of drafted cornerbacks, most notably 2016 first-rounder Artie Burns.That last one is the most important factor. The current Steelers have given no one a reason to be confident they can make Fitzpatrick a stellar component of an elite unit.MORE: Steelers’ Rudolph pick now seems shrewd at worst, genius at bestThere is a saying in coaching: “It’s not the Xs and the Os, it’s the Jimmies and the Joes.” But if a Minkah flops, joining all the Jimmies and Joes drafted and undeveloped by the Steelers over more than a decade, the cause will be obvious.The Steelers haven’t drafted a long-term starter at corner since William Gay in 2007. They haven’t selected a reliable safety since Troy Polamalu in 2003.With Fitzpatrick stepping into the free safety position, though, three of the team’s four regular DBs will have been acquired from other organizations and had some measure of success elsewhere. In his third season with the team, corner Joe Haden has been very good. First-year corner Steven Nelson, a free agent signed away from the Chiefs, has been adequate at least.Through two games, however, the Steelers do not have a single interception. With two passes defensed, they rank last in the league. Neither stat is an anomaly. They were 28th in interceptions last season and 14th in passes defensed. None of this is a surprise, because their defensive backs almost never are near the ball.Fitzpatrick had nine PDs last season; among the Steelers, only Haden topped that. So it is up to defensive coordinator Keith Butler to put his secondary into positions where they can more commonly disrupt opponents’ passing attacks. If Fitzpatrick does not make a difference, if the nature of Butler’s schemes does more to vex him than the opposition, we’ll know for certain where the issue rests. The Steelers made official early Tuesday morning what the unofficial reports flooding the media late Monday made real for those who follow the league: Pittsburgh traded its 2020 first-round draft choice to Miami in exchange for young defensive back Minkah Fitzpatrick, a revolutionary transaction for a franchise known for its orthodoxy.It was a deal that made several profound statements at once, about what the Steelers think of themselves and their immediate future. WEEK 3 NFL PICKS: Against the spread | Straight-up predictionsWhile the Ravens were dazzling at 2-0 but claiming only the Dolphins and Cardinals as victims, the Steelers were stuck opening against the reigning Super Bowl champion and a near-perennial playoff team. Their horrid defensive performances must be attributed, at least in part, to the challenge of facing QBs Tom Brady and Russell Wilson.The issues at the back end of the Pittsburgh D, though, were not invented by those two stars. It’s an old problem with a potentially new solution.