Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to patients with membranous glomerulonephritis who have persistently elevated PLA2R titers but largely improved proteinuria and creatinine?
Depends on the evolution of the PLA2RAB titer. Please see the algorithm from De Vriese et al., PMID 27777266.
Would you recommend anti-platelet or anticoagulation in a patient with recurrent strokes, CADASIL, and Antiphospholipid Syndrome?
It depends on the circumstances (e.g. co-morbidities). Would use neither for CAA alone.
How accurate of an indicator is reticulocyte hemoglobin equivalent for iron deficiency?
I am not sure that question is answerable right now. I can tell you if I had an autoanalyzer with a RET-He, I would use it to determine who needs iron and who does not using a value of 30.7 as the cutoff for iron deficiency and 28.5 to determine the likelihood of responsiveness to iron [remember tha...
Can an acid loading test be used to assist with the diagnosis of RTAs other than an incomplete distal RTA?
This almost seems like a trick question. It is so odd but I have to think the answer is no. An acid load tests the kidneys' ability to respond to metabolic acidosis by increasing Nh4+ excretion. The only situation where that is impaired is distal rta. Normally you do not need to acid load because th...
How would you approach microcytosis without anemia with high TSAT and ferritin?
This is likely thalassemia trait with iron overload. I would look at the smear to confirm, consider hemoglobin electrophoresis. Sometimes HFE mutations are cofactors that can add to the iron overload so I look for those. If the ferritin is >300, I consider careful phlebotomy to assess mobilized iron...
What factors should prompt a kidney biopsy to evaluate for monoclonal gammopathy of renal significance in a patient with MGUS and suspected chronic diabetic nephropathy?
A renal bx may be reasonable if there is an unexpected or unexplained increase in the Cr and proteinuria. The presence of Fanconi's syndrome may also be a signal of light chain tubular injury.
How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?
This is an interesting and challenging question that would require a case-by-case review by a team of rheumatologists, hematologists, and hepatologists, as well as an in-depth discussion of the potential risks and benefits with the patient. This reference, O'Leary et al., PMID 30986390, provides a g...
How do you manage GI side effects related to CFTR modulator therapy?
We have found that for most patients liver enzymes abnormalities are small and transient; however, for about 1% of patients there are severe elevations and these patients are much more difficult to manage, even after withdrawal, and tough to re-challenge; it is also not patients with severe liver di...
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
Do you recommend a kidney biopsy in a patient with myelodysplastic syndrome diagnosed two years prior who develops new onset proteinuria?
The decision to perform a kidney biopsy on any patient should hinge around whether the diagnosis can be made non-invasively (very rare), whether the biopsy should not impose an undue risk to the patient, and if a change in treatment may result from the biopsy diagnosis.In MDS, a variety of lesions m...