Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question and I don't think I have every tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
Are you comfortable using low molecular weight heparin as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis?
Low molecular weight heparin may be used as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis. However, its use requires close monitoring and careful management. Unlike unfractionated heparin which is fully reversible with protamine, LMWH is only partially rev...
How do you decide which patients with asymptomatic hyperkalemia and CKD warrant inpatient admission versus expedited outpatient management?
I would imagine that there is no EKG available as patient is outpatient. I prefer not to admit patients as much as possible. I would not admit patients with potassium levels less than 6. For those between 6 and 6.5, I would try to treat medically and recheck potassium next day. If potassium is >6.5,...
Do you recommend 24 hour urine stone risk studies for patients with no history of nephrolithiasis who are undergoing evaluation as potential kidney donors?
We ask all donors if they have had a history of kidney stones. All donors also get a CT angiogram of the abdomen. Patients with a stone history will need a 24-hour urine stone risk profile. If a donor has an incidental single stone, we may still allow donation, but we would ask for a 24 stone profil...
Has your management of post-transplant FSGS changed with the advent of new FSGS directed therapies?
The pathogenesis of FSGS and specifically recurrent FSGS post-transplant has remained an unmet need in nephrology. Multiple purported " circulating permeability factors " have been identified over the years, each of them providing a piece of the picture, but none that comprehensively and definitivel...
How do you approach the decision to perform preimplantation biopsies in brain-dead kidney donors?
This is a really controversial topic and is often driven by the surgeon. Higher KDPI kidneys are more likely to have a biopsy to assess degree of interstitial fibrosis and therefore help guide whether the kidney should be used, discarded, or used with the mate kidney for dual transplantation. In add...
Do you hold renin-angiotensin system blockade at the time of kidney transplant and restart it only once graft function is established, or do you continue it through the perioperative period?
We do hold ACEs and ARBs at the time of transplant. After three months, we are typically pretty comfortable restarting an ACE or ARB if needed. If proteinuria develops early post-transplant, we might consider earlier institution of an ACE or ARB after renal ultrasound and biopsy. One exception is wi...
Under what circumstances would you consider LDL apheresis in a kidney transplant patient with FSGS recurrence within three months of transplantation?
LDL apheresis has not been part of our protocol for the treatment of recurrent FSGS. Our protocol is still plasmapheresis x 9 runs, and now considering institution of daratumumab. Protocols are still evolving for this vesiculating problem.
What is your approach to differentiating Randall plaques from actual small non-obstructing stones when reviewing imaging testing for your patients with recurrent nephrolithiasis?
Randall‘s plaque represents subepithelial deposits of calcium phosphate in the renal papillae. They typically serve as a nidus for calcium oxalate stones. Differentiating the two radiographically is challenging. However, they have common risk factors: hypercalciuria and low urine volume. My approach...