Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach deprescribing or continuing statin therapy in older adults with end-stage kidney disease who are initiating dialysis?
My practice in older adults starting dialysis is no different from that of younger patients starting dialysis. If the patient is on a statin, I do not discontinue it. If the patient is not on a statin, I do not start it when they begin dialysis, as there is no strong evidence that it reduces cardiac...
When do you refer for peritoneal dialysis catheter placement in a patient with advanced chronic kidney disease who does not currently have dialysis needs but does have a progressive decline in eGFR?
The question, of course, is whether to place the catheter early, when the patient does not yet require dialysis and then need to provide catheter care (e.g., weekly flushes), or to delay catheter placement and risk needing to start urgently, or, much worse, risk placement of a tunneled dialysis cath...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
What is your approach to perioperative risk stratification and optimization of patients with ESRD on HD?
When evaluating a patient with end-stage renal disease (ESRD) on maintenance hemodialysis for surgery, my approach to perioperative risk stratification centers on three major areas: cardiovascular risk assessment, optimization of dialysis-related factors, and careful perioperative medication and met...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
What is your approach to managing hyperkalemia secondary to respiratory acidosis?
Since hyperkalemia in respiratory acidosis is due to transcellular shift, therapy should be directed at treating the underlying respiratory acidosis. Correction of the hypercarbia should lead to resolution of the hyperkalemia. In severe hyperkalemia due to respiratory acidosis that is not easily rev...