Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you pursue a kidney biopsy in an obese patient with a history of preeclampsia who has nephrotic range proteinuria, negative serologic work up, normal serum albumin, and normal creatinine?
Yes. I would wait 6 months after delivery, and if proteinuria is still present, I would do a kidney biopsy.
What is your approach to waiting period for an ESKD patient getting a kidney transplant after just being treated for bacteremia?
In general, I would like a waiting period of at least 6-8 weeks. I would review the clinical course of the hospital admission to ensure that the patient has recovered well physically and that the source of bacteremia has been adequately addressed, e.g., any lines/abscesses. If this is a living donor...
Do you continue calcineurin inhibitor-based immunosuppression after a failed kidney transplant that remains in situ, to reduce HLA sensitization and preserve retransplantation options?
Yes, I do. Mostly if patients continue to have some residual function and have a living donor. I would target lower levels ~2-4.This is a nice review of failed allograft management by Agrawal & Pavlakis, PMID 31135561.
What are your thoughts on patients presenting with hyponatremia receiving IV fluids before urine studies are collected and the etiology is fully characterized?
Whenever possible, I try to obtain serum osmolality, urine osmolality, and urine sodium before giving IV fluids. A urine specimen requires only a small volume and can usually be collected at the same time as the initial bloodwork without meaningfully delaying care. That said, treatment should never ...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
Do you avoid prescribing thiazide diuretics for hypertension management in ADPKD patients, given concerns about vasopressin release?
No. Although thiazide diuretics may theoretically increase vasopressin secretion through mild volume contraction, there is currently no clinical evidence that this adversely affects ADPKD progression or should preclude their use. Notably, the HALT-PKD trials, data from which established much of our ...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Which blood pressure medications do you favor using to manage ongoing hypertension post adrenalectomy for hyperaldosteronism?
If primary hyperaldosteronism is cured by adrenalectomy, it would be the usual management of HTN; otherwise, I would use spironolactone.
Do you monitor magnesium levels in patients on patiromer?
Yes. Patiromer binds magnesium in the colon in addition to potassium, which can lead to hypomagnesemia.
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...