Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to treating nephrotic syndrome with positive PLA2R titers, prior to a kidney biopsy?
According to the 2021 KDIGO guidelines, a positive anti-PLA2R antibody test in a patient with nephrotic syndrome is highly specific (~99%) for primary membranous nephropathy, allowing for diagnosis and treatment without a kidney biopsy unless atypical features—such as a rapidly declining eGFR, concu...
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
How would you manage an ESKD patient who complains of severe fatigue after hemodialysis, but does not experience intradialytic or post-dialysis hypotension and has not responded to dry weight adjustments?
Difficult but unfortunately not uncommon situation. My theory is that more frequent dialysis would be beneficial to avoid dramatic electrolyte and fluid shifts that occur with intermittent hemodialysis. Would see if peritoneal dialysis or home hemodialysis would be an option. If not, maybe 4 days pe...
What is your approach to re-challenging patients with immune checkpoint inhibitors whom developed predominately acute tubular injury without acute interstitial nephritis?
In patients with immune checkpoint inhibitor (ICI)-associated acute interstitial nephritis (AIN) whose renal function has recovered, most do not develop recurrent ICI-associated AIN after rechallenge. However, data on the recurrence of acute tubular injury (ATI) specifically after ICI rechallenge ar...
What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?
In a hypertensive emergency, I find it challenging to tell if the worsening of kidney function is caused by the brisk reductions in blood pressure, or if the hypertensive emergency itself already did the damage to the kidney, and the "brisk" reduction in blood pressure may actually help it.According...
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
What is your approach for managing patients with recurrent nephrolithiasis who have elevated urinary cystine levels but calcium oxalate stone composition?
I agree with Dr. @Dr. First Last that this is a case of heterozygous cystinuria, and the patient is unlikely to make cystine stones in the future. That said, after standard fluid and dietary recommendations, I would choose potassium citrate as my medication of choice. It is effective against calcium...
How do you approach recommending an AVF for a patient with advanced CKD who is concerned about the cosmetic appearance of the fistula?
Assuming that the patient is either not interested or not suitable for peritoneal dialysis and they do not have a potential living donor, I discuss the risks/benefits of AVF vs a tunneled catheter. I offer upper arm AVFs to these patients (even if forearm vessels are adequate), as sometimes they are...
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
Do you recommend patients replace their home blood pressure device after a certain number of years given the risk for inaccurate recordings over time?
No. Sometimes old machines work better than newer ones. I don't recommend that for myself, so I would not recommend that for my patients. If there is a concern, I would have them bring it in and compare it with office values.