Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How should PPIs or H2 blockers be managed in peritoneal dialysis patients with a history of peritonitis and peptic ulcer disease, considering the potential infection risk?
This question should probably be rephrased, with the words "a history of peritonitis and" removed. I am not aware of any literature indicating that the risk of peritonitis with the use of gastric acid suppressants (GAS), either H2 blockers (H2Bs) or proton pump inhibitors (PPIs), is modified by a pr...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
What workup would you perform for a patient with chronic kidney disease and kidney biopsy showing hypersensitivity-type interstitial nephritis?
A thorough history and physical exam, including eye exam, then a very thorough drug history including OTCs, herbals, supplements, & illicits. Other workup would be guided by findings from exam and history (systemic findings) and specific pathology features such as granulomas.
What is your approach to the treatment of fibrillary glomerulonephritis coexistent with monoclonal gammopathy?
Fibrillary glomerulonephritis was initially considered to be an idiopathic disorder, but it is now known to be secondary to malignancy, monoclonal gammopathy, infection (such as HCV), or autoimmune disease in up to 50% of patients. This is a rare disease, and few practitioners outside of glomerulone...
In which patients with atypical HUS would you consider eculizumab discontinuation?
My approach to eculizumab cessation in aHUS is to at least consider cessation in all patients not only given the high cost of the drug, but also given the risk of meningococcemia, which is incompletely protected against by vaccines.In treating aHUS, I initiate eculizumab (and preventive therapy for ...
What is your approach to treating IgA nephropathy in patients who also have IgA vasculitis?
In a patient with known IgA Vasculitis [IgAV], IgA dominant pattern of injury in the kidney biopsy reflects IgA Vasculitis with Nephritis [IgAV-N]. Thus, it would not be appropriate to call it IgA nephropathy [IgAN] in IgAV. Though the histological features in IgAN and IgAV-N can be common in the ki...
Would you pursue more dedicated stone surveillance imaging testing for a patient with recurrent nephrolithiasis who has PET-CT scans twice yearly?
Unless the patient is symptomatic, I am not sure there is a reason to. Though PET CT is not the best imaging to look for stones.
Would you continue spironolactone in a patient who has recently progressed to ESKD on HD with oliguria and was diagnosed with primary hyperaldosteronism years ago?
Although spironolactone does antagonize the effect of aldosterone in the colon, it is unlikely that spironolactone will be effective in treating primary hyperaldosteronism in a patient with ESKD with minimal urine output. Therefore, I would discontinue the spironolactone in such patients.
Would you recommend pregnancy testing for a female patient with recurrent nephrolithiasis for whom you are considering a CT stone scan for routine stone surveillance?
I would go with an ultrasound first and not with CT for screening.
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...