Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What specific strategies have you found most effective in your academic program for inspiring internal medicine residents to consider nephrology as a career?
Probably the best tool we have is having residents rotate with us. Nephrology is a mandatory rotation at RUSH Internal Medicine, and frankly, we are excellent teachers, so that sparks interest that may not have happened if they did not rotate. I cannot believe that all IM programs do not require nep...
What is your approach to managing neobladder acidosis?
Alkali supplementation is the mainstay of treatment of neobladder acidosis. Since prolonged urinary contact with the intestinal epithelium used for urinary reconstruction leads to increased ammonium reabsorption and chloride absorption in exchange for bicarbonate secretion, regular catheterization o...
Do you offer semaglutide for weight loss management in patients with CKD?
I do, but mostly a different GLP-1, trizipitide. I think the side effect profile is cleaner and better tolerated in CKD and post-transplant patients, decreasing renal complications associated with the side effects.
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...