Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
How do you decide when to stop immunosuppression in a patient with granulomatosis with polyangiitis who is on dialysis, has not yet recovered renal function, but has shown improvement in ANCA levels?
In a patient with pauci-immune necrotizing GN from GPA on HD, I usually wait for 3 months and up to 6 months if the biopsy is fresh with minimal chronicity before declaring ESRD and stopping IS. If they have extrarenal disease (ENT, lungs), they would need IS for extrarenal disease.
Do you postpone hemodialysis for a period of time after stem cell transplantation in a hospitalized patient with ESKD?
No. In fact, some patients may require extra HD sessions to manage volume overload post SCT. All ESKD patients are assessed daily for HD and continue to receive thrice-weekly dialysis per routine. If they are persistently hypotensive, they are considered for transition to CRRT.
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...
Would you start sodium citrate for patients with advanced chronic kidney disease and metabolic acidosis who fail to reach serum bicarbonate target despite high doses of sodium bicarbonate?
I don't think sodium citrate is any more effective than sodium bicarbonate in improving metabolic acidosis. Sodium bicarbonate is more likely to cause gastric distention and air. If that results in noncompliance, then it is worth switching. It is also important these patients are on diuretic as much...
Are you comfortable using low molecular weight heparin as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis?
Low molecular weight heparin may be used as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis. However, its use requires close monitoring and careful management. Unlike unfractionated heparin, which is fully reversible with protamine, LMWH is only partially re...
Would you pursue renal artery revascularization in a patient with bilateral renal artery stenosis, stable CKD stage 3A, blood pressure well controlled on two medications, and no episodes of acute pulmonary edema but with decreasing kidney size by 1 cm over two years?
If the renal artery stenosis is due to atherosclerotic disease, I would make sure to optimize atherosclerotic risk factors first, which would have systemic benefit. That includes stopping smoking, aggressively lowering lipids with attention to high-density lipoprotein (HDL)/low-density lipoprotein (...
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
How do you decide which patients with asymptomatic hyperkalemia and CKD warrant inpatient admission versus expedited outpatient management?
I would imagine that there is no EKG available as the patient is outpatient. I prefer not to admit patients as much as possible. I would not admit patients with potassium levels less than 6. For those between 6 and 6.5, I would try to treat medically and recheck potassium the next day. If potassium ...