Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to nephrology referral for patients with lupus nephritis?
The answer to this question "depends" on many factors.I had the luxury of learning under some lupus nephritis greats in the 1990s (John "Jack" Klippel, H Austin, and J Balow... the high-dose NIH CYC regimen guys). Therefore, I am fortunate to feel confident in my abilities to care for LN better than...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
How do you approach a hemodialysis patient with a persistently low Kt/V who refuses to extend their session time?
I would make sure the blood flow, dialysate flow, and dialyzer are optimized. Consider home dialysis or more frequent dialysis. Beyond that, options are limited.
Do you recommend hydrochlorothiazide to manage polyuria in patients with ADPKD who are on tolvaptan?
Indeed, this can sometimes be useful in this context. After other troubleshooting, I have had success with polyuria symptoms with some patients. The published benefit is up to ~1.8 L, according to Kramers et al., PMID 35314480. Kidney function can get a bit off during the transition, although should...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...
Do you treat persistent microscopic hematuria as a clinically meaningful sign of ongoing disease activity in a patient with IgA nephropathy whose proteinuria is well controlled on current therapy?
The KDIGO 2025 guidelines still regard proteinuria (ideally <300 mg) as the validated early biomarker for IgA nephropathy (IgAN), but persistent hematuria is an independent risk factor for disease progression and should be monitored closely as the marker for glomerular inflammation. Depending upon e...
How do you decide when to refer for an access angiogram in a patient on hemodialysis with a drop in Kt/V but no other signs of access dysfunction?
In a JASN study (Coyne et al., PMID 9259360), the 3 comment causes of low Kt/V were: 42%- from poor blood cleaning due to low blood flow or shortened HD time 25% - due to recirculation from access dysfunction or reversed needles 33% - no cause identified, but on subsequent monthly testing, it normal...
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.
In cirrhosis with suspected HRS-AKI and baseline CKD or chronically elevated creatinine, how do you define a clinically meaningful ‘improvement’ during an albumin trial (over 24–48 hours) to distinguish HRS-AKI from volume-responsive AKI?
The guidelines define it as drop in serum creatinine within to 0.3 mg/dl of baseline creatinine.
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...