Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach deprescribing or continuing statin therapy in older adults with end-stage kidney disease who are initiating dialysis?
My practice in older adults starting dialysis is no different from that of younger patients starting dialysis. If the patient is on a statin, I do not discontinue it. If the patient is not on a statin, I do not start it when they begin dialysis, as there is no strong evidence that it reduces cardiac...
How do you manage Fanconi’s syndrome and polyuria related to ifosfamide?
Treatment of ifosfamide-induced Fanconi syndrome and polyuria is primarily supportive. First, the benefits and risks of discontinuation of ifosfamide should be discussed with the oncologist. Treatment of Fanconi syndrome is aimed at repletion of potassium, bicarbonate, and phosphate. Calcitriol is a...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Would you start potassium citrate in a patient with recurrent nephrolithiasis with only minimal uric acid composition who persistently has acidic urine on 24 hour urine stone risk studies?
In treating stone disease of mixed composition, I pay more attention to the primary component. However, if the primary component is calcium oxalate, which is often the case, I would strongly consider using potassium citrate, as it will alkalinize urine and discourage uric acid nephrolithiasis as wel...
What approaches do you take to avoid further eGFR decline in patients undergoing unilateral nephrectomy for renal cell carcinoma?
The most important/effective intervention by far is good blood pressure control. Secondarily, if there is proteinuria, one should consider ACE/ARB, SGLT-2, etc. The optimal blood pressure target can be uncertain, but I would advocate for a systolic pressure of less than 130 mmHg.
Do you recommend holding metformin in a patient with chronic kidney disease who has an upcoming CT contrast study?
I actually do. Over the years I have seen a number of cases of metformin induced lactic acidosis. Although it is very hard to predict who will have it. I would like to be on the safe side.
How do you distinguish TMA caused by CNI toxicity versus antibody mediated rejection in a kidney transplant patient?
It really boils down to "the company you keep". If the biopsy shows evidence of antibody-mediated rejection with peritubular capillaritis, glomerulitis, or C4d positivity, I would lean towards AMR-associated TMA. Also need to always consider whether the primary cause of the ESKD. Was there an undiag...
Do you modify the albumin level below which you would prophylactically anticoagulate a pregnant patient with nephrotic-range proteinuria, given that hypoalbuminemia is expected in pregnancy?
I wouldn't anticoagulate for nephrotic syndrome unless the albumin was <2.5, and that is too low for pregnancy. Besides, "any" pregnant patient with "any" renal disease should be on ASA for preeclampsia prophylaxis. So, all pregnant patients with proteinuria need ASA (not without anticoagulation pro...
How do you approach recommending an AVF for a patient with advanced CKD who is concerned about the cosmetic appearance of the fistula?
My approach is usually 2-fold. First, I try to emphasize the medical benefits of an AVF over a catheter. Second, I point out that the catheter is also the most aesthetically appealing option to have. I then go over possible solutions of covering the AVF (sleeves, etc.). This could also be a good ...
When do you recommend genetic testing prior to kidney transplantation for a patient with ESKD secondary to FSGS?
This is a very important question especially as the cost of genetic testing is now much more affordable with commercially available kit. Genetic FSGS carries a much more favorable prognosis post transplant as recurrence would be very unlikely (with very rare exceptions). We would advise this I situa...