Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend a diuretic renogram prior to planned unilateral nephrectomy for renal cell carcinoma in a patient with normal kidney sizes bilaterally?
This is more a urological question than a nephrological one. If renal function and kidney sizes are normal, then I am not sure I would, unless there is an option of doing a partial nephrectomy. Not sure how that would change management.
How do various therapeutic approaches for IgA nephropathy target the different stages of the four-hit hypothesis?
Based on our mechanistic understanding and some limited biomarkers, we think that ACEI, ARB, SGLT2i, endothelin antagonists like sparsentan, and complement inhibitors like iptacopan all act on the final "Hit 4" of glomerular inflammation. This points out that Hit 4 is actually quite complex! It invo...
How would you treat a patient with alcoholic cirrhosis and IgA nephropathy with high risk features including nephrotic range proteinuria, microscopic hematuria, and declining eGFR?
Cirrhosis is a well-known cause of secondary IgA nephropathy. Impaired removal of IgA-containing complexes by the Kupffer cells in the liver is thought to predispose to IgA deposition in the kidney (Amore et al., PMID 8302021). As in primary IgAN, polymeric IgA1 appears to be the dominant IgA isofor...
What is your approach to managing hyperkalemia secondary to respiratory acidosis?
Since hyperkalemia in respiratory acidosis is due to transcellular shift, therapy should be directed at treating the underlying respiratory acidosis. Correction of the hypercarbia should lead to resolution of the hyperkalemia. In severe hyperkalemia due to respiratory acidosis that is not easily rev...
Do you proactively convert stable kidney transplant recipients from twice-daily immediate release tacrolimus to once-daily extended release tacrolimus to improve long-term adherence?
Yes, we convert to once-daily tacrolimus whenever possible. If we cannot get insurance approval, we work with our pharmacy and the company to try to get the medication for the patient. We expect improved adherence and fewer side effects (due to lack of peak level) for our patients.
What factors do you consider when advising a patient with lupus nephritis on the safety of becoming pregnant?
I agree with Dr. @Dr. First Last's excellent suggestions (with just one exception!). I don't increase prednisone prophylactively for lupus pregnancy - I would only add or increase steroid if there is a flare. The risks of steroid in pregnancy impact both maternal and pregnancy outcomes, so we try to...
Under what circumstances do you recommend targeting a systolic blood pressure of less than 120 mmHg in a patient with CKD?
I am going to deviate a bit from the KDIGO recommendations here, and will try to document my reasons. The SPRINT trial, which was the largest BP target trial for individuals with CKD, did not enroll individuals with an eGFR < 20. The automated office BP measurement used in SPRINT is still not standa...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
Would you recommend adjusting the hemodialysis schedule for a TTS dialysis patient who is scheduled for surgery on a Monday?
It depends on the patient. If the patient has no residual renal function, it’s prone to volume overload or hyperkalemia; such a patient would benefit from a dialysis session on Monday before surgery. If the patient is recently initiated on iHD, or has good volume control and electrolytes are fine, y...
What is your approach to intracatheter alteplase use for hospitalized ESKD patients who are experiencing tunneled dialysis catheter issues?
I do use it in stable patients who do not have any bleeding issues. In others, it would be better to manipulate or exchange the catheter.