Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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.
How would you approach failure of maintenance therapy (Azathioprine) for PR3 positive, c-ANCA positive, pulmonary–renal vasculitis previously induced with cyclophosphamide, with a history of anaphylaxis to rituximab?
This is a challenging clinical situation with several appropriate treatment approaches as follows: Desensitization to rituximab - this would need to be done in the ICU but is effective for patients who are willing to undergo the process for whom other maintenance regimen options are suboptimal. Avac...
Do you rely on CT Hounsfield Units to determine stone composition in your patients with recurrent nephrolithiasis who have yet to submit a stone for laboratory based composition testing?
It is somewhat helpful if the value is low, consistent with Uric Acid stones, if higher, not specifically differentiate the calcium stone type. However, since it is part of routine CT stone protocol, it may add some useful information.
How should PPIs or H2 blockers be managed in peritoneal dialysis patients with a history of peritonitis and peptic ulcer disease, considering the potential infection risk?
This question should probably be rephrased, with the words "a history of peritonitis and" removed. I am not aware of any literature indicating that the risk of peritonitis with the use of gastric acid suppressants (GAS), either H2 blockers (H2Bs) or proton pump inhibitors (PPIs), is modified by a pr...
Do you favor peritoneal dialysis over hemodialysis in patients with an LVAD who have ESKD?
Yes, I prefer peritoneal dialysis (PD) over hemodialysis (HD) in suitable patients with a left ventricular assist device (LVAD) due to its hemodynamic stability. PD provides slow, continuous ultrafiltration over 24 hours rather than the rapid, intermittent fluid shifts seen with ultrafiltration in a...
Would you recommend delaying a 24 hour urine stone risk study until a patient is off of antibiotics if they are on a short course for an upper respiratory infection but are experiencing no medication side effects?
If the patient is eating and drinking as usual, I would have no reservation collecting a 24-hour urine supersaturation study during the illness. I am not aware that antibiotics would affect the volume or mineral content of the specimen.Stephen B Erickson, MD
What is your approach to systemic anticoagulation for patients with hypoalbuminemia and nephrotic syndrome secondary to a non-membranous nephropathy condition?
Patients with nephrotic syndrome (NS) and hypoalbuminemia have a several-fold higher risk of venous thromboembolism (VTE) than the general population and also a somewhat higher risk of arterial thromboembolism (ATE), such as MI and stroke. This risk seems to be higher in membranous nephropathy (MN) ...
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...