Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you hold renin-angiotensin system blockade at the time of kidney transplant and restart it only once graft function is established, or do you continue it through the perioperative period?
We do hold ACEs and ARBs at the time of transplant. After three months, we are typically pretty comfortable restarting an ACE or ARB if needed. If proteinuria develops early post-transplant, we might consider earlier institution of an ACE or ARB after renal ultrasound and biopsy. One exception is wi...
Under what circumstances would you consider LDL apheresis in a kidney transplant patient with FSGS recurrence within three months of transplantation?
LDL apheresis has not been part of our protocol for the treatment of recurrent FSGS. Our protocol is still plasmapheresis x 9 runs, and now considering institution of daratumumab. Protocols are still evolving for this vesiculating problem.
At what eGFR would you begin recommending leukoreduced blood products given the potential future need for kidney transplantation in patients with CKD who are not currently listed?
Most states in the US use pre-storage leukoreduction of blood products, done at the time of blood donation. If one is not sure whether the blood is leukoreduced, then a bedside filter can be utilized. Any patient who might be a candidate for transplant in the future and needs a blood transfusion wou...
Do you prefer an isotonic sodium bicarbonate infusion over other isotonic IV fluids when managing those with AKI in the setting of light chain cast nephropathy?
Theoretically, the physiologic rationale for using isotonic sodium bicarbonate over isotonic saline in light chain cast nephropathy is that urine alkalinization reduces the interaction between light chains and Tamm-Horsfall protein and therefore reduces cast formation. However, there are no strong c...
Can you safely use a cephalosporin in a patient who previously developed acute interstitial nephritis to amoxicillin?
Amoxicillin-associated interstitial nephritis is most often a type IV hypersensitivity reaction. Cross-reactivity with other beta-lactams is possible but poorly studied. I would try hard to find an alternative.
Do you prefer maximizing fluid removal during dialysis or starting new antihypertensive medications for patients with ESKD on intermittent hemodialysis who are chronically hypertensive?
Fluids, fluids, and fluids are the most crucial first step. Challenging dry weight is the most important part in controlling blood pressure, and then adding more blood pressure medications is the next step. The only "exception" is high dose diuretics to reduce intradialytic weight gain. Additionall...
When showing lab results to patients who have chronic kidney disease, do you prefer to use the absolute creatinine value or eGFR?
I look at both. It is easier to follow the creatinine over time, but the eGFR is likely a better measure of the actual kidney function.
What is your approach for minimizing volume intake for patients on dialysis who are receiving total parenteral nutrition (TPN)?
I would use concentrated TPN formulations by using higher concentrations of dextrose and amino acids to deliver more calories and protein per mL. I would adjust the dialysis prescription to account for TPN-related fluid gains. For example, ultrafiltration targets on dialysis days can be increased to...
How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?
This is not exactly a rare problem! I have a number of comments: Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because: a) patients really don't under...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....