Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...
Would you start potassium citrate for a patient with normal urine citrate levels, but who suffers from recurrent calcium oxalate nephrolithiasis and no identifiable risk factors on 24 hour urine studies, as a method of increasing urine citrate levels to further prevent stone formation?
No. I am not aware of data that raising urinary citrate levels above normal is helpful in the prevention of calcium-based kidney stones. My next step would be to encourage the patient to improve dietary and fluid consumption compliance. If the patient cannot comply, my last option would be to go to ...
How do you decide in older adults with newly diagnosed stage 2 hypertension when to start with two antihypertensive agents versus taking a more cautious approach due to concerns about potential orthostasis, frailty, or polypharmacy?
Starting Dual Therapy vs. a Staged Approach in Older Adults with Newly Diagnosed Stage 2 HypertensionThe core question isn't just how high blood pressure is; it's how much treatment this patient can safely absorb.In geriatric cardiology, cardiovascular risk reduction and treatment-related harm are t...
Do you recommend temporarily holding hydroxyurea prior to and after a native kidney biopsy to prevent procedure related bleeding complications?
I would recommend temporarily holding hydroxyurea prior to a native kidney biopsy if the patient has hydroxyurea-induced thrombocytopenia, provided that the hematologist believes a brief interruption is safe.
For a renal transplant patient on chronic immunosuppression with resolved esophageal symptoms (epigastric pain and intermittent dysphagia), does the presence of minimal CMV-positive cells on esophageal biopsy warrant preemptive antiviral therapy, or is clinical monitoring sufficient?
All things equal, in the average patient, if a patient has rare/minimal CMV-positive cells, it could occasionally represent a minimal infection or an incidental finding. However, in a transplant patient who is on immunosuppression, and especially one who has had recent symptoms (such as dysphagia in...
When do you refer for peritoneal dialysis catheter placement in a patient with advanced chronic kidney disease who does not currently have dialysis needs but does have a progressive decline in eGFR?
The question, of course, is whether to place the catheter early, when the patient does not yet require dialysis and then need to provide catheter care (e.g., weekly flushes), or to delay catheter placement and risk needing to start urgently, or, much worse, risk placement of a tunneled dialysis cath...
Do you rely on urinalysis testing for microscopic hematuria as a means to assess for a ureteral stone for patients with recurrent nephrolithiasis who report mild potential stone-related pain?
I agree with answers posted already. Hematuria is not specific to a ureteral stone location.
What is your approach to the treatment of class IV lupus nephritis for a patient with AKI requiring dialysis?
To manage this patient's class IV lupus nephritis with dialysis-dependent AKI, I will initiate an aggressive induction regimen consisting of pulse IV methylprednisolone (500 to 1000 mg daily for 3 days) followed by an oral prednisone taper, combined with high-dose IV cyclophosphamide (NIH regimen) d...
What is your preferred SGLT2 inhibitor when treating patients with CKD for whom there are no coverage barriers?
I consider them equivalent. Based on insurance coverage, most of my patients are on empagliflozin, followed by dapagliflozin. I rarely use other SGLT-2 inhibitors.
Do you recommend gradual initiation of dialysis or conventional initiation of dialysis for pregnant patients with worsening renal function who require dialysis?
The reason for gradual initiation of HD is to avoid dialysis disequilibrium, which is more likely to occur at higher levels of uremic toxins and chronic brain responses to chronic high osmotic loads. Initiation of HD in pregnant patients often occurs at GFR levels that are much higher than those use...