Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Are there instances when you use diuretics for non-oliguric patients with volume overload in the setting of hepatorenal syndrome who have normal MAPs?
Absolutely. First, since most patients with HRS are oliguric and have low MAPs, I would look for alternative explanations for renal insufficiency. But, yes, if someone like this is volume overloaded, then I do use diuretics, often in conjunction with large volume paracentesis, to manage the volume o...
When transitioning a patient with recurrent calcium based nephrolithiasis from one thiazide diuretic to another, do you typically recommend a washout period?
Yes. But since the half-lives of thiazide diuretics differ dramatically, from 1.5 to 2 hours for chlorothiazide to 40 to 60 hours for chlorthalidone, the washout period should be tailored to the specific drugs in question. Checking an electrolyte panel during the transition seems very appropriate to...
Do you prefer to have your patients with recurrent nephrolithiasis who have completed a 24 hour urine stone risk study drop off the entire collection to the respective lab for processing or personally mix and aliquot a representative sample prior to submitting to the lab for processing?
We prefer to get the entire 24-hour urine sample to avoid measurement errors.
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
What is your approach to management of severe hyponatremia in patients with alcohol use disorder who experience seizures that could be secondary to the electrolyte derangement or alcohol withdrawal?
Since it is difficult to make a definitive distinction as to whether the seizure is due to severe hyponatremia or alcohol withdrawal, it is prudent to treat both severe hyponatremia and alcohol withdrawal concurrently. Given that the seizure may be contributed to by the severe hyponatremia, 3% hyper...
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
What is your approach to determining the ideal starting dose of sodium chloride tablets when transitioning a patient with hyponatremia from a 3% sodium chloride infusion?
In the treatment of hyponatremia, the volume of an infusate necessary to induce a given change in plasma sodium concentration differs between hypovolemic hyponatremia and SIADH. In hypovolemic hyponatremia, the infused sodium and water are retained due to the volume depletion, resulting in positive ...