Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?
Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).Why this matters: Transplant > Dialysis: Patients with LN-ES...
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
What is your approach to patients with ESKD who request intravenous diphenhydramine during hemodialysis sessions for various perceived dialysis related complaints?
I would try to avoid giving anyone intravenous diphenhydramine. The only issue comes up with patients who have already been on dialysis for a while and have already been receiving diphenhydramine. I have given it in these cases.
How long would you wait before repeating a kidney biopsy procedure in a patient with inadequate tissue obtained on a prior attempt which was also complicated by a small perinephric hematoma?
I don't think we have any evidence to guide this decision. Somewhat depends on the urgency of the need to get tissue and how easy the first biopsy attempt was. If it is thought that the path to the next biopsy would need to go through the hematoma and no urgency could wait until resolved but usually...
Would you consider using acetazolamide to manage glomerular hyperfiltration in patients with type 1 diabetes, since SGLT2 inhibitors are contraindicated in this population?
Clever idea, but I think it is a bit much to assume that increased Na delivery from carbonic anhydrase blockade proximally would have the same renoprotective effect as an SGLT2i. So, no, I would not do this. However, I admire anyone thinking outside the box!
Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?
Fluid restriction is the mainstay of therapy in patients with SIADH. To correct hyponatremia due to SIADH, electrolyte-free water intake must be less than urinary electrolyte-free water excretion assuming no significant non-renal fluid losses. The degree of fluid restriction may be lessened by the u...
Do you apply manual pressure around the kidney biopsy site immediately post-procedure and prior to supine positioning to help prevent perinephric bleeding?
Yes, I do apply 3-4 minutes of manual pressure immediately at the site of a kidney biopsy while the patient is prone or supine if doing a transplant biopsy. I also apply a pressure dressing and have the patient lie down on it for 2 hours (for native kidney biopsies). This helps in a thin person.
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Under what circumstances would you initiate hemodialysis for fetal protection in a pregnant patient with CKD Stage 4 who does not have any usual indications to start dialysis?
There is no one-size-fits-all approach. You do want to make sure the BUN does not get too high, which can be achieved with dialysis. Note that studies looking at very long dialysis times and treatment hours were for established dialysis patients. In patients with AKI or CKD stage 4, there is still s...