Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you modify your peritonitis prevention strategy for a patient starting peritoneal dialysis who has a history of recurrent staphylococcal skin infections?
At the outset, let me state that I am unaware of any published data regarding this issue. Nor do I have personal experience to draw upon. So, what follows is what I THINK I would do if faced with this situation.First off, I would have a rather high threshold for starting PD in such a patient, especi...
Would you recommend adding a novel agent, such as lumasiran or nedosiran, to treat a newly diagnosed patient with primary hyperoxaluria type 1 who has preserved kidney function and persistent but significantly improved urinary oxalate levels following pyridoxine initiation?
I believe this is a fairly nuanced question. The answer really depends on the patient under question. Important considerations include how completely they responded to the pyridoxine, if there are any issues with them taking it regularly, and their current clinical course, including the number of st...
Would you recommend urinary glycolate testing prior to genetic testing in a patient with elevated urinary oxalate and suspicion for primary hyperoxaluria type 1?
Genetic testing today is much easier than urinary glycolate testing. Sending a saliva specimen is certainly more convenient than doing a 24-hour urine collection. At the moment, via pharma, the testing is free, so that is not a relevant variable either.
Which ESKD patients would you consider transitioning from hemodialysis to hemodiafiltration, given the FDA approval of a hemodiafiltration system in the US?
I believe once operational, we can transition all the patients in the dialysis unit equipped to perform it. In general, convention removes larger molecular weight substances, so patients who may derive the most benefit may be those who have, for example, dialysis-associated amyloidosis/carpal tunnel...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
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) ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...