Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend prescribing Pneumocystis jiroveci pneumonia (PJP) prophylaxis for a patient with membranous glomerulonephritis on rituximab?
In general, I don't use Pneumocystis jirovecii pneumonia prophylaxis (PJP PPx) for patients with membranous nephropathy (MN) who have only received rituximab (RTX), unless they have also received high-dose glucocorticoids (GC) or cyclophosphamide (CYC). I usually give PJP PPx when patients receive h...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
What is your approach to treating hypercalcemia secondary to immobilization?
My first approach is to have the patient become mobile if at all possible, even just increasing mobility in bed by doing leg and arm exercises, which can help, and getting up and walking is preferable if at all possible. Physical therapy is also helpful. I would make sure that the patient is well hy...
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
When would you pursue a kidney biopsy for patients with inflammatory bowel disease who have non-proteinuric progressive CKD of unknown etiology?
I have done kidney biopsies in patients in this setting. Helpful to know what is going on in the kidneys.
How would you approach organ harvesting in an ambulatory patient with ALS who wishes to transition to comfort measures and to be an organ donor?
Data is very limited. If the patient is deemed safe to undergo general anesthesia, it would be reasonable for the patient to be a living donor, either as a direct donation or non-directed/altruistic. There is some theoretical risk of transmission of ALS (based on the potential that some ALS is due t...
What is your preferred blood flow rate for a patient with ESKD who has an AVF but is only undergoing an ultrafiltration session?
I see no reason to limit the blood flow. Clearly, if you are just UF, the blood will "thicken" as you remove protein and cell-free water component of the blood, and the higher the blood flow, the lower the filtration fraction (FF) and the less "thick" the blood will get. If your UF says 3 liters ove...
Which anti-hypertensives do you hold and for how long when screening for hyperaldosteronism in a patient with resistant hypertension and initial screening with unsuppressed renin but elevated aldosterone >20 while on anti-hypertensive therapy?
Only spironolactone for 2-3 weeks. Suppressed renin is the most sensitive test to diagnose primary hyperaldosteronism.