Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
In which patients with atypical HUS would you consider eculizumab discontinuation?
My approach to eculizumab cessation in aHUS is to at least consider cessation in all patients not only given the high cost of the drug, but also given the risk of meningococcemia, which is incompletely protected against by vaccines.In treating aHUS, I initiate eculizumab (and preventive therapy for ...
What is your approach to treating IgA nephropathy in patients who also have IgA vasculitis?
In a patient with known IgA Vasculitis [IgAV], IgA dominant pattern of injury in the kidney biopsy reflects IgA Vasculitis with Nephritis [IgAV-N]. Thus, it would not be appropriate to call it IgA nephropathy [IgAN] in IgAV. Though the histological features in IgAN and IgAV-N can be common in the ki...
Would you pursue more dedicated stone surveillance imaging testing for a patient with recurrent nephrolithiasis who has PET-CT scans twice yearly?
Unless the patient is symptomatic, I am not sure there is a reason to. Though PET CT is not the best imaging to look for stones.
Would you continue spironolactone in a patient who has recently progressed to ESKD on HD with oliguria and was diagnosed with primary hyperaldosteronism years ago?
Although spironolactone does antagonize the effect of aldosterone in the colon, it is unlikely that spironolactone will be effective in treating primary hyperaldosteronism in a patient with ESKD with minimal urine output. Therefore, I would discontinue the spironolactone in such patients.
Would you recommend pregnancy testing for a female patient with recurrent nephrolithiasis for whom you are considering a CT stone scan for routine stone surveillance?
I would go with an ultrasound first and not with CT for screening.
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
What is the best way to assess exercise capacity in kidney transplantation candidates to predict post-transplant outcomes?
This is a great question and quite variable across centers. The most consistently used across centers is the 6 min walk, though we are not yet doing that. Our general guide is for them to try to exercise 30 minutes on non-dialysis days, with the ultimate goal of walking a mile in 30 minutes (though ...
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
When would you suspect an allergy to the dialysis membrane in patients who complain of pruritis during dialysis?
The short answer is no. Pruritus is so common with renal disease, and allergic reactions to dialyzers are uncommon. If the pruritus can confidently be documented to be only during dialysis and not at any other time, then it may be worth trying a different dialyzer but it would take a lot for me to b...
How do you manage early patient-reported polyuria after starting an SGLT2 inhibitor to prevent premature discontinuation?
I have not encountered this situation yet. I would imagine the polyuria improves over time as eventually intake has to equal output. Of course, it is possible that polyuria will cause increased thirst. Reassuring the patient is the best first option.