Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you distinguish TMA caused by CNI toxicity versus antibody mediated rejection in a kidney transplant patient?
It really boils down to "the company you keep". If the biopsy shows evidence of antibody-mediated rejection with peritubular capillaritis, glomerulitis, or C4d positivity, I would lean towards AMR-associated TMA. Also need to always consider whether the primary cause of the ESKD. Was there an undiag...
Do you modify the albumin level below which you would prophylactically anticoagulate a pregnant patient with nephrotic-range proteinuria, given that hypoalbuminemia is expected in pregnancy?
I wouldn't anticoagulate for nephrotic syndrome unless the albumin was <2.5, and that is too low for pregnancy. Besides, "any" pregnant patient with "any" renal disease should be on ASA for preeclampsia prophylaxis. So, all pregnant patients with proteinuria need ASA (not without anticoagulation pro...
When do you recommend genetic testing prior to kidney transplantation for a patient with ESKD secondary to FSGS?
This is a very important question especially as the cost of genetic testing is now much more affordable with commercially available kit. Genetic FSGS carries a much more favorable prognosis post transplant as recurrence would be very unlikely (with very rare exceptions). We would advise this I situa...
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
How do you decide when to stop immunosuppression in a patient with granulomatosis with polyangiitis who is on dialysis, has not yet recovered renal function, but has shown improvement in ANCA levels?
In a patient with pauci-immune necrotizing GN from GPA on HD, I usually wait for 3 months and up to 6 months if the biopsy is fresh with minimal chronicity before declaring ESRD and stopping IS. If they have extrarenal disease (ENT, lungs), they would need IS for extrarenal disease.
What is your recommended sequence of therapies for achieving optimal proteinuria reduction in IgA nephropathy, especially in light of the recent approvals of sparsentan, delayed-release budesonide, and iptacopan?
I am actually quite persistent with conservative therapies first - I push an ARB or ACE inhibitor in an effort to get the proteinuria under 1 gram per day, or ideally 0.75 gram per day. I favor stronger ARBs such as olmesartan or azilsartan over weaker ones such as losartan or valsartan, and really ...
How has propensity-matched data showing lower mortality and fewer cardiovascular events with parathyroidectomy versus cinacalcet affected your PTH threshold for surgical referral in a patient with CKD-related secondary hyperparathyroidism?
I have always been a fan of parathyroidectomy for patients who often have uncontrolled serum phosphorus and PTH despite medical therapy for a number of months or years. If parathyroidectomy is done right, then serum phosphorus will drop significantly for at least a few months, and serum PTH will be ...
Would you start potassium citrate for a patient with recurrent calcium oxalate nephrolithiasis who has normal urinary citrate levels but persistent acidic urine?
An excellent, fundamental question!Before starting medical treatment, I want to know if the patient’s stone burden is increasing in volume. That requires, in my opinion, serial CT scans, typically annually.If the stone burden is increasing in volume, it’s time for metabolic (non-surgical) treatment....
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...