Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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.
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
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...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
How would you approach a patient with class III and V lupus nephritis, already on HCQ, MMF, voclosporin and losartan, but has continued proteinuria not yet attaining complete renal response?
Few things are more complicated than lupus nephritis, and this question is not answered easily. It depends on hematuria, Cr, proteinuria, C3, C4, dsDNA, and systemic symptoms. So, it depends on what I think is causing the incomplete clinical response. If I believe it is the class V lesion, I would g...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Do you recommend a metabolic evaluation in a kidney transplant patient with no prior history of nephrolithiasis who is found to have donor derived kidney stones?
Thanks for an interesting question. It would help if we knew the relevant donor medical history, such as dietary indiscretions or enteric hyperoxalutia, which would not be issues in the recipient. Since this information is typically not available, I would collect two 24-hour urinary supersaturation ...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...