Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
Do you recommend 24 hour urine stone risk studies for patients with no history of nephrolithiasis who are undergoing evaluation as potential kidney donors?
We ask all donors if they have had a history of kidney stones. All donors also get a CT angiogram of the abdomen. Patients with a stone history will need a 24-hour urine stone risk profile. If a donor has an incidental single stone, we may still allow donation, but we would ask for a 24 stone profil...
Has your management of post-transplant FSGS changed with the advent of new FSGS directed therapies?
The pathogenesis of FSGS and specifically recurrent FSGS post-transplant has remained an unmet need in nephrology. Multiple purported " circulating permeability factors " have been identified over the years, each of them providing a piece of the picture, but none that comprehensively and definitivel...
How do you approach the decision to perform preimplantation biopsies in brain-dead kidney donors?
Full Disclosure: This is an opinion from a transplant nephrologist who does not take direct organ offers, but someone who bore witness to many offers that did involve a preimplantation biopsy. The use of preimplantation biopsy appears to be most useful in cases where the clinical parameters would su...
Do you hold renin-angiotensin system blockade at the time of kidney transplant and restart it only once graft function is established, or do you continue it through the perioperative period?
Yes, it is our usual practice to hold RAAS blockade at the time of transplant until renal function has stabilized due to risks of hyperkalemia and delaying renal recovery. For blood pressure control in the early post-transplant period, our first-line agents are usually the calcium channel antagonist...
Under what circumstances would you consider LDL apheresis in a kidney transplant patient with FSGS recurrence within three months of transplantation?
LDL apheresis has not been part of our protocol for the treatment of recurrent FSGS. Our protocol is still plasmapheresis x 9 runs, and now considering institution of daratumumab. Protocols are still evolving for this vesiculating problem.
At what eGFR would you begin recommending leukoreduced blood products given the potential future need for kidney transplantation in patients with CKD who are not currently listed?
Most states in the US use pre-storage leukoreduction of blood products, done at the time of blood donation. If one is not sure whether the blood is leukoreduced, then a bedside filter can be utilized. Any patient who might be a candidate for transplant in the future and needs a blood transfusion wou...
Do you prefer an isotonic sodium bicarbonate infusion over other isotonic IV fluids when managing those with AKI in the setting of light chain cast nephropathy?
Theoretically, the physiologic rationale for using isotonic sodium bicarbonate over isotonic saline in light chain cast nephropathy is that urine alkalinization reduces the interaction between light chains and Tamm-Horsfall protein and therefore reduces cast formation. However, there are no strong c...
Can you safely use a cephalosporin in a patient who previously developed acute interstitial nephritis to amoxicillin?
Amoxicillin-associated interstitial nephritis is most often a type IV hypersensitivity reaction. Cross-reactivity with other beta-lactams is possible but poorly studied. I would try hard to find an alternative.
Do you prefer maximizing fluid removal during dialysis or starting new antihypertensive medications for patients with ESKD on intermittent hemodialysis who are chronically hypertensive?
Fluids, fluids, and fluids are the most crucial first step. Challenging dry weight is the most important part in controlling blood pressure, and then adding more blood pressure medications is the next step. The only "exception" is high dose diuretics to reduce intradialytic weight gain. Additionall...