Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
Are there any special considerations you take with ESA use in hospitalized patients with ESKD who undergo stem cell transplantation?
There really are no guidelines for the use of ESAs in this population. Generally, these patients receive PRBC support for severe and/or symptomatic anemia. We do not prescribe ESAs int this setting because we suspect that the response will be suboptimal given the inflammatory state of these patients...
For outpatients undergoing a kidney biopsy, do you routinely recommend an overnight admission for continued hemoglobin monitoring?
If I perform an uneventful kidney biopsy in the morning on a patient with well-controlled BP and normal hemoglobin, I can observe the patient all day. If vitals are stable and the repeat hemoglobin at 8 hours is stable, I would discharge the patient. However, if I did the biopsy later in the day or ...
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...
Under what circumstances would you consider a bone biopsy in the workup of renal osteodystrophy?
I am always in favor of doing more diagnostic tests. The problem is that it is often practically hard to get a bone biopsy. I would suggest it anytime there a question of what is happening with the bone disease.
When would you consider referring a patient with resistant hypertension for renal denervation?
I consider renal denervation in patients who have 2 kidneys without renal artery pathology, eGFR > 40, a negative secondary workup (including exclusion of primary aldosteronism), uncontrolled BP, and who can return for follow-up monitoring after the procedure. Some of my referrals have been in patie...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
How long would you wait before performing a kidney biopsy in a patient with nephrotic range proteinuria, a negative PLA2R antibody, a negative anti-THSD7A antibody, and stable renal function who recently started treatment a week ago with a DOAC for a pulmonary embolism?
Since the renal function is stable, and holding the DOAC carries significant risk, I would wait at least 3 months, and if the kidney function is still stable then, possible 6 months before the kidney biopsy.
How do you approach managing patients with recurrent nephrolithiasis who have low supersaturation profiles due to polyuria and stable stone disease on imaging but do have persistent urinary abnormalities such as hyperoxaluria, hypercalciuria, and hypocitraturia?
If the stone disease is metabolically stable (no change in stone size or increase in number by serial CT imaging), I do not treat urinary chemical abnormalities. Presumably these patients have high levels of urinary inhibitors of crystallization. I encouraged them to continue their successful stone ...
Would you obtain an abdominal non-contrast CT study for further routine evaluation of stone burden in a patient with recurrent nephrolithiasis who recently completed an abdominal iodinated contrast CT study for non-stone purposes?
Often, there is no pre-contrast imaging, and stones cannot be counted well once contrast enters the kidneys. So, unless there was a pre-contrast phase, the contrast CT cannot be considered adequate for determining stone burden and new stone activity. So if either is at issue, I would obtain a non-co...