Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long would you wait before repeating a kidney biopsy procedure in a patient with inadequate tissue obtained on a prior attempt which was also complicated by a small perinephric hematoma?
I don't think we have any evidence to guide this decision. Somewhat depends on the urgency of the need to get tissue and how easy the first biopsy attempt was. If it is thought that the path to the next biopsy would need to go through the hematoma and no urgency could wait until resolved but usually...
Would you consider using acetazolamide to manage glomerular hyperfiltration in patients with type 1 diabetes, since SGLT2 inhibitors are contraindicated in this population?
Clever idea, but I think it is a bit much to assume that increased Na delivery from carbonic anhydrase blockade proximally would have the same renoprotective effect as an SGLT2i. So, no, I would not do this. However, I admire anyone thinking outside the box!
Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?
Fluid restriction is the mainstay of therapy in patients with SIADH. To correct hyponatremia due to SIADH, electrolyte-free water intake must be less than urinary electrolyte-free water excretion assuming no significant non-renal fluid losses. The degree of fluid restriction may be lessened by the u...
Do you apply manual pressure around the kidney biopsy site immediately post-procedure and prior to supine positioning to help prevent perinephric bleeding?
Yes, I do apply 3-4 minutes of manual pressure immediately at the site of a kidney biopsy while the patient is prone or supine if doing a transplant biopsy. I also apply a pressure dressing and have the patient lie down on it for 2 hours (for native kidney biopsies). This helps in a thin person.
What is your approach to timing of the plasma, arterial, and venous urea collections in a patient on hemodialysis for whom you are attempting to calculate arteriovenous fistula recirculation?
I use the two-needle slow blood flow technique to calculate arteriovenous fistula recirculation: After initiation of hemodialysis, turn off ultrafiltration in approximately 30 minutes and then draw urea samples from the arterial and venous ports of the blood lines. Reduce the access blood flow rate...
What is your approach to interpretation of 24 hour urine stone risk studies that persistently demonstrate elevated urinary creatinine excretion despite a reliable patient who denies improper collection?
I would start with a physical examination, looking at muscle mass. Urine creatinine comes from serum creatinine, which in turn comes from muscle mass. Patients with high muscle mass will have high serum and urine creatinine.
Would you add regional citrate anticoagulation to a CRRT prescription for a patient on systemic heparin but who experiences recurrent filter clotting?
Depending on the need for CRRT vs PIRRT, if I could, I would go with PIRRT first depending on when the clotting occurs in the treatment. Our typical PIRRT treatment is 40 liters over 8 hours, and we can do that daily if needed (often at night), and it totally controls the chemistries and usually vol...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
A practical question! My answer is nuanced. If serial imaging, preferably CT, shows an increase in stone volume on their current treatment program (metabolic stone activity), yes. I think the benefit of controlling their stone formation outweighs the risks and inconvenience of a urinary catheter. I ...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How long do you observe for spontaneous remission after NSAID discontinuation before initiating corticosteroids in a patient with biopsy-confirmed minimal change disease?
The role of steroid treatment in drug-induced acute interstitial nephritis (DI-AIN), including those with MCD, is controversial. There are no large randomized controlled trials, so whether steroids are beneficial or not, and when to give them, is unclear. There have been a number of retrospective st...