Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic range proteinuria, microscopic hematuria, and stable renal function who has been on a tenofovir-based regimen?
I often find the biopsy on these patients unhelpful. Having said that, I do advocate doing a kidney biopsy when there are other circumstances which raise the possibility of other disorders (i.e., possible IgA nephropathy, tenofovir was given for a short period of time, and only TAF was used, etc.).
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Would you recommend adding a mineralocorticoid receptor antagonist or endothelin receptor antagonist for a patient with bevacizumab-induced proteinuria who is already on an ACEi or ARB?
Unfortunately, we have no data to guide the choice of anti-proteinuric agents in this particular setting. We do have biological plausibility for antagonizing the endothelin pathway, as we know that vascular endothelial growth factor inhibition results in upregulation of endothelin-1, and the resulta...
How do you decide when to stop routine laboratory monitoring in a patient with CKD Stage 5 who has chosen conservative management?
I normally don't as patients often change their mind when they are sick. However, if the patient requests not to monitor labs then I would honor their wishes.
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
Do you recommend initiating an ACE inhibitor or ARB in a patient with proteinuric CKD Stage 5?
ACE-I’s and ARB’s have been shown to be renal protective, and patients who have stopped these agents do worse than those who continue them. Potassium binders are an excellent option to lower K levels and enable patients to stay on these RAAS inhibitors. I would not take CKD patients off RAAS inhibit...