Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What clinical criteria do you use to decide between antivirals, rituximab, plasmapheresis, or a combination therapy for treating hepatitis C virus-associated cryoglobulinemic membranoproliferative glomerulonephritis?
Direct-acting antiviral agents would help eradicate the HCV clone and often the HCV-infected B lymphocytes that produce the polyclonal IgM (III cryo) or monoclonal IgM (II cryo) against IgG. Sometimes, despite HCV clearance, B-cell clones persist, leading to cryoglobulinemic vasculitis and MPGN; in ...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.
Would you consider using a combination regimen of rituximab, low-dose cyclophosphamide, and steroids to improve complete remission rates in patient with PLA2R-positive membranous nephropathy?
Patients with membranous nephropathy (MN) with declining GFR, not explained by causes other than MN, massive proteinuria, and high-titer anti-PLA2R antibodies are considered high risk and should be treated with immunosuppressive therapy. Both the Membranous Nephropathy Trial of Rituximab (MENTOR) (1...
Which clinical characteristics would prompt you to consider an oral factor B inhibitor such as iptacopan in the treatment of IgA nephropathy?
I think iptacopan may be a useful choice in patients with a more active, aggressive lesion on biopsy, declining GFR, or heavy proteinuria. It perhaps makes intuitive sense to favor iptacopan if there is strong C3 staining on biopsy as well. We still do not know which among iptacopan, sustained-relea...
Would you advocate for SGLT2 inhibitors if they are not fully covered by insurance in patients with moderately increased albuminuria (< 300 mg/g) who are on maximal dose ACEi/ARB?
I think the benefit would be minimal. I would not necessarily have the patient pay extra money to get them.
What is your preferred fill volume, dialysis solution, and dwell time for patients with suspected peritoneal dialysis associated peritonitis who arrive to the hospital with a dry abdomen?
I agree with Dr. @Dr. First Last's approach with one addition: prior to instilling the fluid for 2 hours, I would do a quick flush of the abdomen- fill and drain immediately- to remove the cells that accumulated while the abdomen was dry, and thereby avoid "muddying" the waters (pun intended).
What is your approach to determining if a patient treated with vancomycin has ATN related to vancomycin or the underlying infection?
For the most part, I would assume it is the underlying infection. Very high vancomycin levels and its combined use with Zosyn make me wonder about vancomycin toxicity, especially if the infection has been well treated.
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How would you approach the decision to biopsy a kidney transplant recipient who previously experienced a Page kidney following a kidney biopsy?
The decision to perform a renal biopsy should be made after thorough deliberation regarding the appropriate indications and the potential diagnostic information that the procedure may yield to inform patient management. Under suitable conditions, renal biopsy is considered a safe and well-tolerated ...
Would you avoid potassium citrate initiation in a pregnant patient with hypocitraturia and recurrent calcium oxalate nephrolithiasis?
Difficult question to answer. There is no clear contraindication; however, if her urine pH is OK, I would likely avoid it. I would make sure she is adequately hydrated and would recommend having fresh squeezed Lemons to help. However, if it appears necessary to use it, I would.