Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you counsel patients on the likelihood of resolution of their hypertension post adrenalectomy for primary hyperaldosteronism?
Primary hyperaldosteronism is a curable cause of hypertension. Removal of an Aldosterone producing adenoma results in correction of biochemical abnormalities in almost all patients. Hypertension also improves but not in all patients. Studies have shown that "cure" of hypertension occurs in about 27-...
Under what circumstances would you initiate hemodialysis for fetal protection in a pregnant patient with CKD Stage 4 who does not have any usual indications to start dialysis?
There is no one-size-fits-all approach. You do want to make sure the BUN does not get too high, which can be achieved with dialysis. Note that studies looking at very long dialysis times and treatment hours were for established dialysis patients. In patients with AKI or CKD stage 4, there is still s...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
Would you recommend starting an SGLT2 inhibitor in a proteinuric CKD patient with chronic asymptomatic bacteriuria?
In spite of the biological plausibility that SGLT2 inhibitors are associated with increased risk for UTI, population-based cohort studies, like the one of Dave et al in diabetic patients, did not show a higher risk of severe or minor UTI with SGLT2 inhibitor users and other antidiabetic drugs. The d...
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...
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 recommend preloading with IV magnesium to decrease the risk of cisplatin nephrotoxicity?
Although there have been studies demonstrating that hypomagnesemia has been associated with an increased risk of AKI, there have been no clinical trials indicating preloading with mag prevents AKI. I would recommend to have the magnesium above 2mg/dl prior to cisplatin.
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?
In a patient with known SLE with proteinuria > 500 mg/g and (+) PLA2R antibodies in the serum, a kidney biopsy would be warranted. PLA2R staining should be performed on the kidney biopsy. PLA2R staining must co-localize on the subepithelial aspect in a granular fashion similar to IgG in PLA2R posit...
How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?
Renal limited ANCA is usually MPO associated. Isolated PR-3 involvement of the kidneys are rare. Further information is needed in making a decision for this case. We need to know when the patient was diagnosed with ANCA vasculitis. What was the Serum creatinine at presentation? When was the kidney b...