Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you proactively convert stable kidney transplant recipients from twice-daily immediate release tacrolimus to once-daily extended release tacrolimus to improve long-term adherence?
Yes, we convert to once-daily tacrolimus whenever possible. If we cannot get insurance approval, we work with our pharmacy and the company to try to get the medication for the patient. We expect improved adherence and fewer side effects (due to lack of peak level) for our patients.
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I do but the issue is complex. Interpreted in context - life events, surgeries, meds etc - they tell me the range of behaviors for a patient in chemistry terms. But it takes a lot of time, and is not a good idea unless you are prepared to take that time.
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?
In my patients who tend to have some degree of renal dysfunction, I find myself using a lot of diuretics. In my experience, many of these patients are significantly volume overloaded. Diuretics tend to work the best to lower the blood pressure and do it in a slow fashion. Of course, if the blood pre...
What is your approach to management of severe hyponatremia in patients with alcohol use disorder who experience seizures that could be secondary to the electrolyte derangement or alcohol withdrawal?
Since it is difficult to make a definitive distinction as to whether the seizure is due to severe hyponatremia or alcohol withdrawal, it is prudent to treat both severe hyponatremia and alcohol withdrawal concurrently. Given that the seizure may be contributed to by the severe hyponatremia, 3% hyper...
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
What is your approach to determining the ideal starting dose of sodium chloride tablets when transitioning a patient with hyponatremia from a 3% sodium chloride infusion?
In the treatment of hyponatremia, the volume of an infusate necessary to induce a given change in plasma sodium concentration differs between hypovolemic hyponatremia and SIADH. In hypovolemic hyponatremia, the infused sodium and water are retained due to the volume depletion, resulting in positive ...
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
Do you routinely switch an ESKD patient from a NOAC to warfarin to allow for deceased donor kidney transplant listing?
We typically ask patients to switch from DOAC to warfarin when we think they are in range of deceased donor offers. We have a median waiting time for B and O candidates around 5.5 years, so we switch at 4 years of waiting/dialysis time. For ABO A candidates, we switch at 2 years. Of course, urgency ...