Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you risk-stratify contrast exposure after apparent renal recovery in a patient within 30 days of dialysis-requiring AKI?
The risk of repeat ATN is actually lower during the recovery phase of AKI, but not zero. If the patient's renal function is worsening after improving, then I would consider other diagnoses besides ATN (obstruction, etc.). However, if the scenario fits, then ATN may be the diagnosis.
Do you use ideal body weight, adjusted body weight, or actual weight when dosing medications for patients with AKI on CRRT?
There is no single body weight metric that applies to all drugs in patients on CRRT. The choice depends on the drug's pharmacokinetic properties (hydrophilic vs. lipophilic, volume of distribution) and on whether a loading or maintenance dose is being calculated. Loading doses are driven by the volu...
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
Acetaminophen is still preferred, but at 3,000 mg or less per day. The next consideration is a COX-2 specific inhibitor, such as celebrex. Narcotics and steroids play no role in management of osteoarthritis.
How are you using fish oil to reduce the risk of stroke and heart attack in CKD patients?
I am not, as of yet. I would like more data before doing that.
Do you recommend avoiding SGLT2i use for patients with proteinuria from diabetic kidney disease if they have urinary retention requiring catheterization?
I would probably avoid SGLT-2 in such a patient because of the risk of infection. Likely, the risk is not worth the benefit.
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
How would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
Proceed with coronary angiogram and dialysis after the procedure.
How often would you recommend urine studies to monitor for potential lupus nephritis in a patient with lupus?
I would recommend every 3-4 months.
Are there instances when you use letermovir without the addition of acyclovir when managing a kidney transplant recipient for CMV prophylaxis?
I am assuming this question is about initial viral prophylaxis after transplant and exposure to induction immunosuppression. We have not used often letermovir as first line CMV prophylaxis outside of a research study, or during valcyte shortages. Cases where one might consider Letermovir as prophyla...