Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach for minimizing volume intake for patients on dialysis who are receiving total parenteral nutrition (TPN)?
I would use concentrated TPN formulations by using higher concentrations of dextrose and amino acids to deliver more calories and protein per mL. I would adjust the dialysis prescription to account for TPN-related fluid gains. For example, ultrafiltration targets on dialysis days can be increased to...
How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?
This is not exactly a rare problem! I have a number of comments: Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because: a) patients really don't under...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...
What is the role of APOL1 genotyping in the evaluation of a living kidney donor?
Testing for APOL-1 in living donors is controversial and a topic of much discussion and debate. There are not standardized guidelines of who and when to test. Some centers incorporate testing into their protocols while others individualize the decision regarding testing. There are a couple aspects t...
How do you counsel patients about the likelihood of improvement in kidney disease after anti-cancer treatment is initiated in a patient with malignancy associated membranous nephropathy?
There are numerous case reports to support that if the patient has a paraneoplastic MN then the expectation is that the renal lesion will respond to cancer directed therapy.
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?
Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).Why this matters: Transplant > Dialysis: Patients with LN-ES...
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
What is your approach to patients with ESKD who request intravenous diphenhydramine during hemodialysis sessions for various perceived dialysis related complaints?
I would try to avoid giving anyone intravenous diphenhydramine. The only issue comes up with patients who have already been on dialysis for a while and have already been receiving diphenhydramine. I have given it in these cases.
How long would you wait before repeating a kidney biopsy procedure in a patient with inadequate tissue obtained on a prior attempt which was also complicated by a small perinephric hematoma?
I don't think we have any evidence to guide this decision. Somewhat depends on the urgency of the need to get tissue and how easy the first biopsy attempt was. If it is thought that the path to the next biopsy would need to go through the hematoma and no urgency could wait until resolved but usually...