Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you approach failure of maintenance therapy (Azathioprine) for PR3 positive, c-ANCA positive, pulmonary–renal vasculitis previously induced with cyclophosphamide, with a history of anaphylaxis to rituximab?
This is a challenging clinical situation with several appropriate treatment approaches as follows: Desensitization to rituximab - this would need to be done in the ICU but is effective for patients who are willing to undergo the process for whom other maintenance regimen options are suboptimal. Avac...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...
Would you recommend pre-dialysis exercise for an ESKD patient as a means of cardioprotection?
It seems beneficial. If a patient is agreeable, I would always favor exercise. However, I can see most of the patients refusing/unable to join.
How do you treat restless leg syndrome in patients with end-stage renal disease?
Based on the 2025 guidelines for RLS in patients with ESRD, I would recommend first checking iron studies and using IV iron sucrose if ferritin and transferrin saturation meet the criteria since the use of iron in this population has moderate certainty of evidence. If an iron infusion is not helpful...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.
What degree of prolactin elevation is typically seen in patients with end stage kidney disease on hemodialysis?
Usually, less than 50, rarely 50-100. If it is higher than 100, one should look for another cause of hyperprolactinemia.
Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic range proteinuria, microscopic hematuria, and stable renal function who has been on a tenofovir-based regimen?
I often find the biopsy on these patients unhelpful. Having said that, I do advocate doing a kidney biopsy when there are other circumstances which raise the possibility of other disorders (i.e., possible IgA nephropathy, tenofovir was given for a short period of time, and only TAF was used, etc.).
What is your approach to managing asymptomatic severe hyponatremia secondary to impaired free water clearance in a patient with oliguric acute kidney injury who is not on renal replacement therapy?
There are limited options in the treatment of severe hyponatremia secondary to impaired free water clearance in a patient with oliguric acute kidney injury who is not on renal replacement therapy. In addition to strict free water restriction, a loop diuretic can be tried to convert from oliguric AKI...