Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When do you use ambulatory blood pressure monitoring to assess hypertension in a living kidney donor candidate?
We use this if there is clinical suspicion of undiagnosed hypertension- for example if the average of the blood pressure log is borderline high (>130/80) or if the average is ok but there are some high readings or if the clinic reading is high. Other risk factors we consider include obesity, prior t...
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...
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.
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...
Do you prefer using losartan in your patients with hypertension and gout due to its uricosuric effects?
I do find losartan helpful. It is especially helpful asking a PCP to change HCTZ to losartan. Though the losartan's urate-lowering effect is a small amount, I combine this with dietary changes (especially greatly limiting the intake of foods high in fructose) and eating purines in moderation, and e...
How do you modify the hemoglobin goal and ESA dosing for patients with sickle cell anemia and ESKD on hemodialysis?
In sickle cell patients, I coordinate care with the patient's hematologist. I will reduce the hemoglobin goal to 8-10 g/dl, and if patients have a history of crises, closer to 10 g/dl, I may choose 7-9 g/dl. ESA requirements seem to be higher in sickle cell patients, so I would start with 100 units/...
Do you have patients with recurrent nephrolithiasis target a certain urine volume or rather consume fluids as needed for goal of having consistent clear urine?
I think you could go either way. To prevent most types of kidney stones, 2L/day seems to be the minimum urine volume required. For cystine stone formers, I double that amount. My more compulsive patients like having a quantitative goal. The amount of fluid intake roughly equals the urine volume, abs...
Do you recommend using a risk equation or eGFR alone in deciding when to refer a patient with advanced CKD for vascular access placement?
This is not an easy question, I still rely on patients trajectory, clinical judgement.
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
Do you recommend switching from tacrolimus to cyclosporine in a kidney transplant patient diagnosed with PTLD?
In general, we would reduce immunosuppression as much as possible. We do not switch Tac to CSA at our center if the patient is on Tac but run the levels low as much as possible. We are more likely to stop the antimetabolite especially if the patient is EBV PCR positive and/or is undergoing additiona...