Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
What is your approach to prednisone use in a kidney transplant recipient with allograft failure, residual allograft function, and an ongoing dialysis requirement for more than one year?
It really depends if this patient is a candidate for another transplant, and whether all the other immunosuppression has been weaned off. If they are a candidate for transplant, I am more likely to leave them on prednisone, especially with the residual renal function. If they are not a candidate for...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?
If the patient does not have APS and does not have nephrotic range proteinuria, then the indication for presumptive anti-coagulation is unclear.
What is the maximum diuretic regimen recommended in patients with end-stage kidney disease who have residual renal function and volume overload?
Studies in peritoneal dialysis have shown both the safety and benefit of high-dose furosemide. One study randomly assigned 61 incident CAPD patients to either furosemide 250 mg every day or no furosemide at the time of CAPD training and they were followed prospectively. Baseline 24-hour urine volume...
Which method provides a more accurate assessment of hypercalciuria: 24-hour urinary calcium excretion or the spot urine calcium-to-creatinine ratio?
24-hour urine should be more accurate. F. Singer
How do you approach discussing the pill burden of voclosporin with patients who already have to take a regimen such as MMF+HCQ+ACEi and possibly more?
Medication adherence and a chronic disease such as lupus is an issue regardless of the number of medications. For example, hydroxychloroquine is very effective, but studies often show poor adherence as measured blood levels may be undetectable or below the intended therapeutic target.For patients wi...
What is your approach to managing patients with recurrent nephrolithiasis and nephrocalcinosis in the setting of hypoparathyroidism?
If patients truly have hypoparathyroidism, then the issue is to manage their hypocalemia, which usually requires large doses of oral calcium as well as treatment with VDRAs, which results in marked hypercalciuria, since they do not have PTH to help reabsorb calcium. This even occurs when they have C...