Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do various therapeutic approaches for IgA nephropathy target the different stages of the four-hit hypothesis?
Based on our mechanistic understanding and some limited biomarkers, we think that ACEI, ARB, SGLT2i, endothelin antagonists like sparsentan, and complement inhibitors like iptacopan all act on the final "Hit 4" of glomerular inflammation. This points out that Hit 4 is actually quite complex! It invo...
Would you continue to monitor urinary protein levels and dose adjust axitinib in a patient with metastatic malignancy who is now dialysis dependent but has residual renal function?
The question lacks specificity, so I will assume that this refers to a patient with irreversible ESRD not due to the TKI itself. Generally, if the proteinuria was exclusively due to the TKI, the HTN and proteinuria will abate when the drug is discontinued. Also, as renal function declines, the prote...
What medications do you use to treat encapsulating peritoneal sclerosis?
There are three stages in the progression of encapsulating peritoneal sclerosis (EPS): the inflammatory stage characterized by the presence of inflammatory markers e.g. CRP and IL-6, which may present with bloody ascites and in which CT scan shows minimal changes, if any; the encapsulating stage cha...
How often do you check renal function panels for patients with recurrent nephrolithiasis?
Interestingly, most patients with recurrent kidney stones have normal or near normal GFR. I check them annually when I do imaging and 24-hour urine supersaturations looking for metabolically active stone disease. For those patients with decreased GFR, I recheck them at the same frequency, I would c...
What level of 24h urine M protein do you consider to define active myeloma in a patient with renal insufficiency, proteinuria and monoclonal gammopathy?
When in doubt, a renal biopsy is preferred to define what is the exact disease process leading to renal dysfunction. If cast nephropathy is seen, this supports a diagnosis of myeloma. If amyloid or light chain deposition disease is seen, this also supports a diagnosis of amyloidosis or MGRS/myeloma,...
How do you manage proteinuria in a patient with type 1 diabetes mellitus who has orthostatic hypotension and is unable to tolerate ACEi/ARBs?
I do agree with Dr. @Dr. First Last that orthostatic hypotension should be evaluated. This could include a 24-hour ABPM and/or careful home BPs + weight monitoring. If dysautonomia is suspected, then seeing a specialist for dysautonomia could be beneficial.Surprisingly, orthostasis symptoms improved...
How do you approach the workup of a patient with a large focal wedge-shaped cortical swelling on CT concerning for renal infarct, but with a normal echocardiogram showing no thrombus or vegetation?
This would depend on the clinical setting - is this someone presenting with signs or symptoms suggesting acute ischemic kidney disease, or an incidental finding on the CT? My first step would be to determine if this is actually a renal infarct by imaging. Either CTA or MRA, or nuclear renogram would...
Do you recommend chanca piedra supplements for patients with recurrent calcium oxalate nephrolithiasis?
NO. No data support its use. The idea of ''breaking' a crystal matrix mass of CaOx crystals does not seem thermodynamically likely.Given it is implausible and unproven I shun the stuff.
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
Do you obtain a urinalysis for glucose testing for your patients on SGLT2 inhibitors to assess for medication adherence?
I do not do a UA solely for this purpose, but it helps to have one for other routine testing purposes that demonstrate the glucosuria.