Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What workup would you perform for a patient with chronic kidney disease and kidney biopsy showing hypersensitivity-type interstitial nephritis?
A thorough history and physical exam, including eye exam, then a very thorough drug history including OTCs, herbals, supplements, & illicits. Other workup would be guided by findings from exam and history (systemic findings) and specific pathology features such as granulomas.
What is your approach to the treatment of fibrillary glomerulonephritis coexistent with monoclonal gammopathy?
Fibrillary glomerulonephritis was initially considered to be an idiopathic disorder, but it is now known to be secondary to malignancy, monoclonal gammopathy, infection (such as HCV), or autoimmune disease in up to 50% of patients. This is a rare disease, and few practitioners outside of glomerulone...
In which patients with atypical HUS would you consider eculizumab discontinuation?
My approach to eculizumab cessation in aHUS is to at least consider cessation in all patients not only given the high cost of the drug, but also given the risk of meningococcemia, which is incompletely protected against by vaccines.In treating aHUS, I initiate eculizumab (and preventive therapy for ...
Would you pursue more dedicated stone surveillance imaging testing for a patient with recurrent nephrolithiasis who has PET-CT scans twice yearly?
Unless the patient is symptomatic, I am not sure there is a reason to. Though PET CT is not the best imaging to look for stones.
Would you continue spironolactone in a patient who has recently progressed to ESKD on HD with oliguria and was diagnosed with primary hyperaldosteronism years ago?
Although spironolactone does antagonize the effect of aldosterone in the colon, it is unlikely that spironolactone will be effective in treating primary hyperaldosteronism in a patient with ESKD with minimal urine output. Therefore, I would discontinue the spironolactone in such patients.
Would you recommend pregnancy testing for a female patient with recurrent nephrolithiasis for whom you are considering a CT stone scan for routine stone surveillance?
I would go with an ultrasound first and not with CT for screening.
What is the best way to assess exercise capacity in kidney transplantation candidates to predict post-transplant outcomes?
This is a great question and quite variable across centers. The most consistently used across centers is the 6 min walk, though we are not yet doing that. Our general guide is for them to try to exercise 30 minutes on non-dialysis days, with the ultimate goal of walking a mile in 30 minutes (though ...
When would you suspect an allergy to the dialysis membrane in patients who complain of pruritis during dialysis?
The short answer is no. Pruritus is so common with renal disease, and allergic reactions to dialyzers are uncommon. If the pruritus can confidently be documented to be only during dialysis and not at any other time, then it may be worth trying a different dialyzer but it would take a lot for me to b...
How do you manage early patient-reported polyuria after starting an SGLT2 inhibitor to prevent premature discontinuation?
I have not encountered this situation yet. I would imagine the polyuria improves over time as eventually intake has to equal output. Of course, it is possible that polyuria will cause increased thirst. Reassuring the patient is the best first option.
Do you use SGLT2 inhibitors in the management of SIADH?
The osmotic diuresis induced by SGLT2 inhibitors results in the urinary excretion of water in excess of Na+ and K+ excretion, thereby resulting in an increase in the serum sodium concentration. However, SIADH is a clinical disorder characterized by an increase in TBW in the setting of relatively nor...