Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there still a role for plasma exchange/PLEX for confirmed or suspected cast nephropathy in multiple myeloma to rapidly reduce light chain burden?
This is a good question that comes up from time to time. The most important thing is time-to-bortezomib, which should be as short as possible.For light chain only disease, I do not do plasma exchange. My reasons are: It only marginally reduces free light chains (see: Hutchison et al., PMID 17229909)...
What factors influence your decision between guidewire exchange versus removal and replacement through a new tunnel tract for patients with tunneled hemodialysis catheter mechanical failure?
Mechanical failure of a tunneled dialysis catheter (TDC) could be from catheter cuff extrusion form the exit site, catheter thrombosis or a fibrin sheath. In all three scenarios I prefer guidewire exchange rather than removal and replacement of the TDC. Removal and replacement are much more invasive...
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...
What is your approach to inpatient immunosuppression for a kidney transplant patient on home tacrolimus, prednisone, and mycophenolic acid who cannot tolerate anything by mouth?
When someone is NPO or cannot tolerate tacrolimus by mouth we give it sublingually. The sublingual dose is twice as potent as po so if someone is on 2 mg twice daily PO we would give 1 mg SL bid and monitor levels. Mycophenolate mofetil is available IV and is a 1:1 dose. Someone on 500 mg po bid MMF...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
How long do you recommend waiting before repeating a serum electrolyte panel after the conclusion of an intermittent hemodialysis session to ensure accurate results are obtained?
Depends on what our goal is. For an accurate potassium level, I would wait at least 4 hours, but likely 6 hours. For an accurate urea level, 1-2 hours would be fine. For phosphorus, again, I would wait longer. At times, I check labs right after dialysis to see if the temporary decrease in serum elec...
What precautions need to be taken to ensure the successful maturation and long-term functionality of an endovascular arteriovenous fistula?
A broad topic - I'll attempt to hit the main points. Considering many fistulas do not mature (forearm fistula > upper arm) - Successful maturation starts with vein preservation (avoiding PICC lines, IV lines, and marking the chosen limb with a bracelet); choosing an appropriate artery (non-calcified...
Would you consider not returning the blood from the dialysis circuit as a strategy for managing polycythemia in a patient with ESKD on hemodialysis who has a hemoglobin level greater than 16 g/dL?
It has been a while since I had a patient on hemodialysis with polycythemia, but I have “wasted” the blood circuit so the patient wouldn’t have to go for phlebotomy on a non-dialysis day. I believe that we didn’t return the blood once a week until his hematocrit was at goal, and then as needed there...
What is the recommended workup for PTH-independent hypercalcemia secondary to an elevated 1,25-dihydroxyvitamin D level?
I presume what is meant is that the PTH is suppressed, and therefore, with an elevated 1,25-dihydroxyvitamin D concentration, it is likely the primary cause? The 2 major causes for elevated 1,25-dihydroxyvitamin D when serum 25-hydroxyvitamin D is normal or sometimes low are due to either a granulom...
Would you recommend CRRT instead of intermittent hemodialysis to prevent lithium rebound in a patient with lithium toxicity after an initial intermittent hemodialysis session?
I think the best way to approach any "overdose" of a drug that is dialyzable and may have a rebound is to start with hemodialysis and run it until you have achieved your desired response (drug level, improvement in some other parameter) and follow that with CRRT to manage any rebound. This is well s...