Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
Proceed with coronary angiogram and dialysis after the procedure.
How often would you recommend urine studies to monitor for potential lupus nephritis in a patient with lupus?
I would recommend every 3-4 months.
Are there instances when you use letermovir without the addition of acyclovir when managing a kidney transplant recipient for CMV prophylaxis?
I am assuming this question is about initial viral prophylaxis after transplant and exposure to induction immunosuppression. We have not used often letermovir as first line CMV prophylaxis outside of a research study, or during valcyte shortages. Cases where one might consider Letermovir as prophyla...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
Do you recommend prescribing Pneumocystis jiroveci pneumonia (PJP) prophylaxis for a patient with membranous glomerulonephritis on rituximab?
In general, I don't use Pneumocystis jirovecii pneumonia prophylaxis (PJP PPx) for patients with membranous nephropathy (MN) who have only received rituximab (RTX), unless they have also received high-dose glucocorticoids (GC) or cyclophosphamide (CYC). I usually give PJP PPx when patients receive h...
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Would you pursue temporary dialysis catheter placement followed by hemodialysis in a hospitalized patient with ESKD who is not able to undergo urgent fistula repair for a non-functioning fistula and receives gadolinium for a MRI study?
There is no role for hemodialysis following the GAD preparations we use these days.
Do you have patients with recurrent nephrolithiasis temporarily hold potassium citrate when prescribed acetazolamide for altitude sickness prevention?
I haven’t encountered this situation before. I can see the theoretical disadvantage of combining the two medications. For short-term use of acetazolamide, I doubt there would be a problem. For longer-term use, I would monitor electrolytes and reduce or stop the potassium citrate as appropriate.