Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...
What is the role of APOL1 genotyping in the evaluation of a living kidney donor?
Testing for APOL-1 in living donors is controversial and a topic of much discussion and debate. There are not standardized guidelines of who and when to test. Some centers incorporate testing into their protocols while others individualize the decision regarding testing. There are a couple aspects t...
How do you counsel patients about the likelihood of improvement in kidney disease after anti-cancer treatment is initiated in a patient with malignancy associated membranous nephropathy?
There are numerous case reports to support that if the patient has a paraneoplastic MN then the expectation is that the renal lesion will respond to cancer directed therapy.
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
How do you decide when to refer for an access angiogram in a patient on hemodialysis with a drop in Kt/V but no other signs of access dysfunction?
In a JASN study (Coyne et al., PMID 9259360), the 3 comment causes of low Kt/V were: 42%- from poor blood cleaning due to low blood flow or shortened HD time 25% - due to recirculation from access dysfunction or reversed needles 33% - no cause identified, but on subsequent monthly testing, it normal...
How do you decide when to stop immunosuppression in a patient with granulomatosis with polyangiitis who is on dialysis, has not yet recovered renal function, but has shown improvement in ANCA levels?
In a patient with pauci-immune necrotizing GN from GPA on HD, I usually wait for 3 months and up to 6 months if the biopsy is fresh with minimal chronicity before declaring ESRD and stopping IS. If they have extrarenal disease (ENT, lungs), they would need IS for extrarenal disease.
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
When would you consider referring a patient with resistant hypertension for renal denervation?
I consider renal denervation in patients who have 2 kidneys without renal artery pathology, eGFR > 40, a negative secondary workup (including exclusion of primary aldosteronism), uncontrolled BP, and who can return for follow-up monitoring after the procedure. Some of my referrals have been in patie...