Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you tailor protein intake recommendations for older patients with stages 3-5 non-dialysis dependent CKD, considering the unique metabolic and physiologic factors that influence protein metabolism in this population?
Personally, I would not restrict their protein intake. I would encourage good protein source intake such as eggs, chicken and fish. If serum BUN is very elevated, then it may be worthwhile discussing lower protein intake. If patient become uremic then dialysis should be discussed if indicated.
How would you approach management and monitoring of AL amyloidosis with isolated renal involvement?
This is tough for sure, and my first question would be to ask how the renal biopsy was determined to be AL amyloidosis. Sometimes typing isn't required if the pattern is overwhelmingly lambda-restricted or kappa-restricted by immunofluorescence... but in this case, mass spectrometry typing may be wo...
How do you manage oral prednisone when initiating nefecon in a patient with IgA nephropathy?
Careful tapering of prednisone and transition planning of budesonide.
How do you evaluate for clinically significant ureteral obstruction in a pregnant patient with AKI, since physiological hydronephrosis on kidney ultrasound is common?
For AKI, it would have to be bilateral, and then I would consult urology.
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
What is your approach to prednisone use in a kidney transplant recipient with allograft failure, residual allograft function, and an ongoing dialysis requirement for more than one year?
It really depends if this patient is a candidate for another transplant, and whether all the other immunosuppression has been weaned off. If they are a candidate for transplant, I am more likely to leave them on prednisone, especially with the residual renal function. If they are not a candidate for...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?
If the patient does not have APS and does not have nephrotic range proteinuria, then the indication for presumptive anti-coagulation is unclear.