Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you use voclosporin or belimumab as adjunctive therapy for treatment of lupus nephritis?
Yes, I would. However, this is not a uniformly accepted practice. Many clinicians believe the effect sizes were not sufficiently large to warrant drugs as initial therapy. The reasons for dual therapy (MMF and belimumab or MMF and voclosporin) go beyond the primary endpoint of the BLISS-LN and Auror...
How do you manage a pregnant patient with lupus who develops renal disease during pregnancy that is not due to pre-eclampsia?
As the question implies, the first order of operations, when a pregnant lupus patient develops clinical features of nephritis, is to distinguish between the two most common etiologies, pre-eclampsia and lupus nephritis. The former is due to an imbalance between SFLT (soluble FMS like tyrosine kinase...
Do you recommend bone mineral density testing in your patients with recurrent nephrolithiasis secondary to medullary sponge kidney?
A majority of patients classified as MSK do not have that disease. They are calcium phosphate stone formers with multiple duct of Bellini crystal plugs. Most of those have idiopathic hypercalciuria and in that genetic syndrome bone mineral loss is not at all uncommon. Some patients - but by no means...
Would you consider adding an SGLT2i for a patient with proteinuric kidney disease who is already on maximal dose ACEi/ARB and has a UACR < 300 mg/g?
I not only would consider it, I've done it on many occasions. There's nothing magical about UACR <300 that eliminates the risk of CKD progression. The risk decreases but it's not an inflexion point. The lower the albuminuria, the lower the risk of progression, which has been well demonstrated in IgA...
Do you recommend treating asymptomatic Proteus urinary infections in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
Yes! Proteus species are typically rapid producers of urease, splitting urea to ammonium and raising urine pH, often into the high 7s and precipitating, magnesium, ammonium phosphate stones, otherwise known as struvite.Your patient’s Proteus infection apparently splits urea more slowly with less ele...
How do you approach “clearing” a patient with SLE and ESRD for renal transplant?
Prefer the term "optimizing" as opposed to "clearing" SLE patients for procedures such as renal transplants and issues here similar to identifying the preferred time to proceed with pregnancy, specifically in patients with a history of LN, with the goal in both scenarios of achieving desired outcome...
How do you manage hemodialysis for an ESKD patient presenting with severe hyponatremia and a serum sodium more than 10 mEq/L below the lowest available dialysate sodium concentration?
There are multiple ways of dealing with this situation. One option is not to dialyze if not urgent and let the sodium come up before starting dialysis. The most exact way of dealing with the situation is to do hemofiltration either continuously or intermittently with a concomitant D5W infusion adjus...
Do you recommend temporarily holding SGLT2 inhibitors in patients with CKD who are undergoing CT imaging with intravenous contrast?
Probably should hold the morning dose before giving contrast. The risk I would assume is very low, likely lower than giving lasix prior to the contrast which we normally do not hold.
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
Are there instances when you recommend kidney stone disorder gene testing in patients suspected of having cystinuria?
If the patient has a stone analysis showing pure cystine, I consider that proof positive of homozygous cystinuria and do not recommend genetic testing for the patient. However, I suggest that first degree relatives get genetic testing for cystinuria, and, if homozygous, I recommend preventive treatm...