Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach the workup of a patient with a large focal wedge-shaped cortical swelling on CT concerning for renal infarct, but with a normal echocardiogram showing no thrombus or vegetation?
This would depend on the clinical setting - is this someone presenting with signs or symptoms suggesting acute ischemic kidney disease, or an incidental finding on the CT? My first step would be to determine if this is actually a renal infarct by imaging. Either CTA or MRA, or nuclear renogram would...
Do you recommend chanca piedra supplements for patients with recurrent calcium oxalate nephrolithiasis?
NO. No data support its use. The idea of ''breaking' a crystal matrix mass of CaOx crystals does not seem thermodynamically likely.Given it is implausible and unproven I shun the stuff.
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
Do you obtain a urinalysis for glucose testing for your patients on SGLT2 inhibitors to assess for medication adherence?
I do not do a UA solely for this purpose, but it helps to have one for other routine testing purposes that demonstrate the glucosuria.
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...