Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What precautions need to be taken to ensure the successful maturation and long-term functionality of an endovascular arteriovenous fistula?
A broad topic - I'll attempt to hit the main points. Considering many fistulas do not mature (forearm fistula > upper arm) - Successful maturation starts with vein preservation (avoiding PICC lines, IV lines, and marking the chosen limb with a bracelet); choosing an appropriate artery (non-calcified...
Would you consider not returning the blood from the dialysis circuit as a strategy for managing polycythemia in a patient with ESKD on hemodialysis who has a hemoglobin level greater than 16 g/dL?
It has been a while since I had a patient on hemodialysis with polycythemia, but I have “wasted” the blood circuit so the patient wouldn’t have to go for phlebotomy on a non-dialysis day. I believe that we didn’t return the blood once a week until his hematocrit was at goal, and then as needed there...
What is the recommended workup for PTH-independent hypercalcemia secondary to an elevated 1,25-dihydroxyvitamin D level?
I presume what is meant is that the PTH is suppressed, and therefore, with an elevated 1,25-dihydroxyvitamin D concentration, it is likely the primary cause? The 2 major causes for elevated 1,25-dihydroxyvitamin D when serum 25-hydroxyvitamin D is normal or sometimes low are due to either a granulom...
Would you recommend CRRT instead of intermittent hemodialysis to prevent lithium rebound in a patient with lithium toxicity after an initial intermittent hemodialysis session?
I think the best way to approach any "overdose" of a drug that is dialyzable and may have a rebound is to start with hemodialysis and run it until you have achieved your desired response (drug level, improvement in some other parameter) and follow that with CRRT to manage any rebound. This is well s...
Do you prefer a mycophenolate or tacrolimus based glucocorticoid-sparing regimen for patients with minimal change disease?
I prefer using CNIs over MMF as a steroid-sparing agent. It is important to note that the mechanism of action of CNIs in glomerular disease is likely not just from its immunomodulatory effects as CNIs can also cause stabilization of the podocyte cytoskeleton Peleg et al., PMID 32152065
Which salt substitutes do you recommend for your patients with recurrent nephrolithiasis who have hypercalciuria from excess sodium chloride intake?
As the questioner correctly implies, dietary sodium will worsen hypercalciuria. For hypercalciuric calcium stone formers, I recommend a no-sodium-added diet. Non-sodium salt substitutes are permissible. I do not have a brand preference. If the patient has renal insufficiency, potassium-containing su...
Given the cardioprotective and renoprotective effects of SGLT2 inhibitors, should we consider administering to patients with well controlled type 1 diabetes despite the risk of DKA?
The key word in this question is "consider". GIven the lack of published clinical trials to assess efficacy (CV and CKD hard outcomes) versus safety (DKA) in this population, an answer at this time would be a qualified yes, with the qualifications being a well-motivated patient who adheres to self-g...
How long do you wait for a reduction in EBV viral load after reducing immunosuppression before deciding to start rituximab in a kidney transplant patient with EBV viremia?
This is a difficult question. If this is in the context of EBV viremia and kidney transplant patients with PTLD that is EBER positive, I make this decision in consultation with the treating hematologist/oncologist. I have not used rituximab in EBV viremia alone.
Are there instances when you obtain an abdominal X-ray over an ultrasound or CT scan for kidney stone surveillance in a patient with recurrent calcium based nephrolithiasis?
I agree with Dr. @Dr. First Last. I see no use for an abd Xray. I, generally, go to US, which has no radiation and is good at localizing stones and can identify relatively small stones as well as give a good sense of stone burden. Occasionally, a CT may be required.
Under what circumstances would you obtain MR imaging of the kidneys in a patient with ADPKD who was recently diagnosed following CT imaging?
If a CT was definitive, an MRI is not needed except to obtain accurate total kidney volume measurements in some cases, depending on CT quality and in cases in which TKV falls on the borderline between categories of Mayo Imaging Classification (MIC) that was affect the ability to make a treatment dec...