Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
Do you recommend plasmapheresis prior to kidney transplantation for patients with elevated panel-reactive antibody percentages?
No, preemptive PLEX is not necessary with a high PRA in the absence of DSA. At our center, we do monitor for emergence of DSA in our patients with the highest PRAs >98%.
How do you approach chronic active AMR concurrent with changes of CNI toxicity?
This can be a tricky situation. With AMR, my approach is to optimize the antiproliferative agents (mycophenolate) and maintain therapeutic levels of the CNI. Adjusting the CNI target level will be dependent on the degree of CNI toxicity, if present. Maybe for mild changes, run the tact levels in the...
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...
How do you advise your patients to optimally store a recently passed kidney stone to ensure it can later undergo composition testing?
I am not aware that kidney stone composition changes significantly ex vivo. Calcium oxalate dihydrate will gradually change to monohydrate, but that does not influence my treatment recommendations. The more challenging problem is capturing the stone for analysis. For patients with colic, I send them...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
In a patient with acute stroke/ICH/SDH/hyperammonemia at risk for rebound edema with new onset renal failure, do you prefer CRRT versus low and slow HD?
In the acute period (first 72-96 hours after ictus), my personal preference is CRRT due to the theoretical advantage of hourly titration of ultrafiltrate. I don't know if it really matters though. As for the frequency of laboratory evaluations, I don't find more frequent than q4 hours to be useful, ...
How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?
For those with a history of skin cancers prior to transplant would recommend every 6 months. For those with no history of skin cancer I recommend skin checks every 6 months starting 1-2 years after transplant. Those at highest risk are the Latino and Caucasian propulations but even those in the less...