Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you recommend oral phosphate for patients with recurrent nephrolithiasis?
Yes. There have been two studies both done long ago looking at the effectiveness of oral phosphates in preventing kidney stones. The first using K Phos Neutral was done at Mayo and showed a decrease in the frequency of stone passage. The second, done in a California system, used K Phos Acid and show...
How long do you wait to repeat a 24 hour urine stone risk study after stopping topiramate in patient with recurrent calcium based kidney stones attributed to the medication?
Assuming normal or near normal GFR, topiramate should be effectively eliminated after approximately 5 days, and urine pH should have returned to its pretreatment level. If more data is desired, a 24-hour urine supersaturation could be collected then. Topiramate predisposes to kidney stones by inhib...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
Are there situations when you a 1K dialysis bath as a long-term outpatient prescription for patients with ESKD?
I cannot think of a situation where this would be needed, and based on available data I recommend against it.In the hospital setting, there is some data that doing dialysis with a 1K bath is beneficial and can reduce mortality, see Singh et al., PMID 34476092.The same cannot be said for long-term di...
Do you wait until serum anti-GBM antibody titers are undetectable before hospital discharge in a patient with anti-GBM antibody disease with renal involvement who is receiving daily plasmapheresis, cyclophosphamide, and steroids?
If such a patient is responding to treatment, titers are declining, is otherwise doing well, and does not have extra-renal issues that would require hospitalization, for example, an ongoing oxygen requirement for lung involvement, they could be managed as an outpatient if pheresis can be arranged. I...
What are the best practices for preparing blood for transfusion in a patient with a kidney transplant to minimize complications?
HLA sensitization via blood transfusions could present problems with transplant candidates (diminishing the chance of finding a compatible donor) and for transplant recipients (greater hazards for deceased censored graft loss, Massicotte-Azarnioch et al., PMID 33912754). Scornik & Meier-Kriesche, PM...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
Do you have specific waiting periods before a patient can be listed for a kidney transplant if they have a past history of malignancy?
The pair of articles by Al-Adra and colleagues (Al-Adra et al., PMID 32976703; Al-Adra et al., PMID 32969590) outlining expert consensus opinions on melanoma/hematological and solid organ malignancies in transplant candidates serve as the primary references for this issue at our center. The treatmen...
Do you recommend hydrochlorothiazide to manage polyuria in patients with ADPKD who are on tolvaptan?
Indeed, this can sometimes be useful in this context. After other troubleshooting, I have had success with polyuria symptoms with some patients. The published benefit is up to ~1.8 L, according to Kramers et al., PMID 35314480. Kidney function can get a bit off during the transition, although should...
What is your approach to dose adjusting mycophenolate in a kidney transplant recipient who is transitioned from tacrolimus to cyclosporine?
When transitioning a kidney transplant recipient from tacrolimus to cyclosporine, it is crucial to adjust the dose of mycophenolate mofetil due to significant pharmacokinetic interactions. Cyclosporine inhibits the enterohepatic recirculation of mycophenolic acid (MPA), the active metabolite of MMF,...