Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?
We follow the SUNTRAC guidelines. For first screening, very high risk (prior history of NMSC)- 6 months post tx. High risk (older, fair-skinned) - 12 months. Medium risk (younger, fair-skinned) - 24 months. Low risk (dark skinned) - 10 years. Retransplants I usually recommend 6-12 months post-transp...
Do you recommend a kidney ultrasound to evaluate for microcystic changes when caring for a patient with chronic kidney disease suspected secondary to chronic lithium use?
Not sure if the ultrasound will add to management beyond lab values and routine ultrasound for patients with CKD. The question comes if someone has microcystic changes and normal creatinine levels, would that indicate a need for a change of therapy? In the past, lithium has been a very effective (ma...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Do you transition to non-tablet formulations of potassium citrate in patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia who are noticing intact tablets in their stool?
Wax matrix slow release tablets release their contents but need not dissolve and are often seen by patients. I never change meds just because of signs of the tablets, I watch the 24 hour urine K, citrate, pH, and the balance between ammonia and sulfate. If the pills are working K and pH and citrate ...
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...