Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long do you wait before arranging AVF placement in patients with AKI who remain dialysis dependent?
About 35-45% of dialysis-requiring AKI patients discharged from the hospital on dialysis will recover sufficient renal function to stop dialysis. The majority of patients who recover kidney function do so within the first 60 days after discharge. Elderly patients and those with poor pre-AKI kidney f...
Is the combination of SGLT2i and GLP 1 R agonist therapy contraindicated in patients who develop an episode of euglycemic DKA?
Therapy always needs to be individualized, but in most cases, SGLT2 inhibitors should be stopped in patients who have had euglycemic DKA. Such individuals likely have low endogenous insulin production. GLP1R agonists could further increase the risk of recurrent euglycemic DKA, and I agree with Mehta...
Do you recommend delaying spot urine protein quantification testing until after nephrostomy tube removal in a patient with obstructive uropathy?
Yes, if the tubes are coming out. Would not want to make treatment decisions under these circumstances. Not an emergency usually.
Would you rely on virtual crossmatch alone to proceed with a kidney transplant?
Yes. We switched to virtual crossmatch prior to transplant. We still do the actual cross match as well, but the results of that often come when the patient is in the OR.
Would you recommend off-label use of nedosiran for patients with primary hyperoxaluria type 2?
For a couple of reasons, no. The evidence is not clear if it works or not for PH2. If there is an effect, it is probably quite a bit less effective on average than for PH1. The cost is extremely high for a trial of something we are not confident will help. It is not FDA-approved for PH2, thus, paye...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
How do you choose between initiating long-term therapy with mTOR inhibitors versus opting for interventional treatments such as embolization or surgery in a patient with tuberous sclerosis, experiencing flank pain, and with renal angiomyolipomas larger than 4 cm?
I have very limited experience, but mTOR has been a game changer for my (2) TS patients. Why would you wait for bleeding, pain, and embolization if you can prevent it?
Do you advise your patients with cystinuria to perform home urine pH testing?
Definitely! Keeping urine pH above 7.0 is one of the most effective ways of preventing cystine crystallization. pH testing strips can be purchased cheaply on the Internet or in “big box” stores. (Pharmacies are much more expensive). I suggest testing four times daily and adjusting the urinary alkali...
For a patient with idiopathic hypercalciuria and a history of calcium kidney stones who has not normalized 24-hr urine calcium level on thiazide diuretic, is there evidence for targeting a certain urine calcium level for decreased future risk of nephrolithiasis and osteoporosis?
A good question, and the answer depends on your definition of a "normal" urine calcium level. If you use the standard definition of abnormal, the upper 5 percentile, depending on your laboratory, you will get values for upper normal calciuria in the 250-300 mg per day. However, approximately 10% of ...
Do you use PTH levels to help differentiate CKD from AKI in patients who are being evaluated for an elevated creatinine level and who lack long term lab data?
Distinguishing between AKI and CKD in the absence of previous labs can sometimes be challenging. Although PTH levels tend to be higher in CKD than AKI patients, PTH levels can increase quickly in AKI, and a substantial portion (25-50%) of AKI patients will have a high PTH level. So, while it may be ...