Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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,...
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?