Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
For which patients with calciphylaxis would you recommend a parathyroidectomy?
In those with refractory hyperparathyroidism (typically PTH above 800-1000 pg/mL) despite medical therapies like cinacalcet.
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
Below what eGFR would you consider discontinuing lithium in a bipolar disorder patient with chronic kidney disease?
It seems nowadays we have other effective therapy besides lithium for the treatment of bipolar disorder. I tend to stop lithium as soon as I get a sense that there is a decline in kidney function as to avoid further damage. Of course, all of this depends on the specific situation and other possible ...
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...
How often do you screen for cerebral aneurysms in patients with autosomal dominant polycystic kidney disease who do not have a family history of intracranial aneurysms or for whom the family history is unknown?
We recently wrote an editorial about this topic. Our conclusion was as follows: "considering the potential for morbidity and mortality in this unique population at risk for ICAs with possibly higher-than-average risk of rupture, we believe that presymptomatic screening for ICA in all individuals wit...
How is monoclonal gammopathy of renal significance (MGRS) different from myeloma kidney?
The terminology around renal failure and myeloma is confusing and sometimes unnecessarily complicated. Here is how I approach it: Light chain (cast) nephropathy - This is from toxic injury to the nephron tubules from excess light chains. This is usually picked up on biopsy or can be ascertained fro...
What is your approach to managing a kidney transplant patient who develops BK viremia after treatment for rejection?
This is always a challenging situation. First, I decrease the mycophenolate, typically by 50%. Some of my management depends on whether the rejection was antibody mediated vs cellular, and how high the BK viral load is. If there was antibody mediated, I prefer to maintain some mycophenolate, if poss...
Do you recommend periodically testing for anti-GBM antibody in patients with ESKD secondary to Alport's syndrome who are status post kidney transplantation?
I would not recommend randomly checking anti-ABM antibodies. If the patient develops an increase in creatinine or new abnormalities in the UA or UPC, then I would pursue renal allograft biopsy and make sure pathology does immunofluorescent staining. It is exceptionally rare, but should be kept in th...
Do you recommend antibiotic prophylaxis for an ESKD patient with a tunneled dialysis catheter who is planned for a dental procedure?
I do not. Which procedures require antibiotic prophylaxis has always been a very confusing issue for me. It also seems to change often. However, with dental procedures, the main organism responsible for bacteremia is streptococcus of viridans group which is an unlikely cause of line infection. I thi...
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...