Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Under what circumstances would you consider obinutuzumab instead of rituximab when treating primary membranous nephropathy?
Obinutuzumab is a Type II fully humanized glycoengineered anti-CD20 monoclonal antibody with marked B-Cell depletion along with greater antibody dependent cytotoxicity when compared to Rituximab.Currently, its use in 'primary' membranous nephropathy is limited to only refractory cases wherein Rituxi...
Would you consider a patient with spina bifida and end stage kidney disease secondary to reflux nephritis with an ileal conduit for a kidney transplant?
In general, patients with ileal conduit and those with neobladder can be considered for kidney transplantation.
Would you recommend transition to hemodialysis for a patient with calciphylaxis, hyperphosphatemia, and ESKD on peritoneal dialysis?
Changing from PD to HD is a tough decision but I would do it for calcemic uremic arteriopathy CUA (calciphylaxis) for two reasons, increase clearance and guarantee IV delivery of sodium thiosulfate (STS). Peritoneal STS has been describedMataic & Bastani, PMID 16771254But I think CUA is life-threate...
Below what platelet count would you avoid using an AV fistula in a patient with ESKD and thrombocytopenia?
Great question & the answer is likely debatable based on personal experience. Review of some case reports show no evidence of prolonged bleeding after AVF cannulation with platelet counts as low as 37,000 (1). Platelet counts can drop by 5- 15% with initiation of HD normally. They fall during the fi...
Would you recommend avoiding PICC line placement in a kidney transplant patient with an estimated GFR of more than 45 ml/min/1.73m2 and no functional AV access?
Great question and of course there is no data to guide decision-making in this scenario. Anecdotally, I would assess the patient as a whole, not just limited to current GFR though that is a great starting point. What is their age and co-morbidities - is this a younger /middle-aged/older patient, is ...
Are there instances when you do not recommend tunneled dialysis catheter exchange in patients on hemodialysis who are found to have bacteremia?
Generally, the answer is no. The only situation I would not recommend tunneled catheter exchange is if the patient has "run out" of catheter insertion sites and removal of the catheter poses the risk of not being able to place another tunneled catheter. That is also tempered by the organism causing ...
What is your approach to managing insomnia in an ESKD patient?
I try to stay away from medication therapy. First, I recommend good sleep hygiene (i.e., avoiding coffee, watching TV while in bed, too much light, etc.). The next step would be recommending as much exercise (mainly walking) as possible. If I have to use medications, I would start with melatonin and...
Would you recommend oral or intravenous iron in a chronic kidney disease stage 4 patient who is not on an ESA and has a hemoglobin of 12.7 g/dl and an iron saturation of less than 20%?
I would not necessarily treat this patient with iron at all. I would check serum ferritin. If low would do a colonoscopy or look for causes of iron deficiency. If not low would observe. In general though for patients with CKD (not on dialysis yet) who need iron therapy, I would try oral iron first. ...
Would you add an SGLT2 inhibitor to augment diuresis during a hospitalization in a patient with nephrotic syndrome, an eGFR above 30 mL/min/1.73m2, and refractory hypervolemia on an intravenous loop diuretic?
Establish true loop diuretic refractoriness (minimum frequency: BID, the max dose depends on CrCl). Add sequential diuretics. Metolazone or other thiazide-like diuretics, with without amiloride or spironolactone. (Latter diuretics are preferred if the patient is hypokalemic). Add 25% albumin if e...
Do you consider starting hydroxyurea in a patient with hemoglobin S-beta thalassemia with chronic kidney disease secondary to FSGS?
I consider initiating hydroxyurea in all individuals with sickle cell disease, even if they have rare or infrequent acute pain episodes. This is because pain is just one manifestation of the disease and ongoing hemolysis leads to a state of chronic inflammation characterized by cytokines, activation...