Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
Do you recommend dietary changes to your patients with recurrent kidney stone disease who consume coffee and low oxalate teas daily?
Thank you for your question. Many patients get tired of drinking water and would prefer coffee, low-oxalate tea, or other beverages instead. Studies have shown no difference in whether the water is hard or soft. Coffee and low oxalate tea do not seem to increase stone passage either. There is some d...
When do you deem it reasonable to transition outpatient management of a kidney transplant patient to general nephrology?
Many transplant centers have different views on when to transition patients. In our program, we transition patients after a year post-transplant and alternate visits between the transplant center and the referring nephrologist until year 3 when we ask the patient to see their nephrologist quarterly ...
How would you treat a kidney transplant patient with both biopsy-proven BK nephropathy and recurrent membranous glomerulonephritis with nephrotic range proteinuria?
Mostly concur with Dr. @Dr. First Last. I would generally shy away from cidofovir - the most recent consensus guidelines for BK management recommend against cidofovir due to evidence largely being poor for effectiveness. IVIg has not much better evidence but is also much less toxic. Once BK is brou...
Do you routinely transition patients with recurrent calcium based kidney stones off of hydrochlorothiazide and onto chlorthalidone or indapamide for optimal control of hypercalciuria?
Yes, I do as they are longer acting thiazides and thus have better control over hypercalciuria. I generally start with Indapamide 1.25 mg daily and will titrate up if necessary. I prefer that as opposed to Chlorthalidone as to start with 12.5 mg Chlorthalidone, you need to cut it in half, which is n...
Would you feel comfortable adding benlysta to patient already taking both mycophenolate and tacrolimus (and hydroxychloroquine) who still has some evidence of active lupus nephritis?
ABSOLUTELY (if the mycophenolate + tacrolimus combination therapy had had positive benefits on decreasing proteinuria plus was well tolerated thus far)!1. Per the package insert label for indications, "BENLYSTA is indicated for patients aged ≥5 with active systemic lupus erythematosus (SLE) or activ...
Would you treat an ESKD patient with renal artery stenosis in an attempt to improve blood pressure control and preserve residual renal function?
When a patient is dialyzing, the dialysis prescription and lifestyle factors, like salt and water intake, dominate blood pressure control. In both CORAL and ASTRAL trials, blood pressure control and residual renal function was not improved by renal artery intervention. For both of those reasons, I w...
Would you consider restarting a SGLT2i at a reduced dose in a patient who you previously discontinued the medication because of an associated significant decline in eGFR?
Restarting an SGLT2i in a patient after a severe episode of AKI requires careful decision-making and patient agreement. If the AKI episode was deemed related to volume depletion (hemodynamically mediated AKI), I restart the SGLT2i at a lower dose. At the same time, I re-counsel the patent on fluid i...
Do you recommend immediate catheter removal or anticoagulating for a certain amount of time before removing the tunneled dialysis catheter of a patient with an incidentally found, asymptomatic thrombus at the end of the catheter that does not interfere with hemodialysis?
I agree with Dr. @Dr. First Last. Since this tunneled dialysis catheter (TDC) is functioning well, there is no urgency to remove it. Infact, removal runs the risk of dislodging the thrombus causing pulmonary embolism. I would provide systemic anticoagulation with a vitamin K antagonist (coumadin) us...
How do you approach COVID-19 vaccination in those with a prior history of glomerular disease?
It is well documented that patients with kidney disease are at increased risk for morbidity and mortality from SARS-CoV2 infection including increased rates of hospitalization, AKI and death. Those with preexisting glomerular disease (GD) have demonstrated impaired GFR recovery following AKI in the ...