Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you use a phosphate binder to manage inpatient hyperphosphatemia in patients with AKI who have no history of CKD?
I agree there is uncertainty about optimal serum phosphate concentrations in patients, and essentially no data in AKI. However, increases in Phos do result in an increased risk of metastatic calcification, and increases FGF23 and PTH, even in AKI and these changes clearly have increased risks, thus,...
How do you approach palliative conversations about what patients can expect when deciding to stop maintenance dialysis?
I typically include this discussion with my patients as part of the discussion of what options are available to address irreversible progressive CKD (eGFR<25). I find it best to present all options for ESKD management in a balanced format and I open the clinic visits to all family and friends to sup...
How do you manage patients with end stage kidney disease and recurrent ascites who do not have any evidence of cardiac or liver disease?
This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...
What are your next steps for managing biopsy-proven interstitial nephritis from checkpoint inhibitors in patients who do not have a response to prednisone?
As indicated by Dr. @Dr. First Last, based on their publication, if there is biopsy-proven evidence for AIN with no evidence of concurrent GN or vasculitis, then a trial of infliximab is reasonable. Our experience at our institution is that the creatinine increases if the prednisone is tapered too q...
Would you perform plasmapheresis for an ABO-incompatible kidney transplant recipient who has titers of 1:16 and a stable creatinine 3 months post-transplant?
I would not perform plasmapheresis for an ABO-incompatible patient with titers of 1:16 (which are not that high and presumably IgG) based on the stable kidney function. At this point, there should be "accommodation" of the graft to anti-blood group antibodies and there is no need to check titers thi...
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...
For patient with polycystic kidney disease and proteinuria who are on maximum dose of ACEi/ARB, what are other anti-proteinuric medications that should be considered?
This is a great question because it highlights that patients with ADPKD should have proteinuria worked up as with any other patient with CKD - sometimes even by biopsy if needed (if tissue can be obtained safely, usually requiring urology and possibly using laparoscopic approach if ultrasound is not...
Do you recommend plasmapheresis for treatment of patients with osmotic demyelination?
No. There are insufficient data to routinely recommend plasmapheresis for the treatment of ODS at this time. Current evidence is based predominantly on case series. In the absence of a control group, it is difficult to assess the effectiveness of plasmapheresis in the treatment of ODS.
Is your decision to prescribe empagliflozin for CKD patients without albuminuria influenced by a recent cost-utility analysis showing that empagliflozin was not cost-effective for this group?
I have not been a proponent of using SGLT2 for patients who do not have proteinuria to begin with. I don't think these patients would benefit much, just as the data for ACE/ARB in these groups of patients is not great. Usually, they progress fairly slowly anyway.
Do you recommend patients with chronic kidney disease avoid supplements containing creatine?
I do not have patients necessarily avoid these supplements. I do advise with supplements in general we don't always know what else is in the supplement and how supplements interact with each other and prescribed medications.