Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend non-bypass bariatric surgeries over intestinal bypass procedures for kidney transplant-eligible candidates to prevent oxalate nephropathy, given the higher risk of kidney oxalate deposition with intestinal bypass?
Yes, my preference is for non-bypass bariatric surgery in my patients with severe obesity and sleeve gastrectomy is preferred. However, the GLP-1 agonists have really had an impact on weight loss in transplant patients and transplant candidates alike. There was a nice editorial by Lorden and Parajul...
Are there any instances when you would not perform 3 consecutive daily dialysis sessions when initiating a patient on hemodialysis?
In-patient - Friday, Saturday, and Sunday (we are not fully staffed on Sundays). Out-patient - I see no reason to do three days in a row. There is nothing magical about starting dialysis. Patients were surviving without it before you started it, there is no rush. Updated answer: YES - I would no...
How long after surgical repair of a pleuroperitoneal leak do you resume peritoneal dialysis?
This is a bit of a challenging question as I'm not aware of any data to help guide my response. It seems to me however that, since failure of the surgical repair would inevitably culminate in permanent shift to HD, one should allow ample time for healing to occur and thereby to achieve the best poss...
Do you recommend Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who have hypocitraturia and mild hyperkalemia for which potassium citrate is contraindicated?
First, my conflict of interest: I am one of the inventors of Moonstone so I do have a financial interest in sales of the product. But 30 mEq of Moonstone product has only 7 mEq of K, so I consider it a useful way of alkalinization if serum K is an issue. And only 10 mEq of Na, the rest Mg. By spread...
Do you recommend starting pyridoxine in a patient with ESKD secondary to primary hyperoxaluria type 1 who is also on lumasiran for plasma oxalate reduction?
If the patient has a monoallelic or biallelic pathogenic variant known to be pyridoxine responsive such as G170R, I would definitely maintain them on pyridoxine 5-10 milligrams/kg. For other patients, I would still air on the side of caution and maintain most patients on pyridoxine since the risk be...
Do you recommend SGLT2i use for patients with chronic kidney disease, diabetes mellitus, and polycystic kidney disease?
While we cannot conscientiously recommend this YET, I do not think it is necessarily contraindicated. I would not use it in conjunction with tolvaptan, but I think the results of the UC Denver trial will be informative. It may indeed be as useful for PKD patients as in other CKD patients, including ...
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
How frequently do you recommend flushing a peritoneal dialysis catheter for patients with ESKD who are hospitalized and are not currently undergoing peritoneal dialysis?
I'm not aware of any data to guide my response, just experience and "gut". It is our practice to flush unused peritoneal catheters on a weekly basis.