Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you require lupus patients with ESKD or advanced CKD to be on minimal immunosuppression around the time of kidney transplantation?
Patients with SLE needs to have overall clinically quiescent disease to be actively listed for kidney transplant. They can be on stable/reduced dose of immunosuppression medications to keep the disease clinically under control. They can still have low complement levels (serologically active).
How do you recommend discussing family member genetic testing with a patient recently diagnosed with ADPKD?
Depends on the age of the family member (adult versus young adult versus under age 18). Depending on whether the "recently diagnosed" patient has had genetic testing, variant testing in the ADULT family member could be recommended in a straightforward manner through most testing companies. That pers...
Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?
It all depends. I would keep pushing for a biopsy and try to overcome the barriers ASAP. If it is the patient who is the barrier (not wanting the biopsy), I would educate them on how a biopsy ends up not even being due to SLE in some cases and immunosuppressant treatment therapy would be exposing t...
What is the optimal approach to treat isolated diastolic hypertension?
Isolated diastolic hypertension occurs less commonly in the adult population, where the majority of the outcome trials in hypertension have been conducted. Much of the treatment of hypertension in younger patients is extrapolated from these trials. In my practice, I look more closely for secondary c...
What recommendations do you offer for patients who have a peritoneal dialysis catheter and who wish to swim?
Exercise is an important part of health maintenance for all individuals, including those with ESKD requiring peritoneal dialysis (PD). Swimming is an excellent form of exercise for PD patients because it is not associated with increased intra-abdominal pressure, and is a low-impact aerobic activity ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
What are your management strategies for patients with biopsy proven IgA nephropathy with rapidly progressive glomerulonephritis?
In adults, I believe these patients should be treated similarly to other patients with RPGN. I would start out with high dose steroids, then move to possibly rituximab versus possibly cyclophosphamide shortly afterwards if no response to steroids alone.
What is your daily correction goal for those patients being treated for hyponatremia?
This is easily a short answer or 10,000 words. I choose the former. I try to limit it to 6 mmol/l/day, will tolerate 7. But a lot depends on where you start. A starting PNa of 100 is a lot different than a PNa of 120 as the relative osmotic shift will be greater at lower PNa.
In which clinical scenarios do you use prolonged intermittent renal replacement therapy (PIRRT)?
I have not been using PIRRT. We talked about it at the height of COVID when we thought we were going to run out of CVVH solutions. However it never needed to be instituted. Other than that scenario, I think we can tweak the settings of the CVVH machine enough to provide aggressive renal replacement ...
How would you approach a patient with end stage kidney disease on peritoneal dialysis who has an adequate Kt/V but persistent azotemia?
This question could serve as the springboard for a very lengthy discussion/ debate regarding PD "adequacy"- a term that ought to be outlawed! That said, I will try to be brief. First off, it must be recognized that Kt/V (by default meaning that for urea) is a very poor measure of the quality of dial...