Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach treating mild hypercalcemia in patients with sarcoidosis?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you prefer assessing cystatin C or creatinine when monitoring a patient’s eGFR who is receiving chemotherapy for malignancy?
If the patient is on a drug known to interfere with creatinine handling in the renal tubules (e.g. abemaciclib), then I will intermittently check the cystatin C to differentiate true AKI from pseudo-hypercreatinemia since these drugs can also cause true AKI.
What is your approach to lab and imaging monitoring in a patient with an elevated creatinine following a unilateral nephrectomy?
One should expect some elevation in serum creatinine after unilateral nephrectomy in the majority of patients. Hyperfiltration seems to be universal but is often not complete. Over time, the serum creatinine stabilizes and often improves some but likely not to baseline. I would repeat serum creatini...
What is the antifungal prophylaxis regimen that you use in patients on peritoneal dialysis who are receiving antibiotics?
Data indicates that either nystatin (500,000 U qid) or fluconazole (200 mg q48 hours) is effective in minimizing the risk of fungal peritonitis in PD patients being treated with antibiotics. See the most recent ISPD guidelines (Kam-Tao Li et al., PMID 35264029) for details. As there is less risk of ...
Is there a subset of ANCA vasculitis patients for which you would try plasma exchange?
Circling back to this now that we have more data. I agree with Dr. @Dr. First Last's main conclusion that GN or the presence of concomitant anti-GBM antibodies are the primary scenarios in which there may be a role for plasma exchange patients with ANCA-associated vasculitis.Following the PEXIVAS tr...
Do you recommend initiating a potassium sparing diuretic in patients with recurrent nephrolithiasis who have hypercalciuria but do not tolerate thiazide diuretics?
No. The idea of using a thiazide diuretic as a preventive treatment for calcium-containing stones is its hypocalciuric effect. Potassium-sparing diuretics do not have this ability. Loop diuretics worsen hypercalciuria and, in general, are inappropriate for use in calcium stone formers. One could con...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
Do you recommend giving IV albumin with furosemide to augment diuresis in a patient with hypoalbuminemia and volume overload?
I'm a fan of IV albumin in patients with edema and hypoalbuminemia <3g/dL. It stabilizes intravascular volume and may blunt the rise in serum creatinine that can occur with diuresis. It may lead to a decrease in serum creatinine in some patients, especially those with liver disease and impending hep...
Are you offering GLP-1 agonists to patients with CKD and diabetes mellitus?
According to KDIGO 2022, GLP-1RA are second line DM Rx (see fig 3: Rossing et al., PMID 36272755); this class of medications still awaiting a CKD-dedicated RCT such as FLOW (Rossing et al., PMID 36651820). However, secondary outcomes of CVOT show kidney protective effects for some GLP-1RAs (non-exen...