Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you offer adjuvant immunotherapy in a patient with high risk RCC with new/worsening post-op renal dysfunction and CrCl<30?
My preference in situations like this is to stabilize the renal function first. I am comfortable treating the patient with adjuvant pembrolizumab with a CrCl <30 mL/min but it should be stabilized first. That will make it easier to diagnose potential irAEs as compared to starting adjuvant treatment ...
Do you rule out active urinary tract infections prior to performing a kidney biopsy?
The 2 infectious reasons to avoid a renal biopsy are- active kidney infection and active skin infection at the site of the biopsy (Luciano & Moeckel, PMID 30661724).Perinephric hematoma is common after a kidney biopsy and there is a report in the literature where this has gotten infected in the pres...
Would you consider reducing the dialysate sodium concentration to 135 meq/L as a strategy to decrease interdialytic weight gain in a hypervolemic ESKD patient?
Yes. It is worth a try. I don't expect miracles though. It may make a minor difference. The best option remains longer and more frequent dialysis if possible and agreeable with the patient which is often not the case.
How soon after an intervention is done for peritoneal catheter inflow or outflow obstruction is it advisable to repeat the Kt/V?
The timing of repeat Kt/V measurement after an intervention to revise a peritoneal dialysis (PD) catheter depends on the extent of the procedure. If the catheter cuff and exit site are not disturbed, then Kt/V can usually be repeated in 1-2 weeks. If the exit site is moved to a new location or a new...
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What is your approach for patients with recurrent nephrolithiasis who require daily use of acetazolamide for management of an unrelated chronic condition?
Acetazolamide, or other carbonic anhydrase inhibitors, typically increase urine pH into the low 7s. Normally, it is approximately 6.0. A mildly alkaline urine favors the formation of brushite and hydroxyapatite kidney stones. My first step is to contact the provider who prescribed the carbonic anhyd...
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
What sort of telehealth approaches do you pursue for a newly diagnosed end stage kidney disease patient starting peritoneal dialysis or home hemodialysis?
All new patients to home dialysis should be seen in person for at least three months. The first three months of home dialysis is a time by which you can make sure that the patient is stable. The patients are always adjusting to home dialysis both physically but also emotionally. After the first thre...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
Would you recommend a TIPS procedure in the management of hepatorenal syndrome for a patient with no history of hepatic encephalopathy?
In the right patient, yes. TIPS will help with ascites and likely with renal function. I believe it is underused.