Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you take any special approaches with patients with recurrent nephrolithiasis who first developed stones prior to adulthood but have negative kidney stone disorder genetic test findings?
No. My pediatric kidney stone consultants tell me kidney stones in childhood are relatively common. If genetic testing is negative (or even if it is positive), I treat them starting with general dietary modification, tailored to their urinary supersaturation data and stone composition, if known. Ste...
Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?
The very premise on which SGLT2i is supposed to work does not exist, if the patient does not have meaningful GFR; in fact most would not use/start SGLT2i once eGFR is <20-25 range. Studies have excluded patients with advanced CKD and any benefit with low GFR seems very doubtful. Zinman et al., PMID...
Do you recommend using doses of ACEi or ARBs that is above the usual dosing with the goal of reducing a patient's proteinuria further?
No, doses above the therapeutic maximum typically result in more side effects without additional benefit. For example, the VA NEPHRON D study showed increased rates of hyperkalemia and AKI with dual RAAS blockade. We now have more medication options to reduce proteinuria including SGLT2-INHs and fin...
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
Do you recommend noninvasive testing or coronary angiography as the initial test for pre-kidney transplant evaluation of an asymptomatic patient older than 50 years of age with ESKD secondary to diabetic nephropathy and no known history of CAD?
There is no evidence that revascularization of asymptomatic patients reduces the risk of transplant. obviously patient should have all relevant risk factors treated. the problem with routine angiography is that inevitably any lesion found is treated with stenting which actually exposes the patient t...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...
Do you pursue any additional testing in your patients with chronic kidney disease who are found to have "small hypodensities too small to characterize" on renal ultrasound?
Renal cell carcinoma in dialysis patients and to a lesser degree in patient with CKD is not uncommon. As such, I would like to re-image these patients after 6 months or so. Usually, these cancers grow slowly and don't cause major disease but it is variable.
Do you periodically check a urine culture for patients without dysuria but who have a history of struvite kidney stones and urinary tract infections with urease producing organisms?
Struvite nephrolithiasis is caused by a high urine pH (usually>7.0). Typically, a urine this alkaline requires urinary infection with a bacterium that produces urease, (Proteus, Providencia, Klebsiella) which in turn splits naturally occurring urea into ammonium, driving the pH to supraphysiologic l...
Do you start patients on a B complex multivitamin if they are on CRRT and have not previous been on renal replacement therapy?
This is a good question. I personally don’t routinely recommend Vitamin supplements for patients on CRRT, but wouldn’t argue with someone who does. It is known that critically ill patients, which includes most CRRT patients, often have deficiencies in micronutrients, including water-soluble vitamins...
Do you routinely perform in-office urine microscopy for your patients with recurrent nephrolithiasis?
Yes and no. We have a dedicated laboratory at Mayo Clinic that specializes in urinalysis and is expert in recognizing crystals. I do not do office microscopy myself. I think it is important for my stone patients to have a urinalysis when I see them. I am looking for hematuria suggesting surgical sto...