Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How long do you observe for spontaneous remission after NSAID discontinuation before initiating corticosteroids in a patient with biopsy-confirmed minimal change disease?
The role of steroid treatment in drug-induced acute interstitial nephritis (DI-AIN), including those with MCD, is controversial. There are no large randomized controlled trials, so whether steroids are beneficial or not, and when to give them, is unclear. There have been a number of retrospective st...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...
Is it safe to use acarbose in patients with advanced chronic kidney disease?
Yes, I think so.
How would you approach a patient with ESKD on HD who denies a history of abdominal hernias but lifts heavy objects daily as part of work requirements and is desiring to transition to PD?
As a general rule, I instruct patients to lift no more than 15 pounds while they have fluid in the abdomen. Therefore, this patient would need to remain dry during work hours. The ability of a patient such as this to successfully perform PD will depend on his/her muscle mass and residual kidney func...
How do you approach vitamin D supplementation in patients with chronic kidney disease, given the findings that vitamin D2 supplementation may lead to decreased conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3?
In early 2000, there was a publication suggesting that ingesting vitamin D2 increases the destruction of vitamin D3 and therefore could increase the risk for vitamin D deficiency. Although I had never seen this happen in my clinic, we decided to conduct a study to evaluate what the effect of vitamin...
How do you approach management for recurrent stone formers who sleep over 8 hours per day and fail to reach 2.5 liters of daily urine output on 24 hour urine stone risk studies?
I suggest the patient plan a schedule by which they drink 2.5 L per day. To get started, I suggest they set their phone to alert them when it is time to drink the requisite amount of fluid, preferably water. After a while, this becomes an automatic habit. Stephen B. Erickson, MD
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
What is your approach to differentiating secondary membranous nephropathy from infection-related glomerulonephritis in a patient with a bacterial infection who has borderline low complement studies?
This is primarily a biopsy distinction. Secondary membranous nephropathy is characterized by subepithelial immune complex deposits without cellular proliferation whereas infection-related glomerulonephritis Is characterized by endocapillary proliferation with large, subepithelial humps and often mes...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...