Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you would pursue a kidney biopsy in a pregnant patient instead of waiting to perform the procedure post-delivery?
Prior to 20 weeks, consideration of a biopsy shouldn't be different than how we would think about biopsy in a non-pregnant individual. The pregnancy is still pre-viable, and so knowing a diagnosis and treating the disease with the goal of improving the kidney function, and thus the pregnancy, makes ...
Would you recommend starting an SGLT2i in a patient with a kidney transplant and moderately increased albuminuria?
I have used SGLT2i in my transplant patients to lower albuminuria either alone or in combination with RAASi. I do not use it in patients who have a Hx of frequent UTIs or who are at increased risk of developing UTIs (e.g. ileal conduit, neurogenic bladder, obstruction) due to the increased risk of u...
Do you recommend a kidney biopsy for patients who develop acute kidney injury after starting sacituzumab?
For all novel agents, I think that it is prudent - if there are no contraindications to the renal biopsy - to proceed with a biopsy. A renal biopsy is helpful in clarifying the etiology of the AKI and may have implications regarding whether the medication can be safely continued - depending on what ...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
Do you recommend starting SGLT2 inhibitors for patients with a normal creatinine but who have microalbuminuria and are unable to tolerate ACEi or ARBs?
In a patient who cannot tolerate RAAS inhibition with standard-of-care ARB or ACE-I, I still would still consider starting SGL2 in a patient with microalbuminuria. In a diabetic patient, an SGL2 inhibitor would definitely be indicated, perhaps with an MRA. The mechanism of benefit in SGL2 is debatab...
What is a reasonable blood pressure goal for refractory HTN in the geriatric population?
Resistant hypertension is defined as a blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes taken at maximally tolerated doses, one of which should be a diuretic. Refractory hypertension is defined as uncontrolled blood pressure despite ...
What are your management strategies for acute kidney injury attributed to pembrolizumab in patients with a kidney biopsy showing predominately acute tubular injury?
Acute interstitial nephritis is the more common type of kidney injury associated with immune checkpoint inhibitors. However, there is also associated acute tubular necrosis secondary to cytokine release from activated T cells. ATN can be also due to chemotherapy used in conjunction with ICI such as ...
Do you pursue a skin biopsy or kidney biopsy in patients whom you suspect have X-linked Alport syndrome?
The approach to the diagnosis of Alport syndrome has changed over the past decade with heavier reliance on molecular genetic testing sometimes prior to or in lieu of tissue diagnosis, however, this is dependent upon many factors including insurance coverage and availability of electron microscopy. G...
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
Do you assess the kidney tissue under a microscope following a kidney biopsy to determine the quality of the specimen obtained and if additional tissue is needed?
While we do have a microscope near the IN suite to check the adequacy of the kidney biopsy, I don't always use it. The following options are available: Take a picture of the core on your phone & magnify it to see if small red dots are visible which are suggestive of gloms. Use 16g biopsy guns to en...