Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is peritoneal dialysis a contraindication to pelvic radiotherapy?
I have never done it except for a few patients with palliation as treating the entire pelvis may increase the risk of complications of dialysis and also may decrease efficacy and with changes in peritoneal permeability unless treating localized field like prostate or below the peritoneal reflection....
How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?
It depends entirely on their disease status and profile. It is not unusual for patients to have decreased disease activity when they go on HD. If there is still clinical activity though, I maintain them on immune suppressives and prefer mycophenolate mofetil (a major anti-renal transplant rejection ...
How do you approach the use of endothelin receptor antagonists in patients with scleroderma renal crisis and hypertension refractory to maximum ACE inhibition and calcium channel blockers?
There is pathologic evidence of endothelin being increased in the renal biopsies of patients with scleroderma renal crisis. There has been one small prospective open study where endothelin receptor antagonists were used in addition to ACE inhibitors in some refractory patients and compared to histor...
How do you approach urate-lowering therapy in patients with advanced chronic kidney disease?
I lower uric acid independent of GFR. There is little evidence to support limiting uric acid-lowering therapy. This misinformation came out due to combining fears that the incidence of allopurinol reactions would increase in patients with renal insufficiency. Allergic reactions are related to exposu...
How do you approach relapsing ANCA-associated vasculitis in a patient who has already undergone kidney transplant?
In a very individualized way (What has the patient been treated with before? What is the current transplant immunosuppression? etc.) and in conjunction with a transplant nephrologist. One could imagine re-induction with rituximab would work in many cases but specifics about each individual case will...
What is your preferred first line regimen for myeloma with severe renal impairment, either on or off dialysis?
In general, for patients with renal insufficiency related to their myeloma, time is nephrons. So the earlier you can correct the hypercalcemia, lower circulating uric acid, stop ongoing bad behaviors (NSAID overuse, etc), and treat the myeloma, the better. If the patient is admitted, I will give pa...
How do you monitor a patient with scleroderma during pregnancy?
One of the most important aspects of monitoring scleroderma patients in pregnancy is the preconception visit to review the stage of the disease including getting cardiopulmonary studies before pregnancy and reviewing medications and adjusting any immunosuppressive medications. Although prospective s...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
What is your approach to using NIH activity and chronicity indices from renal biopsy in tailoring immunosuppression to a patient with new lupus nephritis?
I find the NIH activity and chronicity extremely valuable in LN management. If a patient has a high AI, I’m much more likely to be aggressive with corticosteroids to help stop the inflammation in its tracks. I will, of course, use a concomitant immunosuppressive/immunomodulatory agent as well (we no...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...