Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to managing intradialytic cramping that recurs despite multiple dry weight adjustments in a patient with ESKD?
This is a great question and there is no easy answer. As always, try and make sure the patient is following fluid restriction in between treatments as having less fluid to remove during a session may reduce cramping. I also try gabapentin 100mg prior to treatment for cramping. If they treat early in...
Do you consider Randall's plaque as a form of nephrocalcinosis necessitating genetic testing for monogenic kidney stone disorders?
No. Randall's plaque is the infrastructure of all calcium oxalate kidney stones. It is formed beneath the uroepithelium, due to (according to preliminary research) excess reabsorption of calcium in the thick ascending limb of Henley's loop. it is composed of calcium phosphate and somehow induces the...
Do you recommend decreasing the loop diuretic dose when starting an SGLT2 inhibitor in a CKD patient given its natriuretic and osmotic diuretic effects?
The decision to continue or not a loop diuretic when starting an SGLT2 inhibitor should be individualized based on the patient's blood pressure/volume status.In general, if a patient's blood pressure/volume status is high, like in the setting of heart failure, SGLT2 inhibitors, and loop diuretics ar...
Is there a role for vascular intervention in patients with renal artery stenosis found during work up of resistant hypertension?
The ASTRAL, STAR, and CORAL trials all attempt to this question in different patient populations. A portion of CORAL participants met the diagnostic criteria for resistant hypertension. What I have taken away from the data is that renal artery intervention can be helpful in fibromuscular dysplasia i...
What is the next best anti-hypertensive medication to start after mineralocorticoid receptor antagonists in patients with primary aldosteronism?
I have had a good experience with calcium channel blockers and combined alpha/beta-blockers such as carvedilol in patients with PA. They are my first and second choices after MRA. If tolerated, pushing the MRA dose to get a PRA> 1 ng/ml/hr is important. I check for proteinuria, and if present, I add...
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...