Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
What is the preferred timing for removal of a peritoneal dialysis catheter in a patient who has transitioned to hemodialysis?
I think that depends on the reason for the transfer to HD. If it is absolutely certain that the patient will not return to PD- for example, despite maximal prescription PD unequivocally cannot deliver sufficient solute clearance or provide sufficient UF- then the catheter may be removed immediately....
Do you use both rituximab and plasmapheresis in patients with recurrent primary FSGS within three months of kidney transplantation?
For early recurrence (less than 3 months post-transplant), plasmapheresis is the first line of treatment with the rationale of removing a "permeability factor." Since many patients respond to plasmapheresis alone, rituximab does not need to be added as first-line therapy. In addition, there are risk...
How do you manage anticoagulation bridging for outpatient ESKD patients given concerns for bleeding risk with enoxaparin in this population?
I don't think we know what is the best route to take. Personally I still usually give lower doses of enoxaparin but it all depends on the circumstances. Why the patient needs anticoagulation? Does the risk of hospitalization out way the risk of increased bleeding from enoxaparin? Can the patient get...
What changes in AV access flows measured during hemodialysis would prompt you to refer for an angiogram?
Blood flows of less than 500 ml/min or an access flow drop of 25% from last month's measurement (should be repeated to confirm the change), should prompt a referral for access interrogation. Surveillance with access flow along with monitoring for dysfunction is recommended to help identify patients...
When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?
Scleroderma renal crisis (SRC) is a relatively early complication of Systemic sclerosis that almost invariably occurs within the first five years after the onset of the disease and may even be the initial manifestation of SSc. Abrupt onset of moderate to marked hypertension and acute kidney injury w...
Would you recommend mycophenolate mofetil for patients with progressive IgA nephropathy who do not tolerate corticosteroids?
Multiple studies showed no benefit of immunosuppressive agents (MMF, CYC), so this study is standing alone with relatively small number and limited centers. Better to role those IgAN patients in current ongoing studies, yet, I won't blame trying MMF if appropriate conservative management is optimize...
What is your PTH threshold for referring an ESKD patient with secondary hyperparathyroidism on maximum medical therapy for parathyroidectomy?
I think PTX should be done pretty much never with PTH <800 and most of the time with values >2000. Why such a large range? The biggest consideration is symptoms; if present, my threshold approaches 800. However, ascribing symptoms to hPTH is problematic. Hypercalcemia is the most specific finding wi...
Is there a role for eculizumab in the management of refractory lupus nephritis?
There is no evidence of eculizumab as a treatment for lupus nephritis, yet it might be considered if complement-mediated TMA presents even as a result of SLE as a trigger if direct treatment of SLE fails to achieve clinical goals.
Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?
In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful o...