Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you proceed with outpatient hemodialysis for an asymptomatic ESKD patient who has missed the last three hemodialysis sessions?
In the ideal world, missing too many HD sessions (no magical number) can predispose patients to quick normalization of low Na or very high BUN which we don’t want to! Also, asymptomatic patients don’t mean okay volume, patients' BP might be as high as 200s and this needs extra sessions to get back t...
What do you use to treat a kidney transplant patient with progressive BK nephropathy despite a maximal decrease in immunosuppression for months?
Assuming you are referring to actual BK nephropathy (biopsy evidence of viral inclusion on renal tubular cells staining positive by SV40 either by IF or immunohistochemistry) + serum BK viral PCR. Beyond lowering immunosuppression, adjunctive therapy (none of which are FDA approved of course) includ...
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
In which patients with chronic kidney disease and low 25-OH vitamin D levels do you prefer weekly ergocalciferol to daily cholecalciferol supplementation?
Ergocalciferol (D2), the plant-based form of Vitamin D, and cholecalciferol (D3), the animal-based form, are essentially equivalent in potency with perhaps a small, clinically insignificant edge favoring D3. They both can be given at long interdose intervals; monthly doses provide the same impact on...
Do you prefer that hospitalized peritoneal dialysis patients use their own home dialysis equipment during the admission?
At our hospital, where we have our own PD equipment and RNs on call to set it up, we strongly prefer that patients DO NOT use their personal equipment. Liability concerns, but this approach won't work in a hospital where that backup does not exist. If the patient's choice is to have a TDC placed for...
What is your blood pressure goal for the first three months after kidney transplantation?
We target a BP goal of < 130/80 mmHg in line with KDIGO guidelines. (1)There are no RCTs or other high-quality evidence looking at BP targets in kidney transplant patients that compare outcomes, graft survival or mortality. One small RCT (ESCORT trial) in pediatric transplant recipients, comparing i...
Do you recommend retreatment with an immune checkpoint inhibitor in a patient with a history of immune checkpoint inhibitor-related AKI that resolved with holding the immune checkpoint inhibitor and a glucocorticoid taper?
Yes. You can rechallenge. The risk of recurrent AIN will be around 16 percent based on the largest study on rechallange. The odds are second time there will be no AKI.
What is your approach to the use of intravenous sodium thiosulfate for the management of calciphylaxis in a patient with end stage kidney disease and on hemodialysis?
We have sodium thiosulfate 25gm IV each dialysis given during the last hour of treatment as a standard order in our dialysis order set. We have seen a useful response in some patients after several weeks, but there are no clear trial-based data to support the use of this treatment. I would certainly...
Do you recommend switching to a non-dihydropyridine calcium channel blocker with the goal of decreasing proteinuria in a proteinuric, hypertensive CKD patient already on a dihydropyridine calcium channel blocker?
Blood pressure control has a more powerful effect on reducing proteinuria than the type of calcium channel blocker. It is often difficult to achieve the goal of BP < 130/80 mm Hg while on a non-dihydropyridine CCB. I chose to focus on other anti-proteinuric agents like SGLT2-INH, MRA, and ACEi/ARB, ...
What is your blood pressure goal for a pregnant patient on hemodialysis?
This is a great question with very little evidence behind it. In pregnant patients, just as in non-pregnant patients, the target for BP should be based on their home readings between treatments, rather than readings at the beginning or end of dialysis. I target < 140/90 mm Hg, consistent with the ap...