Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
Do you use biomarkers to improve risk prediction in patients with ADPKD during early disease stages?
Yes. The most important validated prognostic biomarker in early ADPKD is height-adjusted total kidney volume (htTKV), typically measured by MRI and interpreted using the Mayo Imaging Classification. KDIGO recommends htTKV as the preferred imaging biomarker for predicting disease progression and iden...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
What is your approach to perioperative risk stratification and optimization of patients with ESRD on HD?
When evaluating a patient with end-stage renal disease (ESRD) on maintenance hemodialysis for surgery, my approach to perioperative risk stratification centers on three major areas: cardiovascular risk assessment, optimization of dialysis-related factors, and careful perioperative medication and met...
Do you discontinue an ACE inhibitor in a patient with CKD and well-controlled hypertension who is incidentally found to have bilateral renal artery stenosis on imaging, given stable kidney function on current therapy?
In the circumstances described, i.e., good BP control and stable kidney function, I would continue the ACE inhibitor. There is not a great correlation between the extent of stenosis seen on imaging and the hemodynamic functional significance, and the relation depends on the imaging modality used. So...
What is your approach to post-kidney transplant erythrocytosis for an asymptomatic patient already on ACEi but with Hb consistently >18?
My approach is to rule out non-transplant-associated causes of erythrocytosis (examples include obstructive sleep apnea, checking for renal artery stenosis, etc.). Once the diagnosis of post-kidney transplant erythrocytosis has been met, we typically use ACEi/ARB as you mention in the question. If t...
How do you approach the use of ultrafiltration during dialysis sessions in a pregnant patient who was recently started on hemodialysis?
At my university, pregnant patients on dialysis are on fetal monitoring throughout the dialysis session to monitor for fetal distress. Our patients receive 4 hours of dialysis 6 days a week. These patients often have some renal function, as they are not uncommonly initiated on dialysis at GFR > 1...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...