Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend continuing peritoneal dialysis in an ESKD patient on peritoneal dialysis who is diagnosed with encapsulating peritoneal sclerosis since abdominal symptoms may worsen when peritoneal dialysis is stopped?
It is generally accepted that after a diagnosis of encapsulating peritoneal sclerosis (EPS), most patients are transitioned off peritoneal dialysis (PD) and switched to hemodialysis as patients with EPS often have chronic abdominal pain and will often have difficulty with dialysis adequacy and ultra...
What is your approach for a kidney transplant patient who develops proteinuria after everolimus initiation?
The management typically should take into consideration the reasons the patient was converted to mTOR inhibitors and whether everolimus is being used de novo versus converted from calcineurin inhibitor. In general, if the patient was not proteinuric and developed heavy proteinuria (> 1 gram per day)...
How frequently do you monitor urine protein levels in a patient receiving bevacizumab who develops proteinuria of less than 2 grams per day?
We would typically check monthly spot protein to creatinine ratios. This would be managed by both the nephrologist and oncologist as far as when to hold the drug. Would also recommend secondary workup and rule out other etiologies of proteinuria where myeloma has been reported in patients with renal...
Do you recommend obtaining a spot urine or 24-hour urine magnesium measurement when evaluating patients with persistent hypomagnesemia of unknown etiology?
I try to avoid 24-hour collections for just about everything short of stone evaluations (Litholink). They are hard to do properly and bad information is worse than no information. I would use a FeMg and from UpToDate a FEMg > 3% in the setting of hypoMg and nl renal function usually indicates urinar...
In which patients awaiting a kidney transplant do you evaluate for primary hyperoxaluria given the high risk of allograft dysfunction following transplantation?
Primary hyperoxaluria is often diagnosed in adolescents and young and is typically diagnosed prior to being referred for transplant. One might consider work-up in a young to middle-aged adult with a significant history of kidney stones that are not explained by other conditions.
What is your approach to patients with membranous glomerulonephritis who have persistently elevated PLA2R titers but largely improved proteinuria and creatinine?
Depends on the evolution of the PLA2RAB titer. Please see the algorithm from De Vriese et al., PMID 27777266.
For a patient interested in home dialysis modalities, what are some key points that you discuss with them to help them make a decision on peritoneal dialysis versus home hemodialysis?
1. Dialysis access: a major difference between the 2 modalities is dialysis access. Discussion with the patient should include detailed education with photos, videos, or physical examples of a PD catheter in situ and AVF/AVG/catheter. Some patients have strong feelings regarding the issue of needle ...
Can an acid loading test be used to assist with the diagnosis of RTAs other than an incomplete distal RTA?
This almost seems like a trick question. It is so odd but I have to think the answer is no. An acid load tests the kidneys' ability to respond to metabolic acidosis by increasing Nh4+ excretion. The only situation where that is impaired is distal rta. Normally you do not need to acid load because th...
Would you recommend complement testing in a kidney transplant recipient with chronic antibody-mediated rejection and biopsy-proven thrombotic microangiopathy to determine the need for eculizumab?
There is basic and translational data to support the role of IL-6 in acute and chronic humoral rejection, with small single-center trials investigating the use of agents that blockade IL-6/IL-6 receptor interactions for humoral rejection in kidney transplantation. In many of these studies, there is ...
What factors should prompt a kidney biopsy to evaluate for monoclonal gammopathy of renal significance in a patient with MGUS and suspected chronic diabetic nephropathy?
A renal bx may be reasonable if there is an unexpected or unexplained increase in the Cr and proteinuria. The presence of Fanconi's syndrome may also be a signal of light chain tubular injury.