Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you avoid losartan in patients with hypertension and uric acid nephrolithiasis due to the drugs uricosuric effects?
This is an important question. I continue to use losartan or other uricosuric drugs in uric acid stone formers. Control/prevention of uric acid stone formation is primarily related to raising urine pH to 6.5 (at least above 6), since uric acid solubility is so strongly dependent on pH. Any minor inc...
Are there instances when you recommend obtaining more than 2 kidney cores when performing a native kidney biopsy?
At our institution, we perform biopsies under direct ultrasound visualization with a pathologist at the bedside to immediately review gross specimens for adequate cortex. It is not uncommon for us to find that a 3rd core is required due to a paucity of glomeruli or cortical thinning, and certainly, ...
Would you wait a period of time before collecting a 24 hour urine stone risk study in a patient with nephrolithiasis who recently underwent a urologic stone removal procedure?
I generally recommend waiting until the patient is back to steady state, stents are out, pain controlled, and they are back to their usual diet. This time period after urologic procedure varies depending on what the procedure is and if any post-procedure complications and their management.
Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?
There are two major potential concerns in a lupus nephritis patient with systolic dysfunction and a left ventricular ejection fraction (LVEF) of only 30%: QTc prolongation potential worsening leading to acute cardiac death Exacerbation of hypertension leading to worse LVEF and CHF However, with prop...
What is your approach between choosing lumasiran or nedosiran for patients with primary hyperoxaluria type 1?
At this time, the available evidence suggests both agents are more or less equally effective for PH1 in reducing urinary oxalate excretion over many months. Thus I would be comfortable prescribing either for a PH1 patient.
What are some considerations to make when managing a patient on peritoneal dialysis who develops acute pancreatitis?
A few points are noteworthy in this regard: It is unclear whether there is a causal association between peritoneal dialysis and the development of pancreatitis. Recall that the pancreas sits retroperitoneally and is therefore not in direct contact with the peritoneal dialysate. Development of pancre...
What are your top takeaways from ASN 2023?
IgA Protect data was discussed a lot at ASN. The results do show a beneficial impact on proteinuria and eGFR slope. Although the total slope did not reach statistical significance, the chronic slope did and this is clinically impactful There were a few presentations and a lot of posters and discussi...
How do you manage vitamin D dosing in patients with nephrolithiasis and hypercalciuria who require supplemental vitamin D for treating other medical conditions?
This is a common treatment for osteopenia/osteoporosis. For calcium stone formers, I watch for hypercalcemia and/or hypercalciuria. If present, I reduce the dose of calcium and/or vitamin-D until their urinary parameters normalize. Otherwise, I think they can take these medications safely in standar...
For patients with nephrolithiasis and hypercalciuria attributed to a parathyroid adenoma, how long after a partial parathyroidectomy do you assess for improvement in 24-hour urine calcium levels?
An interesting question! The physiology of parathyroid hormone is to reabsorb urinary calcium; that is why most patients with primary hyperparathyroidism are hypercalcemic! The better question is why are they hypercalciuric? I think the best answer has to do with the filtered load of calcium exceedi...
How long would you wait for outflow to improve before consulting surgery in a peritoneal dialysis patient with an outflow obstruction who is prescribed laxatives for catheter migration?
Any PD patient with outflow dysfunction that does not improve with laxatives should undergo abdominal x-ray to evaluate the position of the PD catheter. If the PD catheter is outside of its expected position within the mid-pelvis, there may be ongoing issues of catheter dysfunction if the catheter i...