Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
What is your approach to a living kidney donor evaluation for a patient with normal kidney function who wishes to donate to their monozygotic twin who has ESKD due to an autoimmune disorder?
This really depends on whether there is a genetic component to the autoimmune disorder and whether there is a family history of autoimmune diseases in other members. Depending on the nature of the disease I might get some screening serologies and if positive consider consultation with Rheumatology. ...
Is there a role for a kidney biopsy in patients diagnosed with Fabry disease through genetic testing?
Is there a role for kidney biopsy in patients diagnosed with Fabry disease through genetic testing is not straightforward. However, there is utility most of the time if you are asking: Should you start therapy? When should you start therapy? Could it be something other than Fabry? If the patient ...
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...