Do you recommend starting pyridoxine in a patient with ESKD secondary to primary hyperoxaluria type 1 who is also on lumasiran for plasma oxalate reduction?

If the patient has a monoallelic or biallelic pathogenic variant known to be pyridoxine responsive such as G170R, I would definitely maintain them on pyridoxine 5-10 milligrams/kg. For other patients, I would still air on the side of caution and maintain most patients on pyridoxine since the risk benefit ratio is quite favorable. An exception might be a patient with neuropathy. Although, we do not believe that this is a very common issue with high dose pyridoxine, if the patient did have neurologic symptoms that might be reason not to use pyridoxine if we do not know that they are benefitting. The other situation might be if the patient is very responsive to Lumasiran such that there plasma oxalate is fairly low to normal on dialysis. In th...