Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach the decision to perform preimplantation biopsies in brain-dead kidney donors?
This is a really controversial topic and is often driven by the surgeon. Higher KDPI kidneys are more likely to have a biopsy to assess degree of interstitial fibrosis and therefore help guide whether the kidney should be used, discarded, or used with the mate kidney for dual transplantation. In add...
Do you hold renin-angiotensin system blockade at the time of kidney transplant and restart it only once graft function is established, or do you continue it through the perioperative period?
We do hold ACEs and ARBs at the time of transplant. After three months, we are typically pretty comfortable restarting an ACE or ARB if needed. If proteinuria develops early post-transplant, we might consider earlier institution of an ACE or ARB after renal ultrasound and biopsy. One exception is wi...
Under what circumstances would you consider LDL apheresis in a kidney transplant patient with FSGS recurrence within three months of transplantation?
LDL apheresis has not been part of our protocol for the treatment of recurrent FSGS. Our protocol is still plasmapheresis x 9 runs, and now considering institution of daratumumab. Protocols are still evolving for this vesiculating problem.
At what eGFR would you begin recommending leukoreduced blood products given the potential future need for kidney transplantation in patients with CKD who are not currently listed?
Most states in the US use pre-storage leukoreduction of blood products, done at the time of blood donation. If one is not sure whether the blood is leukoreduced, then a bedside filter can be utilized. Any patient who might be a candidate for transplant in the future and needs a blood transfusion wou...
Do you prefer an isotonic sodium bicarbonate infusion over other isotonic IV fluids when managing those with AKI in the setting of light chain cast nephropathy?
Theoretically, the physiologic rationale for using isotonic sodium bicarbonate over isotonic saline in light chain cast nephropathy is that urine alkalinization reduces the interaction between light chains and Tamm-Horsfall protein and therefore reduces cast formation. However, there are no strong c...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
Can you safely use a cephalosporin in a patient who previously developed acute interstitial nephritis to amoxicillin?
Amoxicillin-associated interstitial nephritis is most often a type IV hypersensitivity reaction. Cross-reactivity with other beta-lactams is possible but poorly studied. I would try hard to find an alternative.
Do you prefer maximizing fluid removal during dialysis or starting new antihypertensive medications for patients with ESKD on intermittent hemodialysis who are chronically hypertensive?
Fluids, fluids, and fluids are the most crucial first step. Challenging dry weight is the most important part in controlling blood pressure, and then adding more blood pressure medications is the next step. The only "exception" is high dose diuretics to reduce intradialytic weight gain. Additionall...
When showing lab results to patients who have chronic kidney disease, do you prefer to use the absolute creatinine value or eGFR?
I look at both. It is easier to follow the creatinine over time, but the eGFR is likely a better measure of the actual kidney function.
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...