Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
What criteria do you use, if any, to recommend statin therapy for patients with polycystic kidney disease?
If the patient has an indication for a statin for cardiovascular risk factors, I will of course recommend statin as per AHA guidelines. For low-risk individuals (e.g. young PKD patients) with borderline lipids, we will discuss the theoretical pleiotropic effects of statins with respect to ADPKD. Dep...
Do you recommend obtaining 24 hour urine ammonium levels in patients with recurrent uric acid nephrolithiasis?
An astute question! As you imply, uric acid stones have very little to do with uric acid! Otherwise, we would see more sodium urate, potassium urate, and ammonium urate stones, which are very rare. Uric acid (hydrogen urate) stones are highly dependent on a lower-than-normal urine pH. The two main r...
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...