Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
What are some measures to prevent flares of loin pain-hematuria syndrome?
Loin pain hematuria syndrome is a difficult problem because there are multiple potential causes that require individual solutions. For example, nutcracker syndrome requires decompression of the left renal vein. Recurrent kidney stones require the expertise of a urologist skilled in ureteroscopic or ...
In patients with intrinsic acute kidney injury of unknown etiology and with pending kidney biopsy results, are there instances when you would recommend a trial of glucocorticoids?
I usually don't if I know I will have preliminary results of the biopsy within 24-36 hours. I do sometimes when it is not possible to do the biopsy in a timely manner. I don't think a 1-2 day delay would make a major difference in the amount of kidney damage.
Which medications do you recommend for lactating mothers with kidney disease and proteinuria that persists post-delivery?
I use ACE inhibitors, including enalapril and lisinopril, in the lactating mothers with proteinuria and hypertension. Captopril is also safe, but as it is dosed multiple times per day, I avoid this. There is no data on ARBs. If they are still recovering from an AKI or there is another issue, like hy...
What considerations do you take when evaluating a patient for kidney transplantation who has a history of kidney disease and an abdominal aortic aneurysm treated with past stenting?
If the external iliac vessels are spared then the patient does not have an absolute contraindication to transplantation. The risk factors associated with the AAA will need careful review, e.g., smoking, cholesterol, hypertension, CAD, and other vascular diseases, and mitigated if possible. Anecdotal...