Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to differentiating secondary membranous nephropathy from infection-related glomerulonephritis in a patient with a bacterial infection who has borderline low complement studies?
This is primarily a biopsy distinction. Secondary membranous nephropathy is characterized by subepithelial immune complex deposits without cellular proliferation whereas infection-related glomerulonephritis Is characterized by endocapillary proliferation with large, subepithelial humps and often mes...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How would you approach the management of a patient who develops primary FSGS during pregnancy?
Would do supportive care regardless, low salt diet, BP control to <130/80, but avoid hypotension to decrease placental hypoperfusion, AC with Lovenox to decrease VTE risk if UPCR >10 grams with albumin <2.5, and ASA 81 mg starting after the first trimester to reduce preeclampsia risk. For progressi...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic range proteinuria, microscopic hematuria, and stable renal function who has been on a tenofovir-based regimen?
I often find the biopsy on these patients unhelpful. Having said that, I do advocate doing a kidney biopsy when there are other circumstances which raise the possibility of other disorders (i.e., possible IgA nephropathy, tenofovir was given for a short period of time, and only TAF was used, etc.).
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...
Do you rely on urinalysis testing for microscopic hematuria as a means to assess for a ureteral stone for patients with recurrent nephrolithiasis who report mild potential stone-related pain?
No. I think hematuria is nonspecific as regards ureteral stones. I use imaging, preferably CT, although ultrasound, looking for hydroureter or even KUB, if positive, would suffice.