Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
When would you suspect an allergy to the dialysis membrane in patients who complain of pruritis during dialysis?
The short answer is no. Pruritus is so common with renal disease, and allergic reactions to dialyzers are uncommon. If the pruritus can confidently be documented to be only during dialysis and not at any other time, then it may be worth trying a different dialyzer but it would take a lot for me to b...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
How do you manage early patient-reported polyuria after starting an SGLT2 inhibitor to prevent premature discontinuation?
I have not encountered this situation yet. I would imagine the polyuria improves over time as eventually intake has to equal output. Of course, it is possible that polyuria will cause increased thirst. Reassuring the patient is the best first option.
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
Do you use SGLT2 inhibitors in the management of SIADH?
The osmotic diuresis induced by SGLT2 inhibitors results in the urinary excretion of water in excess of Na+ and K+ excretion, thereby resulting in an increase in the serum sodium concentration. However, SIADH is a clinical disorder characterized by an increase in TBW in the setting of relatively nor...
Do you avoid low-dose radiation CT stone scans in obese patients with recurrent nephrolithiasis given concerns for inadequate stone detection?
Given about 55% sensitivity of US, I am fine with the reduced sensitivity of low dose CT in obese patients. It is better than the alternative. I do not know off hand if trials have estimated the loss of counting accuracy in the obese, and I suspect it will depend a lot on details of patient selectio...
Do you recommend checking urine sodium 2 hours after loop diuretic administration to determine the need for dose adjustment in a patient with acute decompensated heart failure?
I know that is maybe a more physiologic way, but I can tell if it is working just by the urine output. The urine output is not going to increase following a loop diuretic without a natriuresis. And what good id an increased urine Na if the volume of urine is insufficient? If I am diuresing in decom...
Would you start an SGLT2 inhibitor in patients with diabetic kidney disease who also have a history of prior toe amputation?
I would. I think the risk with SGLT2 and vascular disease is very low. Thus, I would give them if there are no other contraindications.
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...