Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Which clinical characteristics would prompt you to consider an oral factor B inhibitor such as iptacopan in the treatment of IgA nephropathy?
I think iptacopan may be a useful choice in patients with a more active, aggressive lesion on biopsy, declining GFR, or heavy proteinuria. It perhaps makes intuitive sense to favor iptacopan if there is strong C3 staining on biopsy as well. We still do not know which among iptacopan, sustained-relea...
Would you advocate for SGLT2 inhibitors if they are not fully covered by insurance in patients with moderately increased albuminuria (< 300 mg/g) who are on maximal dose ACEi/ARB?
I think the benefit would be minimal. I would not necessarily have the patient pay extra money to get them.
What is your preferred fill volume, dialysis solution, and dwell time for patients with suspected peritoneal dialysis associated peritonitis who arrive to the hospital with a dry abdomen?
I agree with Dr. @Dr. First Last's approach with one addition: prior to instilling the fluid for 2 hours, I would do a quick flush of the abdomen- fill and drain immediately- to remove the cells that accumulated while the abdomen was dry, and thereby avoid "muddying" the waters (pun intended).
Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?
Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).Why this matters: Transplant > Dialysis: Patients with LN-ES...
What is your approach to determining if a patient treated with vancomycin has ATN related to vancomycin or the underlying infection?
For the most part, I would assume it is the underlying infection. Very high vancomycin levels and its combined use with Zosyn make me wonder about vancomycin toxicity, especially if the infection has been well treated.
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
Would you offer peritoneal dialysis to a patient with ESKD who also has a ventriculoperitoneal shunt?
I would not place a PD catheter in an adult ESRD patient who has a ventriculoperitoneal shunt (VPS). I would instead place a hemodialysis vascular access and encourage this patient to do home hemodialysis. However, if the patient had exhausted all vascular access sites and was catheter-dependent, I ...
How would you approach the decision to biopsy a kidney transplant recipient who previously experienced a Page kidney following a kidney biopsy?
The decision to perform a renal biopsy should be made after thorough deliberation regarding the appropriate indications and the potential diagnostic information that the procedure may yield to inform patient management. Under suitable conditions, renal biopsy is considered a safe and well-tolerated ...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...