Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you treat a patient with alcoholic cirrhosis and IgA nephropathy with high risk features including nephrotic range proteinuria, microscopic hematuria, and declining eGFR?
Cirrhosis is a well-known cause of secondary IgA nephropathy. Impaired removal of IgA-containing complexes by the Kupffer cells in the liver is thought to predispose to IgA deposition in the kidney (Amore et al., PMID 8302021). As in primary IgAN, polymeric IgA1 appears to be the dominant IgA isofor...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
What is your approach to the management of patients with recurrent nephrolithiasis who continue to have elevated stone risk parameters in the setting of dietary factors despite receiving education from a dedicated stone clinic dietician?
Diets are notoriously difficult to follow. Once it is apparent that the patient is not going to get satisfactory control of metabolic stone disease (an increase in stone number or size as opposed to the passage of pre-existing stones, unchanged in size or number), it is time to start preventative me...
Do you taper steroids more aggressively to decrease the risk of developing new-onset diabetes after transplantation in kidney transplant recipients who had pretransplant impaired fasting glucose?
Steroids are given after any transplant (kidney, heart, lung, bone marrow, etc.,) to reduce risk of rejection of the transplanted organ. Preservation of organ function is the number one concern for the transplant team. Steroid free regimens for anti-rejection are always a goal but the transition to ...
Would you consider making a diagnosis of hepatorenal syndrome-associated acute kidney injury with a one-day diagnostic fluid challenge instead of a two-day challenge to expedite vasoconstrictor therapy if needed?
Depending on the circumstances, of course. If the patient is already significantly fluid overloaded, even one day of fluids may not be necessary. The main issue is renal vasoconstriction, as these patients are never truly total-body fluid depleted. The key question is whether the renal vasoconstrict...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
Do you plan to initiate combination therapy with an SGLT-2 inhibitor and finerenone, instead of an SGLT-2 inhibitor alone, when treating patients with proteinuric chronic kidney disease and type 2 diabetes in light of the CONFIDENCE trial findings?
I would start one (typically the SGLT-2 inhibitor), then add finerenone potentially later. If both are started simultaneously and there is an AE, then both may have to be stopped. I prefer to see that one is tolerated, then start another.
Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?
The short answer is to add a binder. The best case for this is with Ca-based binders, for which many experts recommend a maximum daily dose of 1 gm of elemental Ca. (That’s only 6 CaAc tabs -169 mg of Ca per 667 mg). Another limit that is supported by some data is for sevelamer. The binding per 800 ...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
Under what circumstances do you order ambulatory blood pressure monitoring in a patient receiving maintenance hemodialysis?
I have done it when the patient is unable to take their bp meds prior to coming for dialysis, and pre-dialysis BP remains high. Other instances are when there is a large difference between the pre and post-dialysis blood pressure readings.