Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a time frame in which you would no longer consider a prior vein mapping study reliable and thus recommend repeating the test in a patient with advanced chronic kidney disease who requires evaluation for fistula placement?
As a standard, typically 6 months is the longest I’d consider utilizing a vein mapping; however, the caveat here is to repeat after any hospitalization or known line placements/extensive blood draws. Vein mapping is very low risk and relatively easy to repeat vs the risk of a failure to mature fistu...
Would you initiate a SGLT2 inhibitor for a patient on chronic lithium with the goal of preserving kidney function?
I would not be inclined to go to an SGLT-2 inhibitor in this situation. The nephrotoxicity of lithium is tubulointerstitial, not glomerular, primarily. I would not expect an SGLT-2 inhibitor to be nephroprotective and may have other adverse effects, given the other kidney effects of lithium. I do no...
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
Do you recommend prescribing Pneumocystis jiroveci pneumonia (PJP) prophylaxis for a patient with membranous glomerulonephritis on rituximab?
In general, I don't use Pneumocystis jirovecii pneumonia prophylaxis (PJP PPx) for patients with membranous nephropathy (MN) who have only received rituximab (RTX), unless they have also received high-dose glucocorticoids (GC) or cyclophosphamide (CYC). I usually give PJP PPx when patients receive h...
At what serum sodium level do you stop desmopressin when using a clamp strategy to prevent overcorrection in hyponatremia?
There is no universally accepted serum sodium threshold above which DDAVP should be stopped. If there is a concern for over-rapid correction of the serum sodium level by more than 8 mmol/L in 24 hours, then DDAVP should be continued. Therefore, urinary output and urine osmolality should be monitored...
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
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...
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...