Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to patients with recurrent nephrolithiasis and low urine volumes who struggle with increasing fluid intake following a sleeve gastrectomy procedure?
This is a difficult situation for both the patient and the provider. I think the best solution is for them to drink small quantities of fluid frequently. This creates a compliance problem. I encourage patients to have fluid regularly available, meaning that they may have to take it with them to work...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
How many days after an AVF clots do you determine that attempting a declot procedure is no longer worthwhile?
Fistulas behave differently than grafts. As time goes by, the clot organizes and makes it difficult to pass the wire across the clot in the fistula. The volume of the clot tends to be large in the fistula as well. For these reasons, fistulas need to be declotted asap. I would say that the chance of ...
What clinical criteria do you use to decide between antivirals, rituximab, plasmapheresis, or a combination therapy for treating hepatitis C virus-associated cryoglobulinemic membranoproliferative glomerulonephritis?
Direct-acting antiviral agents would help eradicate the HCV clone and often the HCV-infected B lymphocytes that produce the polyclonal IgM (III cryo) or monoclonal IgM (II cryo) against IgG. Sometimes, despite HCV clearance, B-cell clones persist, leading to cryoglobulinemic vasculitis and MPGN; in ...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.
Would you consider using a combination regimen of rituximab, low-dose cyclophosphamide, and steroids to improve complete remission rates in patient with PLA2R-positive membranous nephropathy?
Patients with membranous nephropathy (MN) with declining GFR, not explained by causes other than MN, massive proteinuria, and high-titer anti-PLA2R antibodies are considered high risk and should be treated with immunosuppressive therapy. Both the Membranous Nephropathy Trial of Rituximab (MENTOR) (1...
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).
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.