Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is the accuracy of continuous glucose monitors (DEXCOM or Libre) lower in patients undergoing dialysis?
The question of the accuracy of CGM in dialysis patients is an important one and has been debated for some time. CGM is a superior method for glucose management over fingersticks in most clinical settings. Patients with ESRD on dialysis in particular, can have very difficult-to-control diabetes. A r...
For patients on peritoneal dialysis with type 2 diabetes mellitus, do you have a preferred long- acting insulin and time of insulin administration?
Insulin management in patients on peritoneal dialysis can be tricky. In my experience, you have to be very cautious with long-acting insulin. Much of the hyperglycemia occurs during the exchanges with the dextrose solution. Therefore, using long-acting insulin can cause hypoglycemia. My suggestion i...
How do you counsel patients with CKD who are on a PPI given a prior observational study showing an association between PPI use and incident CKD?
I am a little conflicted about this topic and have changed my practice in the last 4-5 years.There are multiple observational studies that suggest an association between PPI and CKD but residual confounding remains a concern in these studies. A nice commentary on this topic was published last year i...
How do you approach the management of a kidney transplant recipient who develops de novo donor-specific antibodies but shows no clinical signs of rejection or graft dysfunction?
Context is important. Was this part of a surveillance protocol for a high risk patient to monitor for DSA early post transplant? Or checked prior to making changes to immunosuppression eg Belatacept conversion? Creatinine and proteinuria are late signs of graft damage. So even if neither is present...
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
Are there any special considerations you take with ESA use in hospitalized patients with ESKD who undergo stem cell transplantation?
There really are no guidelines for the use of ESAs in this population. Generally, these patients receive PRBC support for severe and/or symptomatic anemia. We do not prescribe ESAs int this setting because we suspect that the response will be suboptimal given the inflammatory state of these patients...
For outpatients undergoing a kidney biopsy, do you routinely recommend an overnight admission for continued hemoglobin monitoring?
If I perform an uneventful kidney biopsy in the morning on a patient with well-controlled BP and normal hemoglobin, I can observe the patient all day. If vitals are stable and the repeat hemoglobin at 8 hours is stable, I would discharge the patient. However, if I did the biopsy later in the day or ...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
Under what circumstances would you consider a bone biopsy in the workup of renal osteodystrophy?
I am always in favor of doing more diagnostic tests. The problem is that it is often practically hard to get a bone biopsy. I would suggest it anytime there a question of what is happening with the bone disease.
When would you consider referring a patient with resistant hypertension for renal denervation?
I consider renal denervation in patients who have 2 kidneys without renal artery pathology, eGFR > 40, a negative secondary workup (including exclusion of primary aldosteronism), uncontrolled BP, and who can return for follow-up monitoring after the procedure. Some of my referrals have been in patie...