Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you refer a patient for kidney only or kidney and liver transplantation if they develop advanced chronic kidney disease secondary to primary hyperoxaluria type 2?
We have reasonable experience with kidney and liver transplant in primary hyperoxaluria type 2, and we do believe that it corrects the hyperoxaluria. Thus, in our center, we typically evaluate PH2 patients with kidney failure for potential liver transplantation, especially since the siRNA treatments...
Do you prefer automated peritoneal dialysis during the day or night for a hospitalized patient with ESKD on PD?
I am very fortunate to have my home dialysis unit based in the hospital. Thus, our nurses are here and can set up/ take down the machine every day. We perform APD overnight, generally starting at around 5- 6 PM, before the last nurse leaves for the day, and concluding by 3- 4 AM, with the patient th...
How do you modify your peritonitis prevention strategy for a patient starting peritoneal dialysis who has a history of recurrent staphylococcal skin infections?
At the outset, let me state that I am unaware of any published data regarding this issue. Nor do I have personal experience to draw upon. So, what follows is what I THINK I would do if faced with this situation.First off, I would have a rather high threshold for starting PD in such a patient, especi...
Would you recommend adding a novel agent, such as lumasiran or nedosiran, to treat a newly diagnosed patient with primary hyperoxaluria type 1 who has preserved kidney function and persistent but significantly improved urinary oxalate levels following pyridoxine initiation?
I believe this is a fairly nuanced question. The answer really depends on the patient under question. Important considerations include how completely they responded to the pyridoxine, if there are any issues with them taking it regularly, and their current clinical course, including the number of st...
Would you recommend urinary glycolate testing prior to genetic testing in a patient with elevated urinary oxalate and suspicion for primary hyperoxaluria type 1?
Genetic testing today is much easier than urinary glycolate testing. Sending a saliva specimen is certainly more convenient than doing a 24-hour urine collection. At the moment, via pharma, the testing is free, so that is not a relevant variable either.
Which ESKD patients would you consider transitioning from hemodialysis to hemodiafiltration, given the FDA approval of a hemodiafiltration system in the US?
I believe once operational, we can transition all the patients in the dialysis unit equipped to perform it. In general, convention removes larger molecular weight substances, so patients who may derive the most benefit may be those who have, for example, dialysis-associated amyloidosis/carpal tunnel...
What is your approach to systemic anticoagulation for patients with hypoalbuminemia and nephrotic syndrome secondary to a non-membranous nephropathy condition?
Patients with nephrotic syndrome (NS) and hypoalbuminemia have a several-fold higher risk of venous thromboembolism (VTE) than the general population and also a somewhat higher risk of arterial thromboembolism (ATE), such as MI and stroke. This risk seems to be higher in membranous nephropathy (MN) ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
How would you approach managing a patient with ESKD on peritoneal dialysis who has a milky appearance of peritoneal effluent but low peritoneal fluid triglyceride levels?
The key word here is "low" triglyceride (TG) levels. Peritoneal dialysis fluid should ordinarily be devoid of TGs with virtually undetectable levels, < 10 mg/dL. In a case I reported many years ago (Rocklin et al., PMID 10978409), SVC syndrome presented as cloudy dialysate with a TG level just 25 mg...