Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you routinely mention the risk for encapsulating peritoneal sclerosis as part of your consent process for dialysis initiation in a patient with advanced CKD who is considering the different dialysis options?
I do not do so. The incidence of EPS within the first 5 years of PD is extremely low. Just as I do not discuss with patients the possible occurrence of rare complications of HD (e.g., osteomyelitis), I do not discuss EPS either. The ISPD recommendation is to consider discussing the possibility of EP...
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
How do you decide when to stop immunosuppression in a patient with granulomatosis with polyangiitis who is on dialysis, has not yet recovered renal function, but has shown improvement in ANCA levels?
In a patient with pauci-immune necrotizing GN from GPA on HD, I usually wait for 3 months and up to 6 months if the biopsy is fresh with minimal chronicity before declaring ESRD and stopping IS. If they have extrarenal disease (ENT, lungs), they would need IS for extrarenal disease.
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
How do you approach the decision to perform preimplantation biopsies in brain-dead kidney donors?
Full Disclosure: This is an opinion from a transplant nephrologist who does not take direct organ offers, but someone who bore witness to many offers that did involve a preimplantation biopsy. The use of preimplantation biopsy appears to be most useful in cases where the clinical parameters would su...
What is your preferred treatment agent for type 1 von Willebrand patients needing minor procedures if they have a history of severe hyponatremia with DDAVP?
I would avoid DDAVP. I typically individualize hemostatic management based on the procedure- related risk of bleeding and severity of the VWD. For example, for dental extraction, tranexamic acid alone may suffice; however, communication with the proceduralist to use topical agents such as topical th...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...
Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic range proteinuria, microscopic hematuria, and stable renal function who has been on a tenofovir-based regimen?
I often find the biopsy on these patients unhelpful. Having said that, I do advocate doing a kidney biopsy when there are other circumstances which raise the possibility of other disorders (i.e., possible IgA nephropathy, tenofovir was given for a short period of time, and only TAF was used, etc.).
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...