Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you rely on CT Hounsfield Units to determine stone composition in your patients with recurrent nephrolithiasis who have yet to submit a stone for laboratory based composition testing?
It is somewhat helpful if the value is low, consistent with Uric Acid stones, if higher, not specifically differentiate the calcium stone type. However, since it is part of routine CT stone protocol, it may add some useful information.
Would you consider a BRCA carrier patient for kidney transplantation?
I would certainly consider a potential recipient who is a BRCA carrier. Would involve genetic counseling as well as informed consent regarding the risk of malignancy post-transplant. The mortality risk, depending on co-morbidities, of remaining on dialysis is high and should certainly be considered ...
Would you start a vaptan or monitor an asymptomatic patient with reset osmostat and an average sodium of 126 meq/L?
No therapy is required if the patient has hyponatremia due to a reset osmostat, since the patient will regulate the serum sodium concentration around this new baseline level. The key question is whether or not the patient actually has a reset osmostat. A patient with hyponatremia due to a reset osmo...
How do you tailor protein intake recommendations for older patients with stages 3-5 non-dialysis dependent CKD, considering the unique metabolic and physiologic factors that influence protein metabolism in this population?
Personally, I would not restrict their protein intake. I would encourage good protein source intake such as eggs, chicken and fish. If serum BUN is very elevated, then it may be worthwhile discussing lower protein intake. If patient become uremic then dialysis should be discussed if indicated.
How would you approach management and monitoring of AL amyloidosis with isolated renal involvement?
This is tough for sure, and my first question would be to ask how the renal biopsy was determined to be AL amyloidosis. Sometimes typing isn't required if the pattern is overwhelmingly lambda-restricted or kappa-restricted by immunofluorescence... but in this case, mass spectrometry typing may be wo...
How do you manage oral prednisone when initiating nefecon in a patient with IgA nephropathy?
Careful tapering of prednisone and transition planning of budesonide.
How do you evaluate for clinically significant ureteral obstruction in a pregnant patient with AKI, since physiological hydronephrosis on kidney ultrasound is common?
For AKI, it would have to be bilateral, and then I would consult urology.
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
What is your approach to prednisone use in a kidney transplant recipient with allograft failure, residual allograft function, and an ongoing dialysis requirement for more than one year?
It really depends if this patient is a candidate for another transplant, and whether all the other immunosuppression has been weaned off. If they are a candidate for transplant, I am more likely to leave them on prednisone, especially with the residual renal function. If they are not a candidate for...