Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach the management of a patient with nonoliguric ESKD, massive proteinuria, and hypoalbuminemia who is already on an ACE inhibitor?
This situation does not come up often, but I think there should be serious consideration of attempting to decrease kidney function by measures such as NSAID administration. Severe proteinuria has detrimental effects way beyond any benefit one may obtain from preserving residual renal function. The p...
What is your approach to discharge planning for a patient with chronic SIADH who is admitted with asymptomatic acute-on-chronic hyponatremia?
An acceptable baseline serum sodium level in chronic SIADH is based on both clinical status and risk of complications. Based on literature, in the absence of severe symptoms, the target is a gradual correction to a level that minimizes neurocognitive and physical impairment, typically aiming for a s...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
How would you approach failure of maintenance therapy (Azathioprine) for PR3 positive, c-ANCA positive, pulmonary–renal vasculitis previously induced with cyclophosphamide, with a history of anaphylaxis to rituximab?
This is a challenging clinical situation with several appropriate treatment approaches as follows: Desensitization to rituximab - this would need to be done in the ICU but is effective for patients who are willing to undergo the process for whom other maintenance regimen options are suboptimal. Avac...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...
Would you recommend pre-dialysis exercise for an ESKD patient as a means of cardioprotection?
It seems beneficial. If a patient is agreeable, I would always favor exercise. However, I can see most of the patients refusing/unable to join.
How do you treat restless leg syndrome in patients with end-stage renal disease?
Based on the 2025 guidelines for RLS in patients with ESRD, I would recommend first checking iron studies and using IV iron sucrose if ferritin and transferrin saturation meet the criteria since the use of iron in this population has moderate certainty of evidence. If an iron infusion is not helpful...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.
What degree of prolactin elevation is typically seen in patients with end stage kidney disease on hemodialysis?
Usually, less than 50, rarely 50-100. If it is higher than 100, one should look for another cause of hyperprolactinemia.