Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?
If the patient does not have APS and does not have nephrotic range proteinuria, then the indication for presumptive anti-coagulation is unclear.
What is the maximum diuretic regimen recommended in patients with end-stage kidney disease who have residual renal function and volume overload?
Studies in peritoneal dialysis have shown both the safety and benefit of high-dose furosemide. One study randomly assigned 61 incident CAPD patients to either furosemide 250 mg every day or no furosemide at the time of CAPD training and they were followed prospectively. Baseline 24-hour urine volume...
Which method provides a more accurate assessment of hypercalciuria: 24-hour urinary calcium excretion or the spot urine calcium-to-creatinine ratio?
24-hour urine should be more accurate. F. Singer
How do you approach discussing the pill burden of voclosporin with patients who already have to take a regimen such as MMF+HCQ+ACEi and possibly more?
Medication adherence and a chronic disease such as lupus is an issue regardless of the number of medications. For example, hydroxychloroquine is very effective, but studies often show poor adherence as measured blood levels may be undetectable or below the intended therapeutic target.For patients wi...
What is your approach to managing patients with recurrent nephrolithiasis and nephrocalcinosis in the setting of hypoparathyroidism?
If patients truly have hypoparathyroidism, then the issue is to manage their hypocalemia, which usually requires large doses of oral calcium as well as treatment with VDRAs, which results in marked hypercalciuria, since they do not have PTH to help reabsorb calcium. This even occurs when they have C...
How do various therapeutic approaches for IgA nephropathy target the different stages of the four-hit hypothesis?
Based on our mechanistic understanding and some limited biomarkers, we think that ACEI, ARB, SGLT2i, endothelin antagonists like sparsentan, and complement inhibitors like iptacopan all act on the final "Hit 4" of glomerular inflammation. This points out that Hit 4 is actually quite complex! It invo...
Would you continue to monitor urinary protein levels and dose adjust axitinib in a patient with metastatic malignancy who is now dialysis dependent but has residual renal function?
The question lacks specificity, so I will assume that this refers to a patient with irreversible ESRD not due to the TKI itself. Generally, if the proteinuria was exclusively due to the TKI, the HTN and proteinuria will abate when the drug is discontinued. Also, as renal function declines, the prote...
What medications do you use to treat encapsulating peritoneal sclerosis?
There are three stages in the progression of encapsulating peritoneal sclerosis (EPS): the inflammatory stage characterized by the presence of inflammatory markers e.g. CRP and IL-6, which may present with bloody ascites and in which CT scan shows minimal changes, if any; the encapsulating stage cha...