Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How often do you check renal function panels for patients with recurrent nephrolithiasis?
Interestingly, most patients with recurrent kidney stones have normal or near normal GFR. I check them annually when I do imaging and 24-hour urine supersaturations looking for metabolically active stone disease. For those patients with decreased GFR, I recheck them at the same frequency, I would c...
What level of 24h urine M protein do you consider to define active myeloma in a patient with renal insufficiency, proteinuria and monoclonal gammopathy?
When in doubt, a renal biopsy is preferred to define what is the exact disease process leading to renal dysfunction. If cast nephropathy is seen, this supports a diagnosis of myeloma. If amyloid or light chain deposition disease is seen, this also supports a diagnosis of amyloidosis or MGRS/myeloma,...
How do you manage proteinuria in a patient with type 1 diabetes mellitus who has orthostatic hypotension and is unable to tolerate ACEi/ARBs?
I do agree with Dr. @Dr. First Last that orthostatic hypotension should be evaluated. This could include a 24-hour ABPM and/or careful home BPs + weight monitoring. If dysautonomia is suspected, then seeing a specialist for dysautonomia could be beneficial.Surprisingly, orthostasis symptoms improved...
How do you approach the workup of a patient with a large focal wedge-shaped cortical swelling on CT concerning for renal infarct, but with a normal echocardiogram showing no thrombus or vegetation?
This would depend on the clinical setting - is this someone presenting with signs or symptoms suggesting acute ischemic kidney disease, or an incidental finding on the CT? My first step would be to determine if this is actually a renal infarct by imaging. Either CTA or MRA, or nuclear renogram would...
Do you recommend chanca piedra supplements for patients with recurrent calcium oxalate nephrolithiasis?
NO. No data support its use. The idea of ''breaking' a crystal matrix mass of CaOx crystals does not seem thermodynamically likely.Given it is implausible and unproven I shun the stuff.
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
Do you obtain a urinalysis for glucose testing for your patients on SGLT2 inhibitors to assess for medication adherence?
I do not do a UA solely for this purpose, but it helps to have one for other routine testing purposes that demonstrate the glucosuria.
Is there still a role for plasma exchange/PLEX for confirmed or suspected cast nephropathy in multiple myeloma to rapidly reduce light chain burden?
This is a good question that comes up from time to time. The most important thing is time-to-bortezomib, which should be as short as possible.For light chain only disease, I do not do plasma exchange. My reasons are: It only marginally reduces free light chains (see: Hutchison et al., PMID 17229909)...
What factors influence your decision between guidewire exchange versus removal and replacement through a new tunnel tract for patients with tunneled hemodialysis catheter mechanical failure?
Mechanical failure of a tunneled dialysis catheter (TDC) could be from catheter cuff extrusion form the exit site, catheter thrombosis or a fibrin sheath. In all three scenarios I prefer guidewire exchange rather than removal and replacement of the TDC. Removal and replacement are much more invasive...
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...