Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long do you wait for a reduction in EBV viral load after reducing immunosuppression before deciding to start rituximab in a kidney transplant patient with EBV viremia?
This is a difficult question. If this is in the context of EBV viremia and kidney transplant patients with PTLD that is EBER positive, I make this decision in consultation with the treating hematologist/oncologist. I have not used rituximab in EBV viremia alone.
Would you add regional citrate anticoagulation to a CRRT prescription for a patient on systemic heparin but who experiences recurrent filter clotting?
Depending on the need for CRRT vs PIRRT, if I could, I would go with PIRRT first depending on when the clotting occurs in the treatment. Our typical PIRRT treatment is 40 liters over 8 hours, and we can do that daily if needed (often at night), and it totally controls the chemistries and usually vol...
Are there instances when you obtain an abdominal X-ray over an ultrasound or CT scan for kidney stone surveillance in a patient with recurrent calcium based nephrolithiasis?
I agree with Dr. @Dr. First Last. I see no use for an abd Xray. I, generally, go to US, which has no radiation and is good at localizing stones and can identify relatively small stones as well as give a good sense of stone burden. Occasionally, a CT may be required.
Under what circumstances would you obtain MR imaging of the kidneys in a patient with ADPKD who was recently diagnosed following CT imaging?
If a CT was definitive, an MRI is not needed except to obtain accurate total kidney volume measurements in some cases, depending on CT quality and in cases in which TKV falls on the borderline between categories of Mayo Imaging Classification (MIC) that was affect the ability to make a treatment dec...
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
Do you recommend plasmapheresis prior to kidney transplantation for patients with elevated panel-reactive antibody percentages?
No, preemptive PLEX is not necessary with a high PRA in the absence of DSA. At our center, we do monitor for emergence of DSA in our patients with the highest PRAs >98%.
How do you approach chronic active AMR concurrent with changes of CNI toxicity?
This can be a tricky situation. With AMR, my approach is to optimize the antiproliferative agents (mycophenolate) and maintain therapeutic levels of the CNI. Adjusting the CNI target level will be dependent on the degree of CNI toxicity, if present. Maybe for mild changes, run the tact levels in the...
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...
How do you advise your patients to optimally store a recently passed kidney stone to ensure it can later undergo composition testing?
I am not aware that kidney stone composition changes significantly ex vivo. Calcium oxalate dihydrate will gradually change to monohydrate, but that does not influence my treatment recommendations. The more challenging problem is capturing the stone for analysis. For patients with colic, I send them...