Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
In a patient with acute stroke/ICH/SDH/hyperammonemia at risk for rebound edema with new onset renal failure, do you prefer CRRT versus low and slow HD?
In the acute period (first 72-96 hours after ictus), my personal preference is CRRT due to the theoretical advantage of hourly titration of ultrafiltrate. I don't know if it really matters though. As for the frequency of laboratory evaluations, I don't find more frequent than q4 hours to be useful, ...
How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?
For those with a history of skin cancers prior to transplant would recommend every 6 months. For those with no history of skin cancer I recommend skin checks every 6 months starting 1-2 years after transplant. Those at highest risk are the Latino and Caucasian propulations but even those in the less...
Do you recommend a kidney ultrasound to evaluate for microcystic changes when caring for a patient with chronic kidney disease suspected secondary to chronic lithium use?
Not sure if the ultrasound will add to management beyond lab values and routine ultrasound for patients with CKD. The question comes if someone has microcystic changes and normal creatinine levels, would that indicate a need for a change of therapy? In the past, lithium has been a very effective (ma...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Do you transition to non-tablet formulations of potassium citrate in patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia who are noticing intact tablets in their stool?
Yes, although I often start citrate therapy in liquid form because increasing urine volume is one of the most effective ways to prevent kidney stones. My first beverage preference is water. Tap water is fine. If the patient is hypocitraturic, I recommend a citrate-containing beverage, typically Moon...
Would you use voclosporin or belimumab as adjunctive therapy for treatment of lupus nephritis?
Yes, I would. However, this is not a uniformly accepted practice. Many clinicians believe the effect sizes were not sufficiently large to warrant drugs as initial therapy. The reasons for dual therapy (MMF and belimumab or MMF and voclosporin) go beyond the primary endpoint of the BLISS-LN and Auror...
How do you manage a pregnant patient with lupus who develops renal disease during pregnancy that is not due to pre-eclampsia?
As the question implies, the first order of operations, when a pregnant lupus patient develops clinical features of nephritis, is to distinguish between the two most common etiologies, pre-eclampsia and lupus nephritis. The former is due to an imbalance between SFLT (soluble FMS like tyrosine kinase...
Do you recommend bone mineral density testing in your patients with recurrent nephrolithiasis secondary to medullary sponge kidney?
A majority of patients classified as MSK do not have that disease. They are calcium phosphate stone formers with multiple duct of Bellini crystal plugs. Most of those have idiopathic hypercalciuria and in that genetic syndrome bone mineral loss is not at all uncommon. Some patients - but by no means...