Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What are your recommendations for stone prevention for patients with recurrent calcium based nephrolithiasis who consume well water with a high calcium concentration?
Drink lots of it! Seriously, studies done long ago, looking at the geography of stone formers did not correlate with water hardness (mineral content), but rather with average temperature, the incidence of stone passage being higher in the southern parts of the United States. The amount of calcium co...
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
Are there any special considerations to take into account when managing patients with recurrent nephrolithiasis who are found to have a horseshoe kidney?
Interesting question! Horseshoe kidneys are particularly susceptible to stones, primarily in the lower poles. Stones are typically composed of calcium oxalate. Renal embryology was a neglected topic during my medical education. The prometanephros are located near the fetal cervical spine. They subse...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...
Do you recommend a metabolic evaluation in a kidney transplant patient with no prior history of nephrolithiasis who is found to have donor derived kidney stones?
Thanks for an interesting question. It would help if we knew the relevant donor medical history, such as dietary indiscretions or enteric hyperoxalutia, which would not be issues in the recipient. Since this information is typically not available, I would collect two 24-hour urinary supersaturation ...
Do you use delayed-release budesonide over prednisone or methylprednisolone for the treatment of IgA nephropathy, considering the available safety and efficacy data?
The two agents (TRF-budesonide and systemic glucocorticoids, the latter of which include prednisone and methylprednisolone) have never been compared head-to-head, and so direct comparisons are unavailable. I try to present both options to patients, and in particular, I will focus on the side effect ...
How do you adjust the loading and maintenance doses for Keppra when treating status epilepticus in patients with ESRD, patients on HD, or patients on CVVH?
Ideally, if you have a patient with status epilepticus and known ESRD, then Keppra may not be an ideal first option. You should be reaching for your other status anti-seizure meds that aren’t exclusively renally excreted and are readily available in most hospitals; Depakote (40 mg/kg loading dose) o...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...