Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
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 ...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
How do you decide when to stop immunosuppression in a patient with granulomatosis with polyangiitis who is on dialysis, has not yet recovered renal function, but has shown improvement in ANCA levels?
In a patient with pauci-immune necrotizing GN from GPA on HD, I usually wait for 3 months and up to 6 months if the biopsy is fresh with minimal chronicity before declaring ESRD and stopping IS. If they have extrarenal disease (ENT, lungs), they would need IS for extrarenal disease.
Do you postpone hemodialysis for a period of time after stem cell transplantation in a hospitalized patient with ESKD?
No. In fact, some patients may require extra HD sessions to manage volume overload post SCT. All ESKD patients are assessed daily for HD and continue to receive thrice-weekly dialysis per routine. If they are persistently hypotensive, they are considered for transition to CRRT.
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...