Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
How do you choose between eculizumab and ravulizumab for patients with acute kidney injury from complement mediated thrombotic microangiopathy?
For atypical HUS (aka complement-mediated TMA), both eculizumab and ravalizumab are FDA-approved therapies and are technically equivalent.The main advantage of ravulizumab is that it is a re-engineered form of eculizumab that extends its half-life to 51.8 days vs 11.3 days for eculizumab.Of note, me...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
Do you recommend any specific testing for patients with recurrent nephrolithiasis and suspected absorptive hypercalciuria?
I would consider genetic testing in this situation, although it would not alter my recommendations for diet and thiazide diuretic treatment. I would also look for primary hyperparathyroidism. Counterintuitively, parathyroid hormone increases absorption of urinary calcium; that’s why HPT patients are...
Are there instances when you recommend using sevelamer for patients with recurrent calcium phosphate nephrolithiasis?
Basically no. The main drivers of calcium phosphate stones are mildly alkaline urine and hypercalciuria. Primarily, I am looking for the causes of these conditions. Urine volume is always important. If urine phosphate is elevated, my first intervention in that regard is dietary. Stephen B. Erickson...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...