Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How often do you screen for cerebral aneurysms in patients with autosomal dominant polycystic kidney disease who do not have a family history of intracranial aneurysms or for whom the family history is unknown?
We recently wrote an editorial about this topic. Our conclusion was as follows: "considering the potential for morbidity and mortality in this unique population at risk for ICAs with possibly higher-than-average risk of rupture, we believe that presymptomatic screening for ICA in all individuals wit...
How is monoclonal gammopathy of renal significance (MGRS) different from myeloma kidney?
The terminology around renal failure and myeloma is confusing and sometimes unnecessarily complicated. Here is how I approach it: Light chain (cast) nephropathy - This is from toxic injury to the nephron tubules from excess light chains. This is usually picked up on biopsy or can be ascertained fro...
What is your approach to managing a kidney transplant patient who develops BK viremia after treatment for rejection?
This is always a challenging situation. First, I decrease the mycophenolate, typically by 50%. Some of my management depends on whether the rejection was antibody mediated vs cellular, and how high the BK viral load is. If there was antibody mediated, I prefer to maintain some mycophenolate, if poss...
Do you recommend periodically testing for anti-GBM antibody in patients with ESKD secondary to Alport's syndrome who are status post kidney transplantation?
I would not recommend randomly checking anti-ABM antibodies. If the patient develops an increase in creatinine or new abnormalities in the UA or UPC, then I would pursue renal allograft biopsy and make sure pathology does immunofluorescent staining. It is exceptionally rare, but should be kept in th...
Do you recommend antibiotic prophylaxis for an ESKD patient with a tunneled dialysis catheter who is planned for a dental procedure?
I do not. Which procedures require antibiotic prophylaxis has always been a very confusing issue for me. It also seems to change often. However, with dental procedures, the main organism responsible for bacteremia is streptococcus of viridans group which is an unlikely cause of line infection. I thi...
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
What advice do you offer to patients with recurrent nephrolithiasis who are on a tube feeding diet and seeking stone prevention guidance?
As always, it is important to know their stone composition, so that you tailor the invention appropriately. Regardless, I have seen many such patients with calcium oxalate stones. It is important to get detailed information about their tube feeding formula and dosing, because tube feedings can vary ...
Would you consider treating hypercalcemia with CRRT and regional citrate anticoagulation for a dialysis dependent patient who does not respond to bisphosphonate therapy and low calcium dialysate bath?
Although CRRT with citrate anticoagulation may be effective in treating significant hypercalcemia, this is only a temporary solution if the underlying etiology of hypercalcemia persists. The underlying cause of hypercalcemia should be addressed, if possible. If the underlying etiology cannot be easi...
Do you recommend holding metformin in a patient with chronic kidney disease who has an upcoming CT contrast study?
I actually do. Over the years I have seen a number of cases of metformin induced lactic acidosis. Although it is very hard to predict who will have it. I would like to be on the safe side.