Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
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...
How do you decide which patients with asymptomatic hyperkalemia and CKD warrant inpatient admission versus expedited outpatient management?
I would imagine that there is no EKG available as the patient is outpatient. I prefer not to admit patients as much as possible. I would not admit patients with potassium levels less than 6. For those between 6 and 6.5, I would try to treat medically and recheck potassium the next day. If potassium ...
What is your preferred treatment agent for type 1 von Willebrand patients needing minor procedures if they have a history of severe hyponatremia with DDAVP?
I would avoid DDAVP. I typically individualize hemostatic management based on the procedure- related risk of bleeding and severity of the VWD. For example, for dental extraction, tranexamic acid alone may suffice; however, communication with the proceduralist to use topical agents such as topical th...
Are there instances when you will forgo dialysis catheter placement and instead use an existing AVF/AVG for an ESKD patient who requires CRRT?
Since continuous renal replacement therapy (CRRT) in our institution can run without anyone in the room, we never do CRRT through a fistula or arteriovenous graft (AVG). While the risk of needles coming out is probably low and the acute drop in pressure may (may?) alarm the machine, the potential co...
Would you pursue temporary dialysis catheter placement followed by hemodialysis in a hospitalized patient with ESKD who is not able to undergo urgent fistula repair for a non-functioning fistula and receives gadolinium for a MRI study?
There is no role for hemodialysis following the GAD preparations we use these days.
Would you offer peritoneal dialysis to a patient with ESKD who also has dementia but lives with family who can assist with dialysis treatments?
The key words in this question are "can assist". Change it to "WILL assist" and the answer is an unequivocal "yes". But I would not leave it optional.
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
Would you perform a kidney biopsy to rule out other etiologies before diagnosing Loin Pain Hematuria Syndrome in a patient with persistent microscopic hematuria, left flank pain, no proteinuria, normal renal function, normal cystoscopy, and normal imaging?
Probably not unless something changes.