Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend avoiding PICC line placement in a kidney transplant patient with an estimated GFR of more than 45 ml/min/1.73m2 and no functional AV access?
Great question and of course there is no data to guide decision-making in this scenario. Anecdotally, I would assess the patient as a whole, not just limited to current GFR though that is a great starting point. What is their age and co-morbidities - is this a younger /middle-aged/older patient, is ...
Are there instances when you do not recommend tunneled dialysis catheter exchange in patients on hemodialysis who are found to have bacteremia?
Generally, the answer is no. The only situation I would not recommend tunneled catheter exchange is if the patient has "run out" of catheter insertion sites and removal of the catheter poses the risk of not being able to place another tunneled catheter. That is also tempered by the organism causing ...
What is your approach to managing insomnia in an ESKD patient?
I try to stay away from medication therapy. First, I recommend good sleep hygiene (i.e., avoiding coffee, watching TV while in bed, too much light, etc.). The next step would be recommending as much exercise (mainly walking) as possible. If I have to use medications, I would start with melatonin and...
Would you recommend oral or intravenous iron in a chronic kidney disease stage 4 patient who is not on an ESA and has a hemoglobin of 12.7 g/dl and an iron saturation of less than 20%?
I would not necessarily treat this patient with iron at all. I would check serum ferritin. If low would do a colonoscopy or look for causes of iron deficiency. If not low would observe. In general though for patients with CKD (not on dialysis yet) who need iron therapy, I would try oral iron first. ...
Would you add an SGLT2 inhibitor to augment diuresis during a hospitalization in a patient with nephrotic syndrome, an eGFR above 30 mL/min/1.73m2, and refractory hypervolemia on an intravenous loop diuretic?
Establish true loop diuretic refractoriness (minimum frequency: BID, the max dose depends on CrCl). Add sequential diuretics. Metolazone or other thiazide-like diuretics, with without amiloride or spironolactone. (Latter diuretics are preferred if the patient is hypokalemic). Add 25% albumin if e...
Do you consider starting hydroxyurea in a patient with hemoglobin S-beta thalassemia with chronic kidney disease secondary to FSGS?
I consider initiating hydroxyurea in all individuals with sickle cell disease, even if they have rare or infrequent acute pain episodes. This is because pain is just one manifestation of the disease and ongoing hemolysis leads to a state of chronic inflammation characterized by cytokines, activation...
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
Do you recommend dietary changes to your patients with recurrent kidney stone disease who consume coffee and low oxalate teas daily?
Thank you for your question. Many patients get tired of drinking water and would prefer coffee, low-oxalate tea, or other beverages instead. Studies have shown no difference in whether the water is hard or soft. Coffee and low oxalate tea do not seem to increase stone passage either. There is some d...
When do you deem it reasonable to transition outpatient management of a kidney transplant patient to general nephrology?
Many transplant centers have different views on when to transition patients. In our program, we transition patients after a year post-transplant and alternate visits between the transplant center and the referring nephrologist until year 3 when we ask the patient to see their nephrologist quarterly ...
How would you treat a kidney transplant patient with both biopsy-proven BK nephropathy and recurrent membranous glomerulonephritis with nephrotic range proteinuria?
Mostly concur with Dr. @Dr. First Last. I would generally shy away from cidofovir - the most recent consensus guidelines for BK management recommend against cidofovir due to evidence largely being poor for effectiveness. IVIg has not much better evidence but is also much less toxic. Once BK is brou...