Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Below what ejection fraction would you avoid referral for AV access creation in a patient with advanced CKD and heart failure with reduced ejection fraction?
I would not refer a patient with advanced CKD and heart failure with an ejection fraction less than 30-35% for a hemodialysis vascular access for fear of worsening the heart failure. In addition, in my experience, if an arteriovenous fistula is placed in such a patient, it usually does not mature du...
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
Is reduction in proteinuria with SGLT2i dose dependent?
My understanding of dosing with empagliflozin, in particular, is that it is not dose-dependent, thus a dose of 10 mg versus 25 mg will lead to a similar reduction in proteinuria. This is based on data from the EMPA REG OUTCOME trial published in NEJM in 2016. The composite outcome of incident or wor...
Is there a kidney length for which you would no longer recommend attempting a kidney biopsy due to safety concerns and lack of diagnostic yield?
Yes. I definitely do not biopsy very small kidneys. Where you draw the line is the question. I think it is not only the size of the kidney but also the height of the patient. It may be OK to biopsy a patient with a 7.5 cm kidney who is 4 feet 8 but not OK to biopsy an 8 cm kidney in a patient who is...
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...
Do you have a preferred oral magnesium formulation for patients with hypomagnesemia secondary to Gitleman syndrome and who also have chronic diarrhea?
Compared to other magnesium supplements, magnesium glycinate tends to cause less diarrhea and is better tolerated by my patients with Gitelman syndrome.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
Is there a BMI cutoff for which you no longer recommend kidney transplantation in a patient with end stage kidney disease and obesity?
BMI cutoff for transplantation varies widely across institutions so it is important to know your local transplant center guidelines. In general, a BMI > 40 kg/m2 is considered to be a contraindication with many centers. Some centers will recommend bariatric surgery (often not a bypass or duodenal sw...
Do you have your patients with recurrent nephrolithiasis stop supplements such as turmeric?
That is a good question and a hard one to answer since supplements may contain a variety of ingredients of unknown quantity or impurities. I think it also depends on the stone type. For example, excessive amounts of vitamin D, as were advised by some "practitioners" during COVID, can cause or aggrav...