Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach the decision to use terlipressin in a patient with hepatorenal syndrome type 1, AKI, and a history of heart failure given its potential cardiovascular effects?
I usually do a full workup to make sure the etiology of AKI is type 1 HRS. Would also make sure bleeding or infection not complicating the clinical scenario. This is not as simple as it seems, especially in the setting of primary heart failure as a complicating factor, and requires thorough thinking...
Do you recommend ligation of a functional arteriovenous fistula after kidney transplantation?
The decision to ligate a functional arteriovenous fistula (AVF) after kidney transplantation should be based on several factors. Generally, it is not recommended to ligate a functional AVF post successful kidney transplantation, as it can provide valuable vascular access for hemodialysis in case of ...
What is your approach to achieving hypernatremia in a patient on CRRT for whom increasing the rate of a post-filter 3% sodium chloride infusion is insufficient?
Good question. First, we can always increase the rate of the 3% saline more. Eventually, the increased amount of salt will lead to an increase in serum sodium concentration. It has to be a gradual process though to make sure one does not overshoot. Second, if the patient does not require more dialys...
Do you hospitalize patients with newly diagnosed lupus nephritis and nephrotic syndrome if you are able to provide pulse steroids outpatient and follow them closely?
Usually not. I suspect it all depends upon one's ancillary support situation. We are able to do in-house labs, give immediate in-house IV pulse steroids, and I can call interventional radiology and get an ASAP renal biopsy. If there were complications, such as infection, thrombosis, need for dialysi...
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who are unable to tolerate thiazide diuretics due to hyperglycemia?
I think it is a risk-benefit analysis. The answer depends on the severity of the stone disease and the severity of the hyperglycemia. Obviously, controlling hyperglycemia would have multiple benefits, and I would certainly proceed along that route. But if the calcium-based kidney stone disease is se...
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...
How do you manage unintended hypercalciuria that results from an increase in dietary calcium intake as recommended to patients with recurrent calcium oxalate nephrolithiasis attributed to enteric hyperoxaluria?
I find this to be a common concern. As you know, the idea of treating enteric hyperoxaluria with supplemental oral calcium is to bind dietary oxalate in the gut before it can be absorbed systematically. In addition to arranging an appointment with our stone clinic (not general) dietitian to discuss...
Do you still consider hepatorenal syndrome in patients with renal impairment and liver disease who are found to have rare muddy brown casts on urine microscopy?
I personally do. While the traditional teaching is to try to differentiate ATN versus pre-renal versus HRS using the urine sodium, history, and urine microscopy. While sometimes one diagnosis is compelling, often the clinical picture is not clear cut, and at times there is a component of ATN on some...
Do you recommend a ketogenic diet for patients with autosomal dominant polycystic kidney disease?
So far, what we know based on pilot studies is that the keto diet "doesn't not work" in PKD. I tell this to patients and some are motivated to pursue it, which should be done in a supervised way and focus on fat from salmon and avocado rather than super high saturated fat options where possible. Som...
Are there instances when you recommend performing a kidney biopsy in patients with presumed acute interstitial nephritis who are already on steroids and have improving renal function?
The decision to perform renal biopsy in a patient with presumed allergic interstitial nephritis on steroids, who is demonstrating improvement depends on the magnitude and rate of improvement. In a patient whose magnitude and rate of improvement, I suggest that the prior acute kidney injury baseline ...