Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What sort of telehealth approaches do you pursue for a newly diagnosed end stage kidney disease patient starting peritoneal dialysis or home hemodialysis?
All new patients to home dialysis should be seen in person for at least three months. The first three months of home dialysis is a time by which you can make sure that the patient is stable. The patients are always adjusting to home dialysis both physically but also emotionally. After the first thre...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
Would you recommend a TIPS procedure in the management of hepatorenal syndrome for a patient with no history of hepatic encephalopathy?
In the right patient, yes. TIPS will help with ascites and likely with renal function. I believe it is underused.
Do you think there would be benefit in using sparsentan over irbesartan for FSGS given a higher percentage of patients with partial remission of proteinuria on sparsentan despite no significant difference in eGFR slope in the DUPLEX Trial?
I think yes. The between-group difference in proteinuria reduction is compelling and still stands as an important surrogate endpoint in a disease in which effective treatments are lacking. Although the between-group differences in eGFR slope were not significant, there were several factors that may ...
How do you treat sarcoidosis associated hypercalcemia in a patient with adenopathy and no other signs of systemic involvement?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you check EPO levels in patients with anemia of chronic kidney disease?
No, I never check EPO levels in patients with anemia of CKD since they're uninterpretable. Patients with CKD have inadequate EPO synthesis for their degree of anemia, so their EPO levels may be greater than normal yet still not sufficient to correct the anemia. We now understand the role of inflamma...
Do you obtain spot urine protein or 24 hour urine protein quantification studies in pregnant patients who are found to have proteinuria on a standard urinalysis test?
If a patient has a positive dipstick for protein, I would do a 24-hour collection, just to get the most accurate answer to the question of whether there is truly abnormal proteinuria or not, and taking into account the physiologic protein increase that happens during pregnancy. I generally check a b...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
How often do you monitor plasma oxalate levels for patients with ESKD secondary to primary hyperoxaluria who are on hemodialysis and receiving lumasiran?
There is no absolute correct answer. Largely, it depends on how the patient is doing and how stable their oxalate status has been. Typically, we had like a predialysis plasma oxalate at a minimum once per month in a stable patient. I typically would do this on a Monday so that is the absolute highes...
What strategies have you used to help patients with advanced kidney disease who are asymptomatic understand the severity of their condition?
It is not unusual for patients with advanced kidney disease (stage 4, for example) to be asymptomatic or for the symptoms to be so insidious that the patient doesn't notice them or denies them. That's why it's very useful for such patients to be seen with a significant other or relative who can prov...