Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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 ...
Do you recommend using methionine to acidify the urine in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
I have not used it. Many of these patients have a partial renal tubular acidosis and will develop a metabolic acidemia if so treated. I suggest checking a urinary acidification test before prescribing it. Stephen B. Erickson, MD
How frequently do you monitor anti-PLA2R antibody titers in patients with stable renal function/proteinuria and a past diagnosis of PLA2R-associated membranous nephropathy?
Serum anti-PLA2R antibody levels measured by ELISA are valuable in informing initial treatment decisions when used in combination with clinical and laboratory parameters. However, there are no clear guidelines on how frequently we should measure it. Insufficient data to guide the use of anti-PLA2R a...
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
Do you prefer performing a kidney biopsy on the left or right kidney if both kidneys appear similar on pre-biopsy imaging?
At my institution, we have been biopsying almost exclusively the left kidney per the radiologist's preference. My teaching has been that we should prefer to biopsy the right kidney as if the spleen is enlarged then stabbing that with a needle is more risky than stabbing the liver. These days, with m...