Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
Do you recommend noninvasive testing or coronary angiography as the initial test for pre-kidney transplant evaluation of an asymptomatic patient older than 50 years of age with ESKD secondary to diabetic nephropathy and no known history of CAD?
There is no evidence that revascularization of asymptomatic patients reduces the risk of transplant. obviously patient should have all relevant risk factors treated. the problem with routine angiography is that inevitably any lesion found is treated with stenting which actually exposes the patient t...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...
Do you pursue any additional testing in your patients with chronic kidney disease who are found to have "small hypodensities too small to characterize" on renal ultrasound?
Renal cell carcinoma in dialysis patients and to a lesser degree in patient with CKD is not uncommon. As such, I would like to re-image these patients after 6 months or so. Usually, these cancers grow slowly and don't cause major disease but it is variable.
Do you periodically check a urine culture for patients without dysuria but who have a history of struvite kidney stones and urinary tract infections with urease producing organisms?
Struvite nephrolithiasis is caused by a high urine pH (usually>7.0). Typically, a urine this alkaline requires urinary infection with a bacterium that produces urease, (Proteus, Providencia, Klebsiella) which in turn splits naturally occurring urea into ammonium, driving the pH to supraphysiologic l...
Do you start patients on a B complex multivitamin if they are on CRRT and have not previous been on renal replacement therapy?
This is a good question. I personally don’t routinely recommend Vitamin supplements for patients on CRRT, but wouldn’t argue with someone who does. It is known that critically ill patients, which includes most CRRT patients, often have deficiencies in micronutrients, including water-soluble vitamins...
Do you routinely perform in-office urine microscopy for your patients with recurrent nephrolithiasis?
Yes and no. We have a dedicated laboratory at Mayo Clinic that specializes in urinalysis and is expert in recognizing crystals. I do not do office microscopy myself. I think it is important for my stone patients to have a urinalysis when I see them. I am looking for hematuria suggesting surgical sto...
What are some considerations to make when managing patients with recurrent nephrolithiasis who are found to have nephrocalcinosis on imaging?
Nephrocalcinosis is generally defined as calcification of the renal parenchyma, especially the medulla and papillary tips, as opposed to nephrolithiasis which refers to calcification in the urinary space. The two often coexist. Nephrocalcinosis, and its accompanying nephrolithiasis, are typically pr...
What is your preferred therapy to raise urinary citrate in a patient with recurrent calcium based stone disease and hypocitraturia?
I prefer potassium citrate tablets. For those who have trouble swallowing tablets, it also comes in liquid form. There used to be a powder packet that you could tear open and mix in liquid, but it is my understanding that is no longer available. These products require a prescription. For those on a ...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.