Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend AV fistula placement in a CKD Stage 5 patient who is over the age of 80?
Depends. If this is an active 80-year-old, then creating a distal fistula (radial-cephalic, when vessels are available) would be ideal compared to a catheter. For someone with limited life expectancy, an alternative (graft or catheter) may be acceptable.
How has the introduction of lumasiran affected the need for combined liver and kidney transplantation in patients with ESKD related to primary hyperoxaluria type 1?
A kidney transplant alone with lumasiran pre and post-transplant to maintain lowered serum oxalate levels and prevent the recurrence of oxalate stones is potentially a viable option for simultaneous liver-kidney transplantation.To date, there is only one small case series published of this approach ...
Do you stop tolvaptan below a certain eGFR in a patient with autosomal dominant polycystic kidney disease?
In general, the practical guidelines support continuing tolvaptan until dialysis or transplant (Chebib and Torres, PMID 33705818). There are situations where I will discontinue sooner, either due to apparent lack of benefit, due to precipitous, unexpectedly rapid decline or accelerated decline, or, ...
Are there other therapies such as SGLT2 inhibitors or alpha lipoic acid that you are offering your patients with cystinuria who continue to have active stone disease despite conservative therapy and thiol-based agents?
I am not aware of quality trials for new agents being advocated for the treatment of cystinuria. I do not prescribe them. Generally, the failure to respond to standard therapy reflects a failure of the patient to follow the appropriate diet and titrate the usual medications as regards urine pH and c...
Would you consider using finerenone for proteinuric CKD associated with type 1 diabetes mellitus?
Yes, although T1DM is off-label for finerenone and there may be issues regarding its approval by prescription drug plans. I would start with an ACEi/ARB for proteinuria in a T1DM patient, then add spironolactone. If the patient develops breast problems on spironolactone, I would switch to eplerenone...
Are there instances when you would pursue a kidney biopsy in a pregnant patient instead of waiting to perform the procedure post-delivery?
Prior to 20 weeks, consideration of a biopsy shouldn't be different than how we would think about biopsy in a non-pregnant individual. The pregnancy is still pre-viable, and so knowing a diagnosis and treating the disease with the goal of improving the kidney function, and thus the pregnancy, makes ...
Would you recommend starting an SGLT2i in a patient with a kidney transplant and moderately increased albuminuria?
I have used SGLT2i in my transplant patients to lower albuminuria either alone or in combination with RAASi. I do not use it in patients who have a Hx of frequent UTIs or who are at increased risk of developing UTIs (e.g. ileal conduit, neurogenic bladder, obstruction) due to the increased risk of u...
Do you recommend a kidney biopsy for patients who develop acute kidney injury after starting sacituzumab?
For all novel agents, I think that it is prudent - if there are no contraindications to the renal biopsy - to proceed with a biopsy. A renal biopsy is helpful in clarifying the etiology of the AKI and may have implications regarding whether the medication can be safely continued - depending on what ...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
Do you recommend starting SGLT2 inhibitors for patients with a normal creatinine but who have microalbuminuria and are unable to tolerate ACEi or ARBs?
In a patient who cannot tolerate RAAS inhibition with standard-of-care ARB or ACE-I, I still would still consider starting SGL2 in a patient with microalbuminuria. In a diabetic patient, an SGL2 inhibitor would definitely be indicated, perhaps with an MRA. The mechanism of benefit in SGL2 is debatab...