Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is a reasonable blood pressure goal for refractory HTN in the geriatric population?
Resistant hypertension is defined as a blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes taken at maximally tolerated doses, one of which should be a diuretic. Refractory hypertension is defined as uncontrolled blood pressure despite ...
What are your management strategies for acute kidney injury attributed to pembrolizumab in patients with a kidney biopsy showing predominately acute tubular injury?
Acute interstitial nephritis is the more common type of kidney injury associated with immune checkpoint inhibitors. However, there is also associated acute tubular necrosis secondary to cytokine release from activated T cells. ATN can be also due to chemotherapy used in conjunction with ICI such as ...
Do you pursue a skin biopsy or kidney biopsy in patients whom you suspect have X-linked Alport syndrome?
The approach to the diagnosis of Alport syndrome has changed over the past decade with heavier reliance on molecular genetic testing sometimes prior to or in lieu of tissue diagnosis, however, this is dependent upon many factors including insurance coverage and availability of electron microscopy. G...
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
Do you assess the kidney tissue under a microscope following a kidney biopsy to determine the quality of the specimen obtained and if additional tissue is needed?
While we do have a microscope near the IN suite to check the adequacy of the kidney biopsy, I don't always use it. The following options are available: Take a picture of the core on your phone & magnify it to see if small red dots are visible which are suggestive of gloms. Use 16g biopsy guns to en...
How do you determine the fill volume of icodextrin for a volume-overloaded ESKD on PD patient considering that the dwell may last throughout the day?
For patients with acute, symptomatic volume overload, hypertonic dextrose solutions are often used as these solutions act more quickly. Icodextrin is typically not used in an acute setting because it acts more slowly. However, for patients who are asymptomatic, icodextrin can be used in the long dwe...
Do you recommend placement of a backup AV fistula in an advanced CKD patient who is planning to do peritoneal dialysis?
This is a controversial point for which I don't believe there to be great data. An old study in the British literature- I can't get my hands on it right now- purportedly demonstrated that only 7% of such fistulae were ever used/ useable. With improved fistula technique and survival this number is un...
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
What do you use for treatment induction in pure class V lupus nephritis with nephrotic-range proteinuria when MMF is contraindicated?
I'll begin my response by commenting that other than an allergic reaction, which is very rare or pregnancy, there is really no absolute contraindication to MMF. On the other hand, there are patients who cannot tolerate MMF most often due to G.I. side effects in which case mycophenolic acid is an opt...
How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?
If the patient is asymptomatic and the catheter is functioning well, I recommend starting anticoagulation.If the patient develops symptoms, he or she should still be anticoagulated but the catheter removed. Anticoagulation options in ESRD patients include Coumadin, Eliquis (my preference is a dose o...