Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
What is your approach to using NIH activity and chronicity indices from renal biopsy in tailoring immunosuppression to a patient with new lupus nephritis?
I find the NIH activity and chronicity extremely valuable in LN management. If a patient has a high AI, I’m much more likely to be aggressive with corticosteroids to help stop the inflammation in its tracks. I will, of course, use a concomitant immunosuppressive/immunomodulatory agent as well (we no...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
Do you use serum or urine biomarkers other than creatinine when evaluating patients with acute kidney injury?
I use the urinalysis (including microscopy) as well as the furosemide stress test but no other "novel" biomarkers have sufficient accuracy to guide clinical care at this time.
Are there instances when you do not perform urine microscopy and rely solely on laboratory performed urinalysis when evaluating a patient for acute kidney injury?
Direct visualization of urinary sediment under a proper microscope is a cornerstone of AKI evaluation from intrinsic renal disease. If I am relatively sure the cause of AKI is prerenal or post-renal and AKI improves promptly with intervention, then I may forego sediment evaluation. I am in the lab l...
When do you restart ACEi/ARB medications for patients whom these medications were previously discontinued due to acute kidney injury?
I generally wait until the patient’s kidney function has stablilized at a new baseline, the patient’s acute illness that led to AKI has resolved and the serum potassium is acceptable.
Do you use alkali therapy in those with stable chronic kidney disease and a normal serum bicarbonate level who have a low urine pH?
Generally, no. There is no reason to increase the pill burden with bicarbonate therapy in a patient with normal blood chemistry. I would only treat urine pH in a stone-forming patient with uric acid stones.
How much decrease in eGFR do you tolerate before discontinuing a SGLT2i started in patients with diabetic kidney disease?
SGLT2i are known to have an acute, reversible dip in eGFR in the first 2-4 weeks after initiation. This effect on glomerular hemodynamics (more pronounced in diabetics) usually decreases eGFR by less than 30% and has been associated with better long-term cardio-renal benefits in some studies. A dip ...
How much decrease in eGFR do you tolerate before discontinuing finerenone started in patients with diabetic kidney disease?
I use the same approach investigators did in the Fidelio DKD study: patient on max dose of ACEi/ARB. Add finerenone--> check GFR in 4 weeks. If more than 30% drop hold any NS-MRA up titration and recheck GFR in 1 week. If stable, continue same drug regimen, if GFR further decreases, hold finerenone,...