Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Do you use mannitol when initiating patients on intermittent hemodialysis?
This is a very good question. Mannitol has been used for decades to try and reduce disequilibrium, cramping and intradialytic hypotension. Most of the studies are small and were not placebo controlled and were performed in prevalent patients. In 2019, a randomized controlled trial was done that did ...
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...
Do you routinely prescribe acetazolamide for patients with cystinuria who do not have significant urinary alkalinization or are intolerant to citrate therapy?
I have not used acetazolamide in this situation, although it makes good physiological sense, as urinary alkalinization increases urine cystine solubility. Sodium bicarbonate would be a bad idea because natriuresis increases cystinuria. I have used potassium citrate historically, and it is generally ...
In which patients with non-proteinuric chronic kidney disease would you initiate a SGLT2i?
I agree with Dr. Wish. I do not use SGLT2i in non-proteinuric diseases for kidney protection indication. EMPA-Kidney study also did not show benefit for UACR <30 (HR 1.01, 0.66-1.55) among >1200 participants with UACR <30 in the trial. While the secondary analysis looking at mean annual change in eG...
How would you manage a patient with stable axial spondyloarthritis who develops newly active IgA nephropathy?
Although the data are sparse, in general, the principles of treatment of IgAN in the setting of spondyloarthritis is similar to primary IgAN. BP targets <120/80 RAS inhibitors or sparsentan SGLT2 inhibitors If persistent proteinuria despite above, targeted-release budesonide or oral corticosteroids ...
Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?
No. Although hyperthyroidism is a reported cause of hypercalcemia and hypercalciuria, it must be very rare cause of nephrolithiasis. I suspect the patient would be obviously hyperthyroid on examination. Hyperparathyroidism is a much more common cause of kidney stones. In my practice, if the stone an...
What is your plasma oxalate target when treating patients with lumasiran for end stage kidney disease secondary to primary hyperoxaluria type 1?
We have a lot of experience with the PH1 population on dialysis here using the Mayo Clinic Laboratory Plasma oxalate assay. Ideally, we shoot for a pre-dialysis value of 30 or less. In our experience with this and other Hyperoxaluric patients, the risk of oxalosis would be low at those numbers and a...
What is your approach to recurrent uric acid stone formers who have a persistently acidic urine pH and are unable to tolerate potassium citrate?
I use sodium bicarbonate. I teach the patient how to titrate the dose using pH dipsticks to get the urine pH >6.0. Although sodium may increase urine calcium excretion, in uric acid stone formers, this is not an issue. Long experience with sodium bicarbonate tells us it does not raise blood pressure...
Do you avoid ESAs in patients with end stage kidney disease who also have heart failure due to increased risk of stroke?
If the question is whether I avoid ESAs in patients with ESKD who also have heart failure, the answer is no for several reasons. The warning in the ESA package insert regarding using ESAs with caution in patients with heart failure (HF) comes from the CHOIR study (Singh, et al., PMID 17108343) of no...