Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
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...