Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to the medical management of struvite kidney stones?
It is difficult to separate medical and surgical management of struvite stones, since these stones are typically the consequence of persistent or recurring infections. Surgically, risk factors for infection need to be addressed, which may include efforts to remove any retained stone material, follow...
What dietary advice do you provide your patients with calcium oxalate nephrolithiasis?
High water intake (at least 2.5L of urine volume per day) Low sodium and low animal protein intake (high dietary sodium and high animal protein correlate with higher urine calcium) Normal dietary calcium balance around 1000mg per day (maintain bone health and ensure adequate dietary calcium to bin...
Do you use 24 hour urine stone risk profiles for purposes other than managing nephrolithiasis?
In patients with enteric risk factors for hyperoxaluria and kidney disease without a clear cause or in those with confirmed calcium oxalate deposition on kidney biopsy (even in the absence of history of kidney stones), I check 24-hour urine supersaturation. The data helps guide treatment approach to...
Would you consider clearing a patient with essential thrombocytosis for a kidney donation?
For brevity, I am assuming that the patient is already medically approved for surgery and organ donation, and I will focus on the clinical significance of the essential thrombocytosis (ET) with regard to both. I am also going to assume that the patient actually has ET, and not masked polycythemia ve...
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
What is the preferred timing for removal of a peritoneal dialysis catheter in a patient who has transitioned to hemodialysis?
I think that depends on the reason for the transfer to HD. If it is absolutely certain that the patient will not return to PD- for example, despite maximal prescription PD unequivocally cannot deliver sufficient solute clearance or provide sufficient UF- then the catheter may be removed immediately....
Do you use both rituximab and plasmapheresis in patients with recurrent primary FSGS within three months of kidney transplantation?
For early recurrence (less than 3 months post-transplant), plasmapheresis is the first line of treatment with the rationale of removing a "permeability factor." Since many patients respond to plasmapheresis alone, rituximab does not need to be added as first-line therapy. In addition, there are risk...
How do you manage anticoagulation bridging for outpatient ESKD patients given concerns for bleeding risk with enoxaparin in this population?
I don't think we know what is the best route to take. Personally I still usually give lower doses of enoxaparin but it all depends on the circumstances. Why the patient needs anticoagulation? Does the risk of hospitalization out way the risk of increased bleeding from enoxaparin? Can the patient get...
What changes in AV access flows measured during hemodialysis would prompt you to refer for an angiogram?
Blood flows of less than 500 ml/min or an access flow drop of 25% from last month's measurement (should be repeated to confirm the change), should prompt a referral for access interrogation. Surveillance with access flow along with monitoring for dysfunction is recommended to help identify patients...
When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?
Scleroderma renal crisis (SRC) is a relatively early complication of Systemic sclerosis that almost invariably occurs within the first five years after the onset of the disease and may even be the initial manifestation of SSc. Abrupt onset of moderate to marked hypertension and acute kidney injury w...