Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
Would you recommend mycophenolate mofetil for patients with progressive IgA nephropathy who do not tolerate corticosteroids?
Multiple studies showed no benefit of immunosuppressive agents (MMF, CYC), so this study is standing alone with relatively small number and limited centers. Better to role those IgAN patients in current ongoing studies, yet, I won't blame trying MMF if appropriate conservative management is optimize...
What is your PTH threshold for referring an ESKD patient with secondary hyperparathyroidism on maximum medical therapy for parathyroidectomy?
I think PTX should be done pretty much never with PTH <800 and most of the time with values >2000. Why such a large range? The biggest consideration is symptoms; if present, my threshold approaches 800. However, ascribing symptoms to hPTH is problematic. Hypercalcemia is the most specific finding wi...
Is there a role for eculizumab in the management of refractory lupus nephritis?
There is no evidence of eculizumab as a treatment for lupus nephritis, yet it might be considered if complement-mediated TMA presents even as a result of SLE as a trigger if direct treatment of SLE fails to achieve clinical goals.
Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?
In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful o...
Do you proceed with outpatient hemodialysis for an asymptomatic ESKD patient who has missed the last three hemodialysis sessions?
In the ideal world, missing too many HD sessions (no magical number) can predispose patients to quick normalization of low Na or very high BUN which we don’t want to! Also, asymptomatic patients don’t mean okay volume, patients' BP might be as high as 200s and this needs extra sessions to get back t...
What do you use to treat a kidney transplant patient with progressive BK nephropathy despite a maximal decrease in immunosuppression for months?
Assuming you are referring to actual BK nephropathy (biopsy evidence of viral inclusion on renal tubular cells staining positive by SV40 either by IF or immunohistochemistry) + serum BK viral PCR. Beyond lowering immunosuppression, adjunctive therapy (none of which are FDA approved of course) includ...
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
In which patients with chronic kidney disease and low 25-OH vitamin D levels do you prefer weekly ergocalciferol to daily cholecalciferol supplementation?
Ergocalciferol (D2), the plant-based form of Vitamin D, and cholecalciferol (D3), the animal-based form, are essentially equivalent in potency with perhaps a small, clinically insignificant edge favoring D3. They both can be given at long interdose intervals; monthly doses provide the same impact on...