Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When do you avoid or stop erythropoietin-stimulating agents in patients with anemia and end stage kidney disease?
For the most part, I don't. If the patient has uncontrolled hypertension, then I would air on the side of using less and possibly even not giving it. In patients with cancer, I always check with hem/onc to see if it is okay to give it. Most of the time, I find that they don't have a problem giving i...
When do you avoid or stop iron agents in patients with anemia and end stage kidney disease?
I don't give iron if patients have hemoglobin over 12. There is no reason to give iron if hemoglobin is over the desired range even if the patient seems iron deficient on labs. I also do not give iron if the serum ferritin is > 800-1000. I think at this point the risk of iron overload outweighs the ...
Do you treat low 25-OH vitamin D levels in those with end stage kidney disease?
Low 25-OH vitamin D levels in those with end-stage kidney disease should absolutely be treated. The assumption that calcitriol administration satisfies all the vitamin D needs of the body is incorrect. While it is true regarding the endocrine effects of calcitriol (calcium and phosphate homeostasis)...
Are there cases of glomerulonephritis where you do not perform a kidney biopsy in a patient deemed safe to undergo the procedure?
In adults, there are some circumstances where a biopsy may be deferred/ 1. Patients with nephrotic syndrome, normal kidney function and an elevated PLAR2 Antibody level (in the absence of other systemic diseases e.g. SLE, diabetes). A presumptive diagnosis of PLA2R ab-associated membranous nephropat...
When do you perform a kidney biopsy in a patient with AKI that is thought to be related to an immune checkpoint inhibitor?
I would wait for the response to corticosteroid therapy before the renal biopsy.
Are there preventative measures that you take in your cancer patients with chronic kidney disease who require periodic iodinated contrast CT studies for monitoring of their malignancy?
Recommendations include discussing the utility of other imagining modalities with the hematology or oncology team caring for the patient. In general, the risk for AKI from IV contrast increases with lower eGFRs. Cancer patients may have misleading "normal" or "good" Cr and eGFRs due to malnutrition ...
Do you recommend testing for G6PD deficiency in those with whom rasburicase for tumor lysis syndrome is indicated?
G6PD deficiency is a contraindication to the use of rasburicase and should be tested for prior to the use of this drug.
What changes to immunosuppressant medications do you adopt for kidney transplant patients who contract COVID-19?
It really depends on the severity of their symptoms. For patients with mild symptoms, we typically lower the MMF somewhat as well as treat with paxlovid as the first line. Due to the interactions with the CNIs etc., we adopt the following protocol for tacrolimus and paxlovid: Day 1- First Paxlovid ...
How do you approach COVID-19 vaccination in those who underwent kidney transplantation for native kidney glomerular disease?
The approach to all kidney transplant recipients regardless of the cause of end-stage kidney disease remains the same following the guidelines for immunocompromised patients. The benefits of vaccination and protection against COVID-related hospitalization and death outweigh vaccine-related incidents...
Do you routinely advise patients waiting for a kidney transplant to seek referrals at multiple institutions to decrease waiting time?
If your center is in a region (e.g., California and New York) with long wait time of up to 8-10 years, we routinely advise patients to seek referral at multiple centers with a shorter wait time out of the region if the patient does not have any potential donors.