Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you manage tubulointerstitial nephritis and renal tubular acidosis (RTA) in a patient with Sjogren's who is pregnant?
The most common form or renal disease in Sjogren's (SjD) is tubulointerstitial nephritis. This may result in tubular dysfunction leading to renal tubular acidosis (RTA), most commonly type I RTA leading to hypokalemia and a non-anion gap hyperchloremic acidosis. Over time, nephrocalcinosis can occur...
Do you recommend starting aspirin for a patient with ESKD secondary to lupus nephritis with detected antiphospholipid antibodies on pretransplant workup but no history of a thrombotic event?
I agree. I tend to favor the use of Plaquenil in these APS patients although the data is not absolute either. I noticed that hematologists favor the use of the NOAC than Coumadin, and yet thus far, it appears that Coumadin, based on published data, prevents thrombosis better than other agents.
Would you recommend initiating RRT in a patient with tumor lysis syndrome and a phosphorus of 9 mg/dl or more who does not have symptomatic hypocalcemia or other indications for dialysis?
If the patient is urinating and maintaining a urine output with IV NS, and if there is no other indication for dialysis, then one can argue that the risks of RRT (catheter insertion and infection) outweigh any benefits.
Have you encountered acute kidney injury after starting eltrombopag for aplastic anemia as part of triple immunosuppressive regimen with ATG and cyclosporine?
No, I have not. Of course, cyclosporine is intrinsically nephrotoxic and is the likely candidate. Sometimes, ATG will result in renal issues as well although less frequently.
In what instances might you recommend twice daily 7.5% icodextrin to patients on peritoneal dialysis?
Adequacy in peritoneal dialysis takes into account both the Kt/V from peritoneal dialysis as well as the Kt/V from residual kidney function. As residual kidney function declines over time, adequacy is primarily achieved from peritoneal dialysis. This often requires intensification of the peritoneal ...
How do you manage severe intra-dialytic hypertension that is not responsive to dry weight challenge in an asymptomatic patient with ESKD?
If the patient is truly not hypertensive at the start of treatment but becomes hypertensive during treatment (need solid evidence of this), then the best option would be an ACE or an ARB. If the blood pressure is high throughout then would continue to challenge dry weight as long as patient is able ...
Do you recommend performing a kidney biopsy in patients with suspected ifosfamide nephrotoxicity?
AKI from ifosfamide occurs as a result of direct tubular toxicity of the drug as well as from pre-renal azotemia as a result of nausea/vomiting/anorexia/diarrhea. The urine sediment is usually inactive. The creatinine generally plateaus within 7-10 days. The presence of an active urine sediment, sys...
Do you recommend obtaining a vasculitis work up for all patients seen for chronic kidney disease who are without a kidney biopsy?
I don't. There is a false positivity rate with ANCA testing which can complicate management, especially if the patient has diseases such as inflammatory bowel disease or rheumatoid arthritis. I would only check ANCA levels if the patient has hematuria, worsening renal function, or some other issue t...
Do you recommend holding cinacalcet after kidney transplantation and monitoring PTH levels before restarting it?
Recommend to monitor calcium levels and resume cinacalcet if the patient has hypercalcemia. If the calcium level is normal, do not need to resume post-transplant. In addition, if the calcium level is 9 or below, would stop cinacalcet and monitor calcium levels.
How often do you monitor labs such as complete blood count, liver function panel, and urine protein in a patient with cystinuria receiving tiopronin?
I check patients newly started on tiopronin or after an increase in dosage about one month later. Assuming the lab results are normal, I do not continue to check them. I think late adverse reactions must be very rare. Stephen B Erickson, MD