Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to patients with membranous glomerulonephritis who have persistently elevated PLA2R titers but largely improved proteinuria and creatinine?
Depends on the evolution of the PLA2RAB titer. Please see the algorithm from De Vriese et al., PMID 27777266.
For a patient interested in home dialysis modalities, what are some key points that you discuss with them to help them make a decision on peritoneal dialysis versus home hemodialysis?
1. Dialysis access: a major difference between the 2 modalities is dialysis access. Discussion with the patient should include detailed education with photos, videos, or physical examples of a PD catheter in situ and AVF/AVG/catheter. Some patients have strong feelings regarding the issue of needle ...
Can an acid loading test be used to assist with the diagnosis of RTAs other than an incomplete distal RTA?
This almost seems like a trick question. It is so odd but I have to think the answer is no. An acid load tests the kidneys' ability to respond to metabolic acidosis by increasing Nh4+ excretion. The only situation where that is impaired is distal rta. Normally you do not need to acid load because th...
Would you recommend complement testing in a kidney transplant recipient with chronic antibody-mediated rejection and biopsy-proven thrombotic microangiopathy to determine the need for eculizumab?
There is basic and translational data to support the role of IL-6 in acute and chronic humoral rejection, with small single-center trials investigating the use of agents that blockade IL-6/IL-6 receptor interactions for humoral rejection in kidney transplantation. In many of these studies, there is ...
What factors should prompt a kidney biopsy to evaluate for monoclonal gammopathy of renal significance in a patient with MGUS and suspected chronic diabetic nephropathy?
A renal bx may be reasonable if there is an unexpected or unexplained increase in the Cr and proteinuria. The presence of Fanconi's syndrome may also be a signal of light chain tubular injury.
What is your approach to monitoring for recovery in a patient with non-oliguric AKI requiring dialysis?
In my opinion, the best test to monitor the recovery of renal function in an AKI patient is a daily measurement of serum creatinine. Decreasing serum creatinine is the most reliable marker to indicate recovery of kidney function after AKI. The main confounder would be simultaneous loss of muscle mas...
How would you manage a patient with recurrent calcium phosphate nephrolithiasis who has hypercalciuria, hypocitraturia, and a urine pH greater than 6.3?
Good question! Calcium phosphate stone formers are the second most common type after calcium oxalate stone formers. The underlying problem is an elevated urine pH. Your differential diagnosis will include primary hyperparathyroidism, renal tubular acidosis, medullary sponge kidneys and the use of al...
Do you recommend a kidney biopsy in a patient with myelodysplastic syndrome diagnosed two years prior who develops new onset proteinuria?
The decision to perform a kidney biopsy on any patient should hinge around whether the diagnosis can be made non-invasively (very rare), whether the biopsy should not impose an undue risk to the patient, and if a change in treatment may result from the biopsy diagnosis.In MDS, a variety of lesions m...
Do you recommend using dextrose based solutions to induce osmotic diuresis for euvolemic patients with acute kidney injury in the setting of a hemolytic condition?
The incidence of hemolysis (especially after blood transfusion) has been so low that to my knowledge there have been no good studies about the treatment of AKI with osmotic diuretics in this setting. Older literature has always used Mannitol to induce osmotic diuresis, but whether that improved the ...
Would you perform dialysis on a patient with altered mental status in the setting of an elevated blood urea nitrogen level attributed to a tube feeding diet?
Uremia is symptomatic azotemia, I don't see how you don't dialyze that patient. The idea behind tube feeds is nutrition, that you need amino acids to make protein, but if the BUN is rising, clearly you are catabolizing some of them, and I would check with the dietician to make sure the patient isn't...