Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend targeting a higher Kt/V in an ESKD patient on hemodialysis with pruritis and a Kt/V of 1.4?
I do not. I believe there is not good evidence to suggest more dialysis will help with ckd pruritis and in general slightly higher kt/v usually does not correlate well with actual clinical findings. A better study to be done would be to see if more frequent dialysis will help treat ckd pruritis.
Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?
Certainly the lower the PNa is, any increase in PNa will have a greater effect on serum osmolality, so yes the lower the PNa the more careful I am. I would suggest never to be complacent, but for instance if the PNa was 105 I would make sure not to increase it by more than 6 in 24 hours, but if it w...
How long do you continue a thiazide diuretic in a patient with nephrolithiasis and hypercalciuria who achieves normalization of urinary calcium excretion following therapy initiation?
This question needs to be viewed from many angles in considering the answer. At the first level, an effective therapy choice for stone formation should be continued as long as the patient remains a stone former, which is probably for the rest of their life. We should always remember that the desired...
Do you recommend continuing peritoneal dialysis in an ESKD patient on peritoneal dialysis who is diagnosed with encapsulating peritoneal sclerosis since abdominal symptoms may worsen when peritoneal dialysis is stopped?
It is generally accepted that after a diagnosis of encapsulating peritoneal sclerosis (EPS), most patients are transitioned off peritoneal dialysis (PD) and switched to hemodialysis as patients with EPS often have chronic abdominal pain and will often have difficulty with dialysis adequacy and ultra...
What is your approach for a kidney transplant patient who develops proteinuria after everolimus initiation?
The management typically should take into consideration the reasons the patient was converted to mTOR inhibitors and whether everolimus is being used de novo versus converted from calcineurin inhibitor. In general, if the patient was not proteinuric and developed heavy proteinuria (> 1 gram per day)...
How frequently do you monitor urine protein levels in a patient receiving bevacizumab who develops proteinuria of less than 2 grams per day?
We would typically check monthly spot protein to creatinine ratios. This would be managed by both the nephrologist and oncologist as far as when to hold the drug. Would also recommend secondary workup and rule out other etiologies of proteinuria where myeloma has been reported in patients with renal...
Do you recommend obtaining a spot urine or 24-hour urine magnesium measurement when evaluating patients with persistent hypomagnesemia of unknown etiology?
I try to avoid 24-hour collections for just about everything short of stone evaluations (Litholink). They are hard to do properly and bad information is worse than no information. I would use a FeMg and from UpToDate a FEMg > 3% in the setting of hypoMg and nl renal function usually indicates urinar...
In which patients awaiting a kidney transplant do you evaluate for primary hyperoxaluria given the high risk of allograft dysfunction following transplantation?
Primary hyperoxaluria is often diagnosed in adolescents and young and is typically diagnosed prior to being referred for transplant. One might consider work-up in a young to middle-aged adult with a significant history of kidney stones that are not explained by other conditions.
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 ...