Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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 ...
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 ...
Do you prefer transtubular potassium gradient (TTKG) or urine potassium to urine creatinine ratio when evaluating patients with abnormal potassium levels?
Metrics for assessing dyskalemias have become controversial over the last few years. There is very little data, but a fair amount of theorizing, addressing this issue. Importantly, no metric for diagnosing the cause of a dyskalemia should be used without careful assessment of the overall clinical an...
What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?
Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even th...
Are there instances when you perform a repeat kidney biopsy in patients whom tolerated the first procedure but are still without a definitive diagnosis?
Of course. In general, every time I re-biopsied a patient, I found the same diagnosis that second time around. Of course, if the sample is inadequate then I often re-biopsy. I always suggest to re-review the biopsy already taken before re-biopsying.
What is your mmHg threshold to cancel a kidney biopsy for patients with pre-procedural elevated blood pressures?
I am most comfortable doing a percutaneous kidney biopsy at a BP<140/90. Patients are often anxious prior to the biopsy and this can raise their BP. I usually administer an anxiolytic prior to the procedure. I also administer oral antihypertensives such as clonidine or short-acting nifedipine in the...
Which patients do you recommend referral to interventional radiology to perform a kidney biopsy?
There are a few instances when I would refer to an IR to perform a kidney biopsy: Obese patients when the kidney is deep Biopsy of target lesions within the kidney Transjugular kidney biopsy
What is your approach to the medical management of struvite kidney stones?
It is difficult to separate medical and surgical management of struvite stones, since these stones are typically the consequence of persistent or recurring infections. Surgically, risk factors for infection need to be addressed, which may include efforts to remove any retained stone material, follow...