Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
A practical question! My answer is nuanced. If serial imaging, preferably CT, shows an increase in stone volume on their current treatment program (metabolic stone activity), yes. I think the benefit of controlling their stone formation outweighs the risks and inconvenience of a urinary catheter. I ...
How do you advise patients with recurrent nephrolithiasis and polyuria who require more than one 24 hour collection jug and need to adequately mix the specimens prior to aliquoting for mail-off lab analysis?
A good question! Urinary composition over the 24-hour cycle varies with dietary intake. I would advise the patient to request 2 collection containers from the laboratory. The patient collects all urine produced in the first 12 hours, and then fills the return laboratory specimen container 1/2 full. ...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
Would you consider using acetazolamide to manage glomerular hyperfiltration in patients with type 1 diabetes, since SGLT2 inhibitors are contraindicated in this population?
Clever idea, but I think it is a bit much to assume that increased Na delivery from carbonic anhydrase blockade proximally would have the same renoprotective effect as an SGLT2i. So, no, I would not do this. However, I admire anyone thinking outside the box!
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
Has your management of post-transplant FSGS changed with the advent of new FSGS directed therapies?
The pathogenesis of FSGS and specifically recurrent FSGS post-transplant has remained an unmet need in nephrology. Multiple purported " circulating permeability factors " have been identified over the years, each of them providing a piece of the picture, but none that comprehensively and definitivel...
How do you determine the optimal time to restart a diuretic in a patient with cirrhosis, ascites, and lower extremity edema who presented with acute kidney injury that resolved with IV albumin and holding diuretics?
Good question. It is tricky. Spironolactone can be resumed fairly quickly. With loop diuretics it is harder to resume them. If necessary, I would resume at lower dose and slowly uptitrate as needed with close monitoring. Ideally, it is better to do frequent paracentesis with albumin infusion than gi...
What is your approach for managing patients with recurrent nephrolithiasis who have elevated urinary cystine levels but calcium oxalate stone composition?
This is usually heterozygous cystinuria, and the urine cystine is in the range of 50 mg. Supersaturation with cystine is absent, and the cystine can be ignored. Rarely, urine cystine is high enough to produce stones, and I treat both stone risk factors. In all cases where urine cystine is above 100 ...