Latest Questions

A patient developed anuria post-delivery by 10 days after severe bleeding – patient was diagnosed with AKI and required RRT. When do you perform a renal biopsy in this case?

A 26 year-old lady with nephrotic syndrome secondary to membranous nephropathy with normal baseline serum creatinine (S Cr between 0.86 – 1.1 mg/d), hypertensive controlled with Losartan 25 mg b.i.d. She received Pentoxifillin for 2 months while she received steroid without any effect and along with statins.

Her 11g/day of proteinuria failed to respond to steroid alone and steroid+MMF therapy but had partial response to steroid and cyclosporine with proteinuria improving to 5 g/day. Her renal function continues to be normal. What should be the next step to treat this patient?

I have read at least MAP of 60 is needed for the blood pump to work but no other data for what is the lowest BP at which we can start CRRT?

I would like to know your opinion in relation to the use of mycophenolate mofetil as induction in patients with lupus nephritis class 4 and who are receiving hemodialysis support by presenting as acute renal failure and suggest a scheme to follow. 

A 58 year old female with a known case of ESRD on regular HD was presented to the ER in the early morning of her dialysis day with mild dyspnoea. Her vitals were stable with clear chest K WAS 6.2 and no ECG changes.The resident gave her salbutamol nebulization awating dialysis after 2 hrs. The patient then developed acute pulmonary eodema and arrested. What was most appropriate: 1-salbutamol as given 2-ca carbonate 3-insulin with glucose 4-immediate dialysis 5-just wait for HD?

A pregnant woman (eight weeks of pregnancy) with GNM treated in the past with a long course of cyclosporine has a recurrence of nephrotic syndrome (proteinuria range: 4-6g/die) from a membranous glomerulonephritis (stage 2 on biopsy performed about 10 years ago); her arterial pressure is normal, creatinine, GRF and other laboratory tests in the normal range.

A 33 year old female patient with secondary subfertility for 9 years was presented with nephrotic syndrome and renal biopsy confirmed the diagnosis of FSGS. Oral prednisolone was started at a dose of 1mg/kg/day. She presented after 1month with persisting proteinuria of 11g/24 hrs and was found to be pregnant. She was having hypertension and normal renal functions. The patient was keen to pregnancy. Prednisolone was continued with thrombo prophylaxis, but seem to be resistant as proteinuria was found to be 9g/24hrs.

What treatment options are available in this setting? Will cyclosprin lead to worsening of hypertension in this patient with worse pregnancy outcomes?

Thanks in advance for the answers. Recently, I have a 17 year-old girl who has clinical SLE. She has been treated in a children’s hospital for lupus nephritis with oral cyclophosphamide for 84 days, and despite this, her kidney function has deteriorated with serum creatinine 5 mg/dL and has been referred for hemodialysis twice weekly for 2 months now. Because of her age, she is now being referred for further care as adult case. Her serum creatinine 1 month ago before the scheduled hemodialysis was 6.11 mg/dL and proteninuria 3+ with normal kidneys size, but loss of cortico-medullary differenciation. Her urine output was about 250cc/day. BP 120/80 mm Hg. After 1 month of swiching to prednisolone 40 mg/day with MMF 1.5 g/day (along with furosemide, EPO and iron), her urine output seems increasing to 500 cc/day, but serum creatinine after hemodialysis is 3.71 mg/dL and up to 5.5 mg/dL the next day. Clinically she feels a bit better and her ANC moves from 85 to 127.

My questions are:
1.) Would the regimen work? What are clinical signs and lab to follow?
2.) When should I switch to another therapy? and what is that another regimen?
3.) Could she be off from hemodialysis in the future and how/when to do it?

Thanks again for the answers. Bunse Leang

One of my patients is 90 years old on dialysis having severe autonomic neuropathy due to long standing DM. His lying blood pressure is 190/ 105 and standing blood pressure 120/ 64 mmhg. The patient also has an ischemic heart and is nearly blind (hand movement).

What is his real blood pressure, and what is the target level of his blood pressure in view of the recent guidelines of blood pressure management?

My patient has been diagnosed with recurrent Uric acid nephrolithasis requiring multiple lithotripsy, stenting, etc. Despite treatment with potassium citrate or sodabicarb , he continues to be burdened by more Uric acid stones. My question is, will rasbicurase will help him? Anybody has used it before and seen success?

60-year-old male, creatinine 0.9, 3 g proteinuria. monoclonal IgG, 0.6 g/DL M spike. equivocal monoclonal staining on kidney biopsy I F. The fibrillary deposits have also been seen in other tissues; analogous to amyloid deposition disease?

What is the minimum Blood pressure to consider CRRT over Intermittent Hemodialysis / SLED? Amongst the CRRT modalities Is any CRRT Modality considered to be more superior in hemodynamically unstable patients?

There is a patient who has been diagnosed with myelodysplastic syndrome for one year who also has end stage renal disease. Can this patient be considered for Kidney transplantation? Does the type of myelodysplastic syndrome matter in deciding the suitability for kidney transplantation?

(Donor was father and CDC crossmatch as well as DSA by luminex are negative.)

This patient was dignosed as aHUS in July 2012 after P.vivax malaria infection treated with Quinine. HUS was not responded to plasmapharesis and steroid (managed by another nephrologist). He progressed to ESRD and started hemodialysis 3 times a week. Kidney transplant was done in August, 2013 after confirming that there is no ongoing hemolysis. Baseline immunosuppresants were tacrolimus, MMF and steroid with ATG as induction agent. Baseline S.Creat was 1.2 . Within 3 months patient was switched to everolimus from Tac. S.Creat was steady at 1.1 for 9 months and then increased to 1.8. Kidney biopsy was showing features of acute ABMR with c4d positivity and fibrinoid necrosis in one glomeruli. Everolimus was switched to Tac. But, after 3 days, markers of haemolysis became positive that were earlier normal. So Tac was switched to everolimus. After giving 3 pulse doses of methylpred, we have started plasmapharesis with rituximab. S.creat after 2 cycles of plasmapharesis is 1.6.

Patient is a young girl of 12 years, presented with RPGN on dialysis. Renal biopsy revealed Collapsing Glomerulopathy.

Patient on dx.

Patients having loss of parenchyma after surgery may develop secondary FSGS, if their proteinuria does not respond to ACE inhibtors or other conservative measures, is there then any role seroids can play?

A patient had a kidney transplant last year in April 2013. This month, he picked up the BK virus. Is there any form of treatment ?

Is bisphosphonates safe to use and/or effective in CKD/transplant patients. How would you diagnose and treat osteoporosis in ESRD patients

A 19-year old female who was transplanted (father donor) 2 years back. Native kidney disease unknown. Pre-transplant ANA negative. Urine R- 2+ protein, no RBCs. No episodes of hematuria prior to transplant. She was treated with triple immunosuppression (Tac, MMF, Steroid). One episode of CMV disease a few months after transplant treated with valganciclovir. Subsequently she has been stable with S. Cr 1.0 mg/dl. Multiple post-tx urine routine negative for blood and protein. 4 weeks back she developed transient hematuria and upper resp tract infection. Hematura recurred 2 weeks later. S. Cr. was 1.1 mg/dl. Another week later she developed edema and hematuria recurred. S. Cr had increased to 1.8. Admitted for further evaluation. Ultrasound of kidneys WNL. Repeat S. Cr 1.6 –> 1.8 next day. Transplant biopsy done. Suspecting BKV nephropathy vs. Rejection vs. glomerulonephritis. Biopsy report showed crescentic GN strongly positive for anti-GBM staining – 5 of 7 gloms showing active cellular crescents. No scarring. mild tubular damage. C4d negative. ASO, C3, C4, all normal. ANA positive 1:40 speckled (Rheumatologist opines this as non-significant) S. Cr incresed to 2.2 mg/dl. Pulse steroids (500 mg x 3) + plasma exchange initiated (5 cycles completed). S. Cr now 1.8 and macroscopic hematuria has cleared. Anti-GBM and ANCA titers pending. Current immunosuppressive medications: Oral Prednsone increased to 1 mg/kg (50 mg/day) MMF increased to 500 mg tid (from bid) Tacrolimus remains at 1.5 mg bd (trough level 7.3) Need your advise on further care. ? Cyclophosphamide – dose and duration ? Rituximab – dose and duration