Community Minded

Community Minded summaries are written by ASN Community Leaders and are published weekly in the ASN In The Loop newsletter.  The summaries highlight a recent popular, controversial or other outstanding discussion in the ASN Communities.  If you are interested in writing for Community Minded, please contact Susan Willner, swillner@asn-online.org

 

Puzzling Hyponatremia

A 72 year old man with a history of a pituitary tumor presents with seizures and a serum Na of 125 meq/l. He appeared hypovolemic and his UNa was <20 meq/l. He was given normal saline, and his PNa increased to 130 meq/l, but his UNa remained <20 and he developed edema. He was subsequently found to have hypopituitary hypocortisolism. He was given hydrocortisone alone and his PNa eventually normalized. The discussion focused on how hypocortisolism can cause hyponatremia and it being a SIADH like syndrome, realizing the difficulties in this diagnosis when the patient initially developed edema as he was clearly in a Na and Water retaining state, something that would rule out SIADH. The discussants expressed their own ideas on whether or not the hyponatremia seen in hypoadrenalism qualifies as a form of SIADH, or has its own pathophysiology. Is this just a matter of semantics? Read the thread and form your own opinion.

Summary provided by Roger Rodby MD, FACP, FASN

Uncontrolled Blood Pressure in HD Patient

A 45 year old male on hemodialysis has uncontrolled blood pressure despite seven blood pressure medications to the point that he requires frequent admissions to the intensive care unit. Medication compliance is not the issue since he takes these medications when admitted but usually ends up requiring an IV nicardipine drip to control his blood pressure. What is the cause of “resistant” hypertension in this patient and the many just like him? Is there a role for bilateral nephectomy or vascular radio frequency ablation? Is this simply a volume issue and if so what is the best approach to get him to a lower dry weight? Is there a role for online hematocrit monitors, IVC diameter measurements, fluid status by bioempedance measurements, BNP levels and low sodium dialysates. This discussion is strengthened by being full of opinions and experiences from nephrologists that have been practicing for many decades.  

Summary provided by Roger Rodby MD, FACP, FASN

Calciphylaxis in PD Patient

A 68 year old female with ESRD on peritoneal dialysis (PD) develops calciphylaxis (calcemic uremic arteriopathy CUA). She is poorly compliant with any attempts at medical treatment for her CUA. The treating doctors want to give her sodium thiosulfate (STS). But while STS is typically given intravenously after hemodialysis (HD) to patients before they leave the HD unit, STS administration is a patient receiving PD is logistically very different. Should the patient be temporarily converted to HD specifically for STS treatment? Can STS be given intra-peritoneally and if so how often and at what dose? Can it be given orally? Very different opinions and experiences are expressed in this international discussion.  

Summary provided by Roger Rodby MD, FACP, FASN

Proteinuria/Nephrotic Syndrome in Pregnancy

A 30 year old woman develops progressive proteinuria in the third trimester of an otherwise uncomplicated pregnancy. Her blood pressure and renal function are normal and she has no edema. Many questions arise. Should a biopsy be done? Should she be delivered early? What blood tests should be done? Are diuretics safe? Is an empiric trial of steroids indicated? Should she be anticoagulated? Could this be preeclampsia? How should we define hypertension in pregnancy since so much weighs on this finding. Will we someday be measuring sFlt and PIGF ratios to help us with that diagnosis and will we have targeted therapies to make that ratio more favorable for a successful term pregnancy? Many questions are proposed and many differing opinions abound in this lively discussion. 
Summary provided by Roger Rodby MD, FACP, FASN

Tubulointerstitial Nephritis in a Young Patient

A 19 year old woman presents with hypertension and CKD. Her urinalysis is entirely normal and her kidneys are slightly echogenic. A renal biopsy has only 3 glomeruli, 2 of which are globally sclerosed, and there is extensive acute and chronic interstitial inflammation. What has caused this severe renal disease in such a young woman? Can hypertension alone explain these findings? What other work-up should be considered? Should genetic testing be done for autosomal dominant interstitial nephritis or nephronophthisis? Should she receive an empiric trial of steroids? Is there a role for another biopsy? Read the thread to see what the discussants decide. 

Summary provided by Roger Rodby MD, FACP, FASN