Mark Fahlen

Solo practice nephrologist in the Golden State, husband, father, swimmer, skier, and landlocked surfer. #nephrology #solopractice #dialysis

[Gopambuj Singh Rathod @IamGopambuj]

🩺 Podocyte-protecting drugs are changing modern nephrology practice.

Podocyte injury is a key driver of proteinuria and CKD progression. Important podocyte-protective therapies include:

✅ RAAS blockers (ACEi/ARBs)
✅ SGLT2 inhibitors
✅ Finerenone & other MRAs
✅ Calcineurin inhibitors
✅ Endothelin pathway inhibitors
✅ Rituximab in selected glomerular diseases

🎯 Goals:
• Reduce proteinuria
• Preserve glomerular filtration barrier
• Slow CKD progression
• Improve long-term renal outcomes

The strongest evidence today supports:
🛡️ RAAS blockade + SGLT2 inhibitor ± Finerenone
#GSR #BuddingNephros
#Nephrology #Proteinuria #KidneyDisease #GlomerularDisease #MedTwitter

[Hans-Joachim Anders @hjanders_hans]

Now open access in @NDTsocial

Coffee consumption and chronic kidney disease

🧐Current evidence suggests that moderate caffeine intake is probably safe in CKD and may be potentially beneficial.

▶️https://t.co/UksqIYFlWK

[Nature Reviews Nephrology @NatRevNeph]

Anti-neutrophil cytoplasmic antibody-associated vasculitis: biological insights and biomarker-guided disease management https://t.co/qmGOtMstYA

[Mark Fahlen @markfahlen]

Hemodiafiltration is good. Hopefully it will be implemented in the US ESRD population soon.

[Gopambuj Singh Rathod @IamGopambuj]

🚰 Hemodialysis is no longer just about diffusion.
💡 The future is convective.

#Hemodiafiltration (#HDF) combines diffusion + convection to achieve superior clearance of middle molecules and protein-bound toxins.

📚 Trials like
• ESHOL Trial
• CONTRAST Trial
• CONVINCE Trial
suggest better survival and cardiovascular outcomes with high-volume HDF.

🎯 Target convection volume:
➡️ ≥ 23 L/session

Why nephrologists are increasingly embracing HDF:

✅ Better middle molecule clearance
✅ Improved hemodynamic tolerance
✅ Better phosphate control
✅ Reduced inflammation
✅ Potential survival benefit

“More than filtration.
It’s better purification.
It’s better care.”
#GSR #BuddingNephros
#Nephrology #Dialysis #KidneyDisease #CKD #NephTwitter #MedTwitter #HDF

[Sayed S Rahman @SayedSRahman1]

KIDNEY DISEASE CONTINUUM :
AKI,AKD,CKD
Based on KDIGO Guidelines

#KDIGO

[AJKD @AJKDonline]

Navigating Anemia Therapy in CKD: The Role of Hypoxia-Inducible Factor Activators

https://t.co/7JJVOqmVas (OPEN ACCESS)

[Beatriz Fernandez Fernandez @beaff26]

Amazing paper leading by #EURECAM @ERAkidney @FJDNefrologia @SENefrologia

[Gopambuj Singh Rathod @IamGopambuj]

🧵 Antibiotics in CKD – Quick Clinical Guide

1️⃣ CKD changes drug handling
→ ↓ clearance = ↑ toxicity
→ Always think dose adjustment

2️⃣ Golden rules:
✔ Loading dose = SAME
✔ Adjust maintenance dose
✔ Use eGFR/CrCl
✔ Monitor toxicity

3️⃣ 💊 NEED dose adjustment:

β-lactams (except ceftriaxone)

Vancomycin

Aminoglycosides ⚠️

Levofloxacin / Ciprofloxacin

TMP-SMX

4️⃣ ✅ SAFE (no adjustment):

Ceftriaxone

Linezolid

Doxycycline

Azithromycin

Clindamycin

👉 Prefer these in CKD

5️⃣ ❌ Avoid / caution:

Aminoglycosides (nephrotoxic)

Nitrofurantoin (eGFR <30)

Amphotericin B

High-dose acyclovir

6️⃣ 🩺 Dialysis pearls:
HD → give AFTER dialysis
PD → prefer intraperitoneal route

7️⃣ 🎯 Clinical picks:
UTI → Ceftriaxone
Pneumonia → Ceftriaxone + Azithro
MRSA → Linezolid 👍 / Vancomycin

8️⃣ 🚨 Red flags:

Confusion = β-lactam toxicity

Hyperkalemia = TMP-SMX

Hearing loss = aminoglycosides

📌 Takeaway:
Right drug + right dose + renal adjustment = safe therapy in CKD
#GSR #BuddingNephros #Antibiotics #CKD

[Gopambuj Singh Rathod @IamGopambuj]

🧠 Post Renal Transplant Infections Timeline – Must Know!

🕒 0–1 month (Surgical phase)
• Nosocomial infections dominate
• UTI, SSI, pneumonia
• Not immunosuppression-driven

🕒 1–6 months (🔥 Peak immunosuppression)
• Opportunistic infections
• Cytomegalovirus infection (most common)
• Pneumocystis jirovecii pneumonia, TB, fungi
• BK virus nephropathy

🕒 >6 months (Community phase)
• CAP, UTI, influenza
• Late CMV, PCP (if no prophylaxis)
• Post-transplant lymphoproliferative disorder

💡 Pearls:
✔ Timeline = diagnosis shortcut
✔ CMV = key player
✔ Think TB in India
✔ TMP-SMX prophylaxis saves lives
#GSR #BuddingNephros #Transplant #Infection

[AJKD @AJKDonline]

Hemodiafiltration: A Mini Review

@SilberjRogosin

https://t.co/qkiAYOM8mP

[Gopambuj Singh Rathod @IamGopambuj]

People often ask that if they are doing good after starting dialysis , why they should go for transplant ?

💉 Here's a Survival Reality Check between HD and Transplant-

📊 5-year survival on hemodialysis: ~35–45%
👉 Only ~4 out of 10 patients make it to 5 years

🧬 Kidney Transplant changes the story:
✅ 1-year patient survival: 95–98%
✅ 5-year patient survival: 85–90%
✅ Graft survival at 5 years:
• Living donor: ~85–90%
• Deceased donor: ~70–80%

⚖️ The difference is clear:
Transplant offers ~2–3× better long-term survival than dialysis

❤️ Beyond survival:
✔ Better quality of life
✔ Freedom from dialysis
✔ Improved cardiovascular outcomes

📌 Bottom line:
Dialysis sustains life…
👉 Transplant restores it
#GSR #BuddingNephros
#Nephrology #KidneyTransplant #Dialysis #CKD #MedEd #NephTwitter

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

Update on gadolinium and CKD/ ESKD ca. 2021 from @NephRodby @MPerazella
#Nephpearls

Risk of nephrogenic systemic fibrosis is low w/ group II gadolinium-based contrast media GBCM, so potential harms of delaying/ withholding group II GBCM for MRI in a patient w/ AKI or eGFR < 30 is likely to outweigh risk in most situations

👉 https://t.co/lFUicEy5sg

[ASN Publications @asnpublications]

The dramatic expansion in CKD therapeutics to prevent progression of kidney disease and reduce cardiovascular events calls for thoughtful implementation. The 2025 guidelines synthesize new evidence for Primary Care Management of CKD in this #ASNCJASN #perspective https://t.co/6yj0GWECfy

[Gopambuj Singh Rathod @IamGopambuj]

🧠 Living Kidney Donor Criteria

➡️ Shift from “cut-offs” → 🎯 individualized lifetime ESRD risk

✅ GFR ≥90 → Accept | <60 → Reject
⚖️ 60–89 → Case-based

✅ ACR <30 → OK | >300 → No
✅ Controlled HTN → Acceptable
❌ Diabetes (usually exclude)
⚠️ BMI >30 caution

🚫 Absolute: CKD, proteinuria, uncontrolled HTN, active malignancy

💡 KEY: Donor safety FIRST — long-term risk matters more than numbers
#GSR #BuddingNephros
#Nephrology #KidneyTransplant

[Mark Fahlen @markfahlen]

Agree.

[Dr. Chacón-Lozsán F .'. @franciscojlk]

🩻Contrast-induced AKI:
one of the biggest myths still shaping clinical decisions

For decades we were taught:

👉 “Contrast damages the kidneys”
👉 “Avoid CT with contrast in CKD”
👉 “Hydrate, protect, delay imaging if needed”

But what if… most of this is wrong?🤔

->The uncomfortable reality

Modern evidence shows:

👉 Low-osmolar contrast rarely causes true nephrotoxicity
👉 Even in CKD, AKI, and ICU patients
👉 The risk is often overestimated—or nonexistent

So where did the fear come from?

📍 1950s high-osmolar contrast (actually toxic)
📍 Poorly controlled observational studies
📍 “Creatinine rise = contrast injury” assumption

👉 Correlation became causation
👉 And the dogma stayed

⚠️What recent data tells us

✔ No difference in AKI rates with vs without contrast
✔ No benefit from bicarbonate, NAC, or aggressive hydration
✔ Even ICU and AKI patients show no worsening outcomes

->Translation to real life

👉 The patient was going to develop AKI anyway...Not because of contrast!!

->The real problem: “Renalism”

👉 Avoiding necessary imaging
👉 Delaying diagnosis
👉 Choosing inferior tests

And that leads to:

❌ Missed PE
❌ Delayed sepsis source control
❌ Worse outcomes

->Clinical mindset shift

Instead of asking:

👉 “Will contrast harm the kidneys?”

We should ask:

👉 “Will NOT doing the scan harm the patient?”

->Who still deserves caution?

✔ eGFR <30
✔ Severe hemodynamic instability
✔ Multiple nephrotoxins

Even then:

👉 Optimize volume
👉 Minimize dose
👉 Don’t delay critical imaging

🤓Bottom line

✔ Contrast nephrotoxicity exists… but is rare
✔ The fear is bigger than the risk
✔ The harm of NOT imaging is often greater

In critical care

👉 We don’t treat creatinine
👉 We treat patients

And sometimes…

👉 The most dangerous thing is NOT the contrast

👉 It’s hesitation.

📃Reference
Florens N, Demiselle J.
Kidney360 7: 445–449, 2026. doi: https://t.co/CWzi7WC9Wx

[Arvind Canchi (Conjeevaram)🇮🇳 @arvindcanchi]

Prevention of Urinary Stones with Hydration - PUSH Trial
1. Didn't work
2. Tough to get pts to drink more water.
The PUSH Trial in Lancet - https://t.co/z3FeZofyKs
A nice synopsis of the trial here - https://t.co/UsgpNWNeCh

[CKJ @CKJsocial]

Furosemide plus oral sodium chloride for syndrome of inappropriate antidiuresis after fluid restriction failure

https://t.co/1GGN2CGj9N

[Gopambuj Singh Rathod @IamGopambuj]

Confused about osteoporosis drugs in CKD?
👉 Low PTH = build bone → Teriparatide
👉 Any CKD = use safely → Denosumab (watch Ca!)
👉 Early CKD only → Bisphosphonates
Simple rule: Turnover guides therapy
#GSR #BuddingNephros #Nephrology #CKD

[ERM @Owner_X429]

#ISNWCN

[Sayed S Rahman @SayedSRahman1]

KDIGO 2026 AKI/AKD guidelines
Key takeaway https://t.co/d6E2i6uiuR