SGLT2 Inhibitors in Management of Severe Hypomagnesemia in Patients Without Diabetes: A Report of 4 Cases.

Sodium/glucose cotransporter 2 (SGLT2) inhibitors have demonstrated a class effect in improving serum magnesium levels in patients with diabetes. Additionally, recent reports have shown their promising beneficial effects in the treatment of refractory hypomagnesemia in patients with diabetes. However, their role in treating hypomagnesemia in patients without diabetes remains unexplored. Here, we report 4 cases of severe and refractory hypomagnesemia that showed dramatic improvement after initiating SGLT2 inhibitors in patients without diabetes. Case 1 had calcineurin inhibitor-associated severe hypomagnesemia. Cases 2, 3, and 4 had refractory hypomagnesemia associated with platinum-based chemotherapy with or without gastrointestinal losses. Case 1 was able to withdraw from high-dose oral magnesium supplementation. Cases 2 and 3 achieved independence from intravenous magnesium supplementation, whereas case 4 had decreased intravenous magnesium requirements. All the cases demonstrated sustainably improved serum magnesium levels. Withdrawal of SGLT2 inhibitors in case 4 resulted in worsening serum magnesium levels and intravenous magnesium requirements. The extraglycemic benefit of this group of medications not only suggests the need for further studies to better understand the effect of SGLT2 inhibitors on magnesium homeostasis but also supports expanded use in a larger patient population.

Point of care ultrasonography in onco-nephrology: A stride toward better physical examination.

Onco-Nephrology is an emerging subspecialty of Nephrology that focuses on a broad spectrum of renal disorders that can arise in patients with cancer. It encompasses acute kidney injury (AKI), complex fluid, electrolyte, and acid-base disorders, as well as chronic kidney disease caused or exacerbated by cancer and/or its treatment. In many such scenarios including AKI and hyponatremia, objective evaluation of hemodynamics is vital for appropriate management. Point of care ultrasonography (POCUS) is a limited ultrasound exam performed at the bedside and interpreted by the treating physician intended to answer focused clinical questions and guide therapy. Compared to conventional physical examination, POCUS offers substantially higher diagnostic accuracy for various structural and hemodynamic derangements. In this narrative review, we provide an overview of the utility of POCUS enhanced physical examination for the Onconephrologist supported by the current evidence and our experience-based opinion.

Impact of Chronic Kidney Disease and Acute Kidney Injury on Safety and Outcomes of CAR T-Cell Therapy in Lymphoma Patients.

INTRODUCTION: Chimeric antigen receptor T-cell (CAR-T) therapy is standard-of-care in relapse/refractory aggressive B-cell non-Hodgkin lymphoma. There are limited data regarding the impact of pre-existing chronic kidney disease (CKD) and acute kidney injury (AKI) post CAR-T and we sought to evaluate these in our patients. METHOD: In this single center retrospective analysis CKD cohort was defined KDIGO staging with eGFR of <60 mL/min/1.73 m2 (Stage ...3) at the time of pre-CAR-T assessment. Remaining patients constituted the no CKD group. AKI was defined by CTCAEv.4 and data were abstracted through Day 100 post-CAR-T therapy. The primary outcome was impact of pre-existing CKD on progression-free survival (PFS), overall survival (OS) and adverse events. Additionally, we also analyzed the impact of AKI on PFS and OS. RESULTS: Thirty-two patients were identified with 7 having pre-existing CKD. Among the patients with or without CKD, the median PFS was 8.8 and 2.9 months respectively (pvalue 0.78). The median OS was 10 and 7 months respectively (p-value 0.64). AKI developed in a total of 9 patients (29%) post CAR-T, including 7 patients without CKD at baseline. The median PFS was 3.6 and 2.8 months for patients not developing AKI and developing AKI (p-value 0.84). Median OS in similar order was 10 and 3.9 months respectively (p-value 0.2). On univariate analysis, creatinine at baseline (p-value 0.018) and ICANS grade 2+ (p-value 0.016) were associated with an increased risk of developing AKI. CONCLUSIONS: CKD or AKI after CAR-T showed no impact on post procedure OS and PFS.

Demystifying hyponatremia: A clinical guide to evaluation and management.

Hyponatremia (serum sodium <135 mEq/L) is a frequent electrolyte abnormality complicating the clinical care of hospitalized patients. Hyponatremia has been associated with an increased risk of mortality. Hyponatremia can be seen in patients with euvolemia, hypovolemia, or hypervolemia. Evaluation of hyponatremia relies on clinical assessment and estimation of serum sodium, urine electrolytes, and serum and urine osmolality in addition to other case-specific laboratory parameters. In addition, point-of-care ultrasonography is an important adjunct to physical assessment in estimation of volume status. Understanding the pathophysiology of the underlying process can lead to a timely diagnosis and appropriate management of hyponatremia.

Monoclonal gammopathy of renal significance (MGRS): Real-world data on outcomes and prognostic factors.

Monoclonal gammopathy of renal significance (MGRS) is a recognized clinical entity. Literature regarding treatment and its outcomes in MGRS is sparse due to the rarity and misdiagnosis of MGRS. We retrospectively analyzed 280 adults with an MGRS diagnosis from 2003 to 2020 across 19 clinical centers from 12 countries. All cases required renal biopsy for the pathological diagnosis of MGRS. Amyloidosis-related to MGRS (MGRS-A) was present in 180 patients; nonamyloidosis MGRS (MGRS-NA), including a broad spectrum of renal pathologies, was diagnosed in 100 patients. The median overall survival in the studied cohort was 121.0 months (95% CI: 105.0-121.0). Patients with MGRS-A had a shorter overall survival than patients with MGRS-NA (HR = 0.41, 95%CI: 0.25-0.69; p = 0.0007). Both hematologic and renal responses were associated with longer survival. Achievement of ≥VGPR was generally predictive of a renal response (OR = 8.03 95%CI: 4.04-115.96; p < 0.0001), one-fourth of patients with ≥VGPR were renal nonresponders. In MGRS-A, factors associated with poor prognosis included elevated levels of creatinine, beta-2-microglobulin, and hemodialysis at diagnosis. In MGRS-NA, only age >65 years was associated with increased risk of death. Treatments provided similar hematologic response rates in both types of MGRS. Autologous stem cell transplantation led to better response than other treatments. This multicenter and international effort is currently the largest report on MGRS.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees.

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at the bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice, including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum, including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, is needed before POCUS training is universally incorporated across nephrology fellowship programs.