5 Questions with Dr. Chirag Parikh

Summary

Blood, Sweat and Smears – A Machaon Diagnostics Podcast
Episode: 5 Questions with Dr. Chirag Parikh
Date: March 25, 2026
Host: Bjorn Stromses (with Dr. Brad Lewis)
Guest: Dr. Chirag Parikh, Director of Nephrology, Johns Hopkins

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Episode Overview

This episode continues the “5 Questions” series, featuring distinguished nephrologist Dr. Chirag Parikh. Through direct, insightful questions, the conversation explores trends in nephrology, the future of non-invasive diagnostics for acute interstitial nephritis (AIN), patient and physician perspectives regarding biopsies, and broad opportunities for innovation in kidney disease. Dr. Parikh brings both clinical expertise and a vision for advancing patient care through precision medicine and human connection.

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Key Discussion Points and Insights

1. Distilling Nephrology to Two Words: “Fluid” and “Balance”

[01:24]

• Dr. Parikh summarizes nephrology as fundamentally about “fluid and balance.”
• He elaborates that the kidneys’ role is to maintain equilibrium of the internal environment: “...regulating internal environment and managing fluid volumes, electrolytes, acid base and keeping the body in equilibrium.”
• The field is rooted in concepts of homeostasis and precise, mathematical reasoning.

2. The Impact of a Non-Biopsy Diagnostic Pathway for AIN

[01:55 - 05:30]

• Dr. Parikh and colleague Dr. Dennis Moldina have pioneered non-biopsy diagnostics for AIN.
• For patients:
  • Faster, non-invasive diagnosis means earlier treatment, preserved kidney function, and reduced chronic kidney disease risk.
  • Avoids risks and discomfort of biopsies (pain, bleeding, complications).
  • Expands diagnostic access to outpatients and primary care settings.
• For clinicians and systems:
  • Enables standardized, algorithm-driven care and reduces variability.
  • Frees up biopsies for cases where necessary (atypical presentations, ambiguous diagnoses, or concomitant diseases like vasculitis).
  • Facilitates clinical trials, as non-invasive tests allow for easier subject selection and monitoring.
• Quote:

  “If we have a validated non diagnostic pathway, it would improve the patient outcomes for AIN in so many different ways, mainly by enabling a safer and a more equitable diagnosis and treatment.” (B, 05:17)

3. Addressing “Biopsy Culture” Among Physicians

[05:30 - 08:59]

• Facing physicians who are “biopsy guys,” Dr. Parikh emphasizes shared goals: achieving accurate diagnoses while minimizing patient harm.
• Argues for evidence- and risk-based decision-making, appealing to practicality:

  “What is the decision threshold? What would you like out of a test that would change your diagnostic certainty and your management?” (B, 06:28)

• Encourages trial periods for non-biopsy approaches, collaborative learning, and multidisciplinary discussions to reach consensus.

4. Non-Invasive Diagnostics for Monitoring Disease Progression

[08:59 - 10:47]

• The utility of non-invasive tests extends beyond diagnosis—could enable longitudinal monitoring of disease activity or treatment response.
• Certain biomarkers, such as IL9, already show promise in tracking steroid responses.
• Non-invasive monitoring is especially pertinent for diseases or drugs with episodic or late-manifesting effects (e.g., immune checkpoint inhibitors, proton pump inhibitors).
• Quote:

  “If we had a serial monitoring possible, we can see what should be the duration of steroids or sometimes they're competing drugs present and we can see which drug to stop in a given patient who's... showing that effect.” (B, 09:34)

5. Other Renal Diseases Ripe for Disruption

[10:47 - 12:00]

• Nephrotic syndrome and glomerulonephritis (GN): Progress in genetics and biomarker studies is leading to precision therapies (e.g., for IgA nephropathy, FSGS, vasculitis).
• Acute Kidney Injury (AKI): Emerging biomarkers are identifying at-risk patients and driving FDA approvals; the field is primed for interventions that prevent progression to chronic kidney disease.

6. Bonus Question: A Non-Medical Recommendation

[12:00 - 13:15]

• Dr. Parikh’s advice is simple yet profound: foster connection and gratitude.
• Quote:

  “Spend like five minutes every day thinking about someone... and one specific thing you appreciate about them or what will you do for them that day... These practices of just small gratitude builds in human connection and this consistent acts, they accumulate over time and they reduce stress and improve mood.” (B, 12:40)

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Notable Quotes and Memorable Moments

• “[Nephrology is about] fluid and balance. Kidney medicine is fundamentally about regulating internal environment and managing fluid volumes, electrolytes, acid base and keeping the body in equilibrium.” (B, 01:32)
• “With a non invasive test... you can select patients for trial. You can use this test to guide therapy and to develop new drugs… and that I feel is the real home run when it happens.” (B, 04:59)
• “A lot of times we pick up the disease very late... So having a monitoring test could be useful for certain drugs. Immune checkpoint inhibitor is a classic example where AIN can come and go...” (B, 09:31)
• “We are truly in the era of precision medicine.” (B, 11:09)
• “Connection. We need to spend like five minutes every day thinking about someone... These practices of just small gratitude builds in human connection...” (B, 12:40)

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Key Timestamps

• 01:24 – Defining nephrology in two words: “fluid” and “balance”
• 01:55 – 05:30 – Impact of non-biopsy diagnostics on patient care and healthcare systems
• 05:44 – Strategies for conversations with “biopsy-driven” colleagues
• 08:59 – How non-invasive testing can enable longitudinal disease monitoring
• 10:57 – Which kidney diseases are ripe for innovation: GN, AKI
• 12:24 – Dr. Parikh’s broader recommendation: cultivating human connection

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Summary

Dr. Chirag Parikh brings clarity, vision, and compassion to contemporary nephrology, envisioning a future where precise, non-invasive diagnostics improve patient care, clinical trial efficiency, and equity of access. He underscores the importance not just of technological advancement but also of shared decision-making, multidisciplinary collaboration, and the cultivation of gratitude and connection in both medicine and daily life. The episode offers a blend of pragmatic clinical insight and humanistic advice, making it a valuable listen for clinicians and lay audiences alike.

Transcript

[A]

Hello and welcome to Blood, Sweat and Smears, your Macheon Diagnostics podcast with tag team hosts including Our medical director, Dr. Brad Lewis, senior Director Bjorn Stromses, that's me and other guest hosts. We hope you find these podcasts interesting and informative. Thank you for listening. And away we go. Hi, my name is Bjorn. Continuing our series 5 questions posing 5 questions to physicians in and around the disease areas we work in today we are joined by Dr. Chirag Parikh, Director Division of Nephrology, and the Ronald Peterson professor of Medicine and the Co Director of Data Science and AI at the Reyes center, both at Johns Hopkins School of Medicine. He's also someone that I managed to have lunch with at last year's Kidney Week conference. So thank you for joining us today, Dr. Parikh.

[B]

Great to meet you Bion, and looking forward to speaking with you for next

[A]

30 minutes or less, probably faster. We'll see. Well, I don't know. We'll see, I guess. All right, so on to our first question. A lot of nephrology seems to come down to sodium and math. If you had two words to describe your subspecialty, what would they be and why?

[B]

I would pick fluid and balance. And kidney medicine is fundamentally about regulating internal environment and managing fluid volumes, electrolytes, acid base and keeping the body in equilibrium is the real job of the kidney. And this we so balance, if you want to say like balance, captures homeostasis, fine tuning and mathematical reasoning that underpins most of the nephrology.

[A]

Perfect. You and Dennis, Dr. Dennis Moldina, are known in part for your work looking at acute interstitial nephritis or AIN and a non biopsy diagnostic path. What would it mean for the field and for patients if this non biopsy approach were to be widely adopted?

[B]

This is a great question beyond if a reliable non diagnostic biopsy pathway is widely adopted, the effects would be large and multifaceted and I can see the effects on for patients, for clinicians and for the healthcare system. First, if you take patients, for all patients, we want faster diagnosis and treatment and nothing like a non invasive test where there would be a rapid identification of ain and this means earlier stopping of offending drugs or initiation of therapy like corticosteroids. The thing that I like the most is earlier treatment can preserve kidney function and reduce the risk of persistent chronic kidney disease for patients. Also there is a risk of procedure and the discomfort that comes with renal biopsies. Patients get pain, there's bleeding risk and occasionally there are more serious complications that could be Avoided if there was a reliable test, there could be a greater access to diagnosis. Currently biopsy is done in the inpatient setting, so not everybody has it. AIN can happen in the setting of outpatient disease, it can happen in primary care setting, etc, and a wider access to this modality could be there. And finally, I think it would be lower cost and a faster throughput. Biopsy typically takes three to four days between processing the specimen, getting the pathologist to read it, get the biopsy and then call the patient back in to discuss the results with this whole thing could be a faster throughput with a non invasive test. The second part would be for the clinicians and the healthcare system for clinicians. We all like a broader standardized approach. If there's a validated algorithm for any disease or a pathway, it gives actionable guidance, it reduces diagnostic uncertainty and decreases variability in practices. And we can still have biopsy, but it is reserved for patients where cases are atypical or the diagnosis is ambiguous, or there is alternate diagnosis such as vasculitis, or in the setting of gnome, where we would really want a kidney diagnosis, tissue diagnosis. And we may not be satisfied just with noninvasive tests. The other thing that I have thought about is when there is a non invasive test, it would improve the trials. Eventually we want better drugs for ain. And with a non invasive test you can select patients for trial. You can use this test to guide therapy and to develop new drugs in impossible to do like two biopsies in a short period of time in patients with ain. And that I feel is the real home run when it happens. So in the bottom line, I think if we have a validated non diagnostic pathway, it would improve the patient outcomes for AIN in so many different ways, mainly by enabling a safer and a more equitable diagnosis and treatment.

[A]

Fantastic. Okay, so my third question, I once heard someone say that their chief was a biopsy guy. How do you convince a biopsy doctor to consider not doing a biopsy?

[B]

This is a great question. And this happens in medicine frequently. Like to send a patient for surgery or to do medical treatment, or to put them in ICU or not, or biopsy or no biopsy. And a lot of times in this discussion we start from shared goals and I speak with the physician. I also like to do biopsy, but in general I speak with somebody who's very biopsy driven is what really matters. Is it accurate diagnosis that we want in the patient that would guide treatment and minimize harm? And I frequently frame the argument around evidence, risk and benefit and practicality so the key point to raise with those people is what is the decision threshold? What would you like out of a test that would change your diagnostic certainty and your management? And a lot of times patients say I would treat empirically, like without a biopsy if I was greater than 80% sure or 90% sure. That gives us a concrete target for the non biopsy tools to meet and a lot of people to like change their mind or consider alternative treatment. A lot of times we have to do a good job in terms of summarizing the evidence around validation, the timing and sensitivity, specificity to show that how they can be complementary and synergistic to a biopsy approach. Frequently there are a lot of cases where biopsies cannot be done. Patients are on aspirin or have a high bmi where we would not get a good tissue or they are on certain drugs where it's just not possible. Frequently the patients refuse biopsies because of the risks involved. Even if the patient is at low risk, we are exposing them to risk of AV fistulas or bleeding or blood transfusion. And a non diagnostic or a non biopsy pathway could be a good start. When the probability of diagnosis is lower where you want to rule out test and the risk of harm is to be avoided, sometimes it still gets difficult. So what I have done, at least in my setting for difficult discussion where I'm trying to change practices, we create reasonable boundaries or we create a trial period with a safety net. We can say let's do a period without biopsy and see and compare data and then we can compare with your historical c and then both the groups can learn what is going on. And we have to do this in the setting of heart failure or cardiac surgery where people were frequently divided in terms of what is best for the for the patient. But if we make it multidisciplinary and we involve colleagues, typically we find a win win. But at the end of the day we have to convince people that it's the same thing we both want to do. We want to reach the right diagnosis without exposing the patient to unnecessary risk. And in this patient, what would be the right approach to get there fastest? And we can create some inroads there.

[A]

Yeah, fantastic. Would a non invasive test for ain mean that you could track disease progression or response to treatment in a, in a different way than you can now?

[B]

Yes, if you get like. So for several diseases the outcomes have changed. Like I'm talking about non kidney diseases. But the same test can serve for diagnosis and the same test can be used for monitoring prognosis and treatments, etc. There are a lot of cardiac tests or oncologic test that way. So if we had a serial monitoring possible, we can see what should be the duration of steroids or sometimes they're competing drugs present and we can see which drug to stop in a given patient who's show showing that effect. Lot of times we pick up the disease very late and the disease is also sporadic. So you may, you may do a biopsy, but and not have ain. But then patients can develop AIN later on the same drug, like we have seen with proton pump inhibitors. So having a monitoring test could be useful for certain drugs. Immune checkpoint inhibitor is a classic example where AIN can come and go and response to therapy may be very important. So disease recurrence, disease relapse, all of these become very, very important in terms of having a longitudinal test available for disease progression. So some of these biomarkers, at least we have shown they do show response to steroid IL9 in particular. But evidence needs to be built around how well these panels or new algorithms can be used for this purpose.

[A]

Great. So beyond ain, what other renal diseases or conditions do you think are ripe for disruption?

[B]

Kidney disease is in a wonderful era right now. Lot of biology is getting uncovered, lot of investments are being made and we are truly in the era of precision medicine. The two areas which I am watching and participating closely, one is nephrotic syndrome and GN, where people are identifying precision therapies, say for IgA or FSGS or vasculitis, and driven by all the studies that they've done in genetics or transcriptomics or biomarker studies and multiple drugs are coming out. The second area which I personally am involved and I'm very optimistic, is acute kidney injury precision and detection. We have to prevent patients going from AKI to ckd. And there are lots of interesting biomarkers that are determined telling us which patients are at risk. Some of these are getting FDA approved, but this is the area that is ripe for intervention and disruption.

[A]

Yeah, great. And if you've been keeping account, that's five questions which, which brings us to our bonus question, which is, which is what is something you would recommend? And it does not need to be medical. It does. We've had, we've had Reading Brene Brown, we've had Tequila, Michigan football, champagne, traveling to jap. What is one thing that you'd recommend?

[B]

I think looking at current era, we had a faculty meeting recently, etc. We were discussing what matters and I think the thing that's coming to mind is connection. We need to spend like five minutes every day thinking about someone. It could be your patient, your colleague, your loved one and one specific thing you appreciate about them or what will you do for them that day? I'm seeing like everyone's busy. There is a lot of burnout creeping in. There are competing demands and these practices of just small gratitude builds in human connection and this consistent acts, they accumulate over time and they reduce stress and improve mood. So I'm telling this to people in my division.

[A]

Well that's fantastic and thank you for connecting with us today and answering our five questions. It's been a pleasure. Thank you very much.

[B]

Thank you Bijon.

[A]

That wraps up another episode of Blood, Sweat and Smears, a matrian diagnostics podcast. Subscribe wherever you listen to your podcast to make sure you don't miss the next episode. See you soon.