Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to the management of a patient with PAH who is resistant to contraception and planning a pregnancy?
PAH in pregnancy is associated with high maternal mortality despite the advanced therapies we now have available. Therefore, my first step is counseling the patient so she is aware of all the potential risks associated with a pregnancy. If she is already pregnant, I then discuss the option of termin...
In patients with secondary Sjogren's how do you approach screening for lymphoproliferative malignancy?
1. Firstly, I do not discriminate between "secondary" and "primary" Sjogren's disease. There is currently a "Nomenclature Initiative" by the Sjogren's Foundation, led by Dr. Alan Baer, Director of the Sjögren’s Clinic at Johns Hopkins, and Dr. Manuel Ramos-Casals, a Sjogren's expert in Spain. Thus f...
What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?
It depends on numerous factors: What's the underlying CTD? Has the patient been trialed on immunomodulatory agents before? What's the risk of therapy in this patient? And many others. It's a big topic. To delve into some of the above by bullet point: Most guidance for immune suppression is driven by...
Do you use serum or urine biomarkers other than creatinine when evaluating patients with acute kidney injury?
I use the urinalysis (including microscopy) as well as the furosemide stress test but no other "novel" biomarkers have sufficient accuracy to guide clinical care at this time.
Are there instances when you do not perform urine microscopy and rely solely on laboratory performed urinalysis when evaluating a patient for acute kidney injury?
Direct visualization of urinary sediment under a proper microscope is a cornerstone of AKI evaluation from intrinsic renal disease. If I am relatively sure the cause of AKI is prerenal or post-renal and AKI improves promptly with intervention, then I may forego sediment evaluation. I am in the lab l...
When do you avoid or stop erythropoietin-stimulating agents in patients with anemia and end stage kidney disease?
For the most part, I don't. If the patient has uncontrolled hypertension, then I would air on the side of using less and possibly even not giving it. In patients with cancer, I always check with hem/onc to see if it is okay to give it. Most of the time, I find that they don't have a problem giving i...
When do you avoid or stop iron agents in patients with anemia and end stage kidney disease?
I don't give iron if patients have hemoglobin over 12. There is no reason to give iron if hemoglobin is over the desired range even if the patient seems iron deficient on labs. I also do not give iron if the serum ferritin is > 800-1000. I think at this point the risk of iron overload outweighs the ...
Are there cases of glomerulonephritis where you do not perform a kidney biopsy in a patient deemed safe to undergo the procedure?
In adults, there are some circumstances where a biopsy may be deferred/ 1. Patients with nephrotic syndrome, normal kidney function and an elevated PLAR2 Antibody level (in the absence of other systemic diseases e.g. SLE, diabetes). A presumptive diagnosis of PLA2R ab-associated membranous nephropat...
When do you perform a kidney biopsy in a patient with AKI that is thought to be related to an immune checkpoint inhibitor?
I would wait for the response to corticosteroid therapy before the renal biopsy.
Are there preventative measures that you take in your cancer patients with chronic kidney disease who require periodic iodinated contrast CT studies for monitoring of their malignancy?
Recommendations include discussing the utility of other imagining modalities with the hematology or oncology team caring for the patient. In general, the risk for AKI from IV contrast increases with lower eGFRs. Cancer patients may have misleading "normal" or "good" Cr and eGFRs due to malnutrition ...