Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When do you refer for peritoneal dialysis catheter placement in a patient with advanced chronic kidney disease who does not currently have dialysis needs but does have a progressive decline in eGFR?
The question, of course, is whether to place the catheter early, when the patient does not yet require dialysis and then need to provide catheter care (e.g., weekly flushes), or to delay catheter placement and risk needing to start urgently, or, much worse, risk placement of a tunneled dialysis cath...
What is your approach to perioperative risk stratification and optimization of patients with ESRD on HD?
When evaluating a patient with end-stage renal disease (ESRD) on maintenance hemodialysis for surgery, my approach to perioperative risk stratification centers on three major areas: cardiovascular risk assessment, optimization of dialysis-related factors, and careful perioperative medication and met...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Is there an eGFR or urine output rate for which you would no longer recommend pre- and post-hydration for a patient with AKI who requires liposomal amphotericin B?
I'm not aware of any data to guide recommendations on this. Since it is a simple measure, I err on the side of caution and (barring overt volume overload) recommend hydration in any patient with AKI receiving ampho B, regardless of eGFR and urine output.
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
How do you evaluate exercise induced hematuria that persists after one week of cessation of exercise?
Exercise-induced hematuria typically resolves within a week. If the hematuria persists after one week of cessation of exercise, further work-up of the hematuria is warranted. First, hematuria should be confirmed by excluding myoglobinuria and march hemoglobinuria. If hematuria is confirmed, then one...
Do you stop hemodialysis and monitor the patient in clinic, or taper dialysis frequency first, when urine output and lab markers suggest kidney recovery in a hemodynamically stable outpatient with dialysis-requiring AKI?
The absence of interdialytic weight gain is generally the first sign of recovery from acute kidney injury (AKI). However, one thing to avoid getting burned on is the patient with severe heart failure who was previously on high-dose diuretics that were stopped when dialysis began. They may have signi...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...