Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you approach management of a young patient with an AKI, normal kidney biopsy findings, and no abnormal proteinuria?
If the kidney biopsy was indeed normal, then this would have to be pre-renal AKI, and hence the approach would be to correct any volume deficits which exist, and/or search for a cause for the pre-renal AKI.
When do you consider starting a bicarbonate drip for hospitalized patients?
In general, it’s best to follow the serum pH and not the bicarbonate, as there can be respiratory compensationYou should start to worry when the serum bicarbonate is in the range of 10 to 13. Strongest case for treating: pH ≤7.10 with AKI stage 2–3, especially in shock or sepsis. Weaker case: pH bet...
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
This is such an important question given the prevalence of painful osteoarthritis (knees and other joints, including erosive/inflammatory OA in the hands) in elderly patients who often have concurrent gastrointestinal, cardiac and renal disease. The recently published retrospective study from the Un...
What are your thoughts on patients presenting with hyponatremia receiving IV fluids before urine studies are collected and the etiology is fully characterized?
Whenever possible, I try to obtain serum osmolality, urine osmolality, and urine sodium before giving IV fluids. A urine specimen requires only a small volume and can usually be collected at the same time as the initial bloodwork without meaningfully delaying care. That said, treatment should never ...
What are your top takeaways from ASN Kidney Week 2026?
Two of the topics I found interesting were:Hemoadsorption columns: there are now newer synthetic resins that are used for adsorption, and the initial clinical trials have had interesting results, including improved mortality in endotoxemic septic shock, improved hemodialysis (HD) clearance of large ...
How do you manage persistently high interdialytic weight gain in a patient whose ultrafiltration rate regularly exceeds 13 mL/kg/hr?
If the patient is willing to do longer dialysis or an extra day of dialysis, then that would be the best option. If not, then the only choice is to remove more than 13 mL/kg/hr as otherwise, over time, the patient will be fluid overloaded. Of course, all patients should be educated on low salt/low f...
Do you avoid certain cranberry extract supplements for patients with recurrent calcium oxalate nephrolithiasis who have hyperoxaluria of unknown etiology given potential for the supplement to increase urinary oxalate levels?
Yes. Hyperoxaluric calcium oxalate stone formers ought to be on a low-oxalate diet. I consider cranberries and their extracts as high oxalate foods.
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
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...