Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you would use urea to treat SIADH in patients with cirrhosis?
In SIADH, the administered urea is subsequently excreted in the urine, resulting in a urea osmotic diuresis. The osmotic diuresis results in the excretion of water in excess of sodium and potassium, thereby leading to an increase in the serum sodium concentration. In contrast, the increased ADH secr...
Would you add tolvaptan to manage difficult to treat SIADH in a patient who is already on high doses of sodium chloride tablets and urea but fails to reach adequate serum sodium levels?
First of all, I am NOT a fan of salt tablets for SIADH; it takes a bit over 7 one-gram salt tablets to equal the mmol supplied by a single 15-gram packet of urea. And that many (large) pills can be nauseating, much more so than urea. By far, I would prefer tolvaptan over urea, but tolvaptan is often...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Do you recommend transitioning elderly patients from thiazide diuretics to alternative agents when managing hypertension given the increased concern for hyponatremia in this patient population?
In short, no.If hyponatremia from a thiazide occurs, which is rare (~2% among individuals in the intensive treatment arm of SPRINT), it is more likely to be in the first month after thiazide initiation. Hyponatremia occurring in an individual with chronic thiazide use very likely represents the pres...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
How do you balance the benefits and risks for thiazide diuretic use in patients with recurrent nephrolithiasis and hypercalciuria in the setting of Bartter syndrome?
Bartter syndrome is a rare genetic disorder causing excess urinary losses of sodium, potassium, and chloride. Assuming the patient is a calcium stone former, I would be inclined to start potassium citrate first. If the patient continued to show evidence of metabolic activity on follow-up CT scanning...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
Would you pursue renal artery revascularization in a patient with bilateral renal artery stenosis, stable CKD stage 3A, blood pressure well controlled on two medications, and no episodes of acute pulmonary edema but with decreasing kidney size by 1 cm over two years?
If the renal artery stenosis is due to atherosclerotic disease, I would make sure to optimize atherosclerotic risk factors first, which would have systemic benefit. That includes stopping smoking, aggressively lowering lipids with attention to high-density lipoprotein (HDL)/low-density lipoprotein (...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
What is your approach to nephrology referral for patients with lupus nephritis?
The answer to this question "depends" on many factors.I had the luxury of learning under some lupus nephritis greats in the 1990s (John "Jack" Klippel, H Austin, and J Balow... the high-dose NIH CYC regimen guys). Therefore, I am fortunate to feel confident in my abilities to care for LN better than...