Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to managing patients with recurrent nephrolithiasis who have 24 hour urine chemistry results that demonstrate low risk for stone formation but continue to experience stone events?
My first question is what constitutes a "kidney stone event"? If it is a stone passage, l know of no treatment that will "glue" pre-existing stones in place. Uric acid and cystine stones can be dissolved, however. If the event is the formation of new stones or the growth of preexisting stones with n...
Is there benefit to performing CVVH instead of intermittent hemodialysis for a patient with AKI secondary to rhabdomyolysis who requires renal replacement therapy?
My CRRT threshold is low, but a patient with AKI and rhabdo will have continuous K and Phos release from dead cells so I prefer a continuous therapy. This depends on the degree of rhabdo and the degree of AKI, but would lean towards CRRT for a moderate to bad rhabdo, same for TLS and same with acute...
In which patients with nephrocalcinosis and an incomplete distal RTA would you consider further testing for medullary sponge kidney?
Yes, definitely. The better question is how to test. Since sponge kidney is an anatomical disorder of dilated collecting ducts in the renal papillae, it's best to look anatomically. These are 3-dimensional structures and are best seen with a 3-dimensional image. We no longer have intravenous pyelogr...
Would you recommend switching a diabetic CKD patient on oral semaglutide to the subcutaneous form since the benefits in CKD have primarily been reported in studies using subcutaneous GLP-1 receptor agonists?
Personally, I would not do so today. Obviously, the patient was prescribed oral semaglutide (SEMA) as opposed to injected SEMA for some reason. Assuming that the reason persists (e.g., preference for oral, greater availability) and the response with respect to A1c and weight has been reasonable, I w...
Do you intensify the dialysis prescription for patients with end stage kidney disease who develop uremic pericarditis despite regular dialysis sessions?
This was what we did 30 years ago, it did not work. I remember as a fellow there were two explanations for pericarditis in a renal patient, uremic pericarditis if they had not started RRT and something else ("viral etc) if they were on RRT. This was based on the assumption that RRT was good enough t...
In which patients with suspected IgA nephropathy and microalbuminuria would you recommend a kidney biopsy?
There are no guidelines to answer this question. This is my approach. In proteinuric patients, with intact kidney function, threshold proteinuria (UPCR) of 0.5 g/g, or UACR <300 mg/g would be an indication to biopsy. In diseases such as IgA Nephropathy, treatment is driven by the degree of proteinur...
What are the important aspects that you mention when consenting patients for hemodialysis?
I will answer this question a little differently than I think was the intent of the person asking the question. I find that many patients are resistant to starting dialysis at first. In my first conversation with them, I will make it clear to them that the problem is the kidney failure and not the d...