Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your preferred treatment agent for type 1 von Willebrand patients needing minor procedures if they have a history of severe hyponatremia with DDAVP?
I would avoid DDAVP. I typically individualize hemostatic management based on the procedure- related risk of bleeding and severity of the VWD. For example, for dental extraction, tranexamic acid alone may suffice; however, communication with the proceduralist to use topical agents such as topical th...
Are there instances when you will forgo dialysis catheter placement and instead use an existing AVF/AVG for an ESKD patient who requires CRRT?
Since continuous renal replacement therapy (CRRT) in our institution can run without anyone in the room, we never do CRRT through a fistula or arteriovenous graft (AVG). While the risk of needles coming out is probably low and the acute drop in pressure may (may?) alarm the machine, the potential co...
Would you pursue temporary dialysis catheter placement followed by hemodialysis in a hospitalized patient with ESKD who is not able to undergo urgent fistula repair for a non-functioning fistula and receives gadolinium for a MRI study?
There is no role for hemodialysis following the GAD preparations we use these days.
Would you offer peritoneal dialysis to a patient with ESKD who also has dementia but lives with family who can assist with dialysis treatments?
The key words in this question are "can assist". Change it to "WILL assist" and the answer is an unequivocal "yes". But I would not leave it optional.
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
Would you perform a kidney biopsy to rule out other etiologies before diagnosing Loin Pain Hematuria Syndrome in a patient with persistent microscopic hematuria, left flank pain, no proteinuria, normal renal function, normal cystoscopy, and normal imaging?
Probably not unless something changes.
Is there a role for cinacalcet in the management of PTHrP-mediated hypercalcemia?
Cinacalcet is a calcimimetic, meaning that it mimics calcium and interacts with the calcium sensor in the parathyroid glands, which is a signal to decrease the production of PTH. Cinacalcet will not decrease the production of PTHRP in cancer cells. However, cinacalcet will decrease the production of...
How would you manage suspected MGRS in a patient refusing a kidney biopsy?
To diagnose MGRS, a biopsy is necessary. If a patient has M protein on serum protein electrophoresis (SPEP) but shows no evidence of paraprotein-mediated kidney disease, this indicates MGUS. In contrast, conditions like PGNMID are also paraprotein-mediated but can be caused by a small clone that is ...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
How do you decide when to treat hypocalcemia in hospitalized patients?
When I think about when to treat hypocalcemia in hospitalized patients, I anchor the decision on three things: symptoms, the absolute calcium level, and the trajectory. First, it’s important to confirm true hypocalcemia: either a serum calcium <8 mg/dL or an ionized calcium <1.1 mmol/L, and to consi...