Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend initiating an ACE inhibitor or ARB in a patient with proteinuric CKD Stage 5?
ACE-I’s and ARB’s have been shown to be renal protective, and patients who have stopped these agents do worse than those who continue them. Potassium binders are an excellent option to lower K levels and enable patients to stay on these RAAS inhibitors. I would not take CKD patients off RAAS inhibit...
Would you recommend initiating a SGLT2i for proteinuria secondary to bevacizumab in a patient who has a sub-optimal response to an ACEi or ARB?
We don't have specific data for this scenario, but there is no reason to think that SGLT2i would not have a beneficial role though I agree with Dr. @Dr. First Last that risk/benefit needs to be weighed. At the same time, in this particular scenario, I'd carefully look at the time course of proteinur...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
Do you temporarily hold diuretics when measuring 24-hour urine calcium levels in the evaluation of primary hyperparathyroidism?
It is mandatory to stop diuretics at least 2 weeks before evaluating a patient for PHPT. One should have a fasting blood sample on the morning of the end of the collection for calcium phosphate and PTH to complement the urine collection. Thiazide-type diuretics raise serum calcium and lower urine ca...
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
How often do you check serum glucose and lipid levels after starting a thiazide diuretic for patients with recurrent calcium based nephrolithiasis?
I think checking serum glucose, electrolytes, and lipids about one month after starting a thiazide is reasonable. If levels are normal, I would revert to annual monitoring. Stephen B. Erickson, MD.
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
How do you advise patients with recurrent nephrolithiasis and polyuria who require more than one 24 hour collection jug and need to adequately mix the specimens prior to aliquoting for mail-off lab analysis?
My understanding of methods for dealing with large volume collections (more than 1 container) is that each container is sampled and tested separately, and the results are combined by the processing laboratory to provide the actual 24-hour totals. While one could envision methods for mixing the conte...
What is your approach to managing patients with recurrent nephrolithiasis and hypercalciuria who develop sun photosensitivity following thiazide diuretic initiation?
Sun avoidance and/or protection are my first thoughts. Failing that, I would recommend more intense dietary modification and look for other metabolic abnormalities amenable to pharmaceutical treatment. Treatment follow-up is critically important, preferably with CT scanning, looking to see if there ...
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...