Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
How do you approach checking an aldosterone to renin ratio in an outpatient with hypertension and hypokalemia that is difficult to correct with oral potassium replacement?
It is well known that hypokalemia can affect the aldosterone-renin ratio (ARR). Since hypokalemia directly inhibits aldosterone production, this can lead to false negative results when using ARR to screen for primary aldosteronism. If it is difficult to correct hypokalemia with oral potassium repla...
Is there a role for early GLP-1 therapy for weight loss in patients with early-stage ADPKD and obesity, given the association between obesity and the risk of progression to ESKD?
Indeed, maintaining a healthy BMI is an important evidence-based guideline in ADPKD, but no data exist for early GLP-1 therapy and early-stage ADPKD at this time. Weight loss has not yet been shown to be protective of eGFR in ADPKD, although of course, conceptually, we believe that to be true. That ...
In a hospitalized patient who undergoes a MRI with gadolinium contrast study, would you perform hemodialysis if they have AKI with prior dialysis requirements but do not currently otherwise meet criteria for dialysis?
I would not. Although gadolinium contrast has been associated with nephrogenic systemic fibrosis in patients with advanced CKD or AKI, the risk is much lower for the newer generation contrast agents with more tightly chelated Gd. That said, the risk is not zero, as reviewed in a recent CJASN perspec...
Can contrast instilled through a displaced PEG tube that extravasates into the abdomen cause acute kidney injury?
That's an interesting question. Gastrografin (diatrizoate), used for gastrointestinal (GI) imaging, is poorly absorbed from the GI tract. Nonetheless, low levels of renal excretion of Gastrografin can be seen in some normal individuals and in patients with losses of GI mucosal integrity. Leakage of ...
What is your approach to managing hyperkalemia secondary to respiratory acidosis?
Since hyperkalemia in respiratory acidosis is due to transcellular shift, therapy should be directed at treating the underlying respiratory acidosis. Correction of the hypercarbia should lead to resolution of the hyperkalemia. In severe hyperkalemia due to respiratory acidosis that is not easily rev...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
What criteria do you use to determine if a patient with chronic asymptomatic hyponatremia is safe to proceed with surgery?
A patient with chronic hyponatremia is generally considered safe to proceed with surgery when the serum sodium level is ≥ 125 mmol/L (preferably ≥ 130 mmol/L) if the level is stable and truly chronic and the patient is clinically asymptomatic. In addition, the surgical team should be advised on the ...
What is your approach to differentiating Randall plaques from actual small non-obstructing stones when reviewing imaging testing for your patients with recurrent nephrolithiasis?
In truth, I almost never can tell with present CT imaging. Once we have a URS with images, it is easier in a given case. Even more misleading is plugging, which can be dense looking on CT and essentially in tissues and not amenable to removal, now requiring surgery. Specialized, very high-resolution...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...