Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
Yes, tolvaptan at 7.5 mg per day can be effective in treating SIADH with a decreased rate of overcorrection. Hanna et al., PMID 32734225
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...
Do you initiate peritoneal dialysis with an incremental strategy to ease patients into their treatment, even though it might lead to frequent lab monitoring and the risk of underdialysis?
The benefits of incremental peritoneal dialysis, in patients who have residual kidney function, cannot be overstated. In addition to "easing into treatment" as suggested in this question, other benefits include: reduced exposure to dialysate and glucose in dialysate, potentially preserving the perit...
Do you recommend cholestyramine for your patients with recurrent nephrolithiasis secondary to enteric hyperoxaluria?
Although it is reasonable to use it, my experience has been mixed. Sometimes, I have found a reliable fall in urine oxalate; other times, no. I have not published any research on this topic, but have reviewed the literature and in it find more or less the same as in my practice. So I can see no reas...
What is your approach to patients with recurrent nephrolithiasis and low urine volumes who struggle with increasing fluid intake following a sleeve gastrectomy procedure?
This is a difficult situation for both the patient and the provider. I think the best solution is for them to drink small quantities of fluid frequently. This creates a compliance problem. I encourage patients to have fluid regularly available, meaning that they may have to take it with them to work...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
How many days after an AVF clots do you determine that attempting a declot procedure is no longer worthwhile?
Fistulas behave differently than grafts. As time goes by, the clot organizes and makes it difficult to pass the wire across the clot in the fistula. The volume of the clot tends to be large in the fistula as well. For these reasons, fistulas need to be declotted asap. I would say that the chance of ...
What clinical criteria do you use to decide between antivirals, rituximab, plasmapheresis, or a combination therapy for treating hepatitis C virus-associated cryoglobulinemic membranoproliferative glomerulonephritis?
Direct-acting antiviral agents would help eradicate the HCV clone and often the HCV-infected B lymphocytes that produce the polyclonal IgM (III cryo) or monoclonal IgM (II cryo) against IgG. Sometimes, despite HCV clearance, B-cell clones persist, leading to cryoglobulinemic vasculitis and MPGN; in ...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.