Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you transition a patient with recurrent calcium nephrolithiasis and hypercalciuria from chlorthalidone to indapamide if they report sexual dysfunction side effects?
Yes. Indapamide is a thiazide-like diuretic that decreases urinary calcium excretion by increasing renal tubular reabsorption of calcium. In my experience, it is less likely to create sexual dysfunction than a true thiazide diuretic. Stephen B. Erickson, MD
Would you increase the delivered dose to more than 25 ml/kg/hr in a patient on CKRT if a prolonged interruption for a procedure is planned for the day?
Guidelines, all guidelines have to be taken with a grain of salt. The Ronco CVVH trial found 35 ml/kg/hr was the goal, definitively. It was questioned because it was a single center with too many surgical patients. Is that really such a valid criticism? Not to be ignored, his study was pure post-dil...
Do you check a fractional excretion of sodium in nonoliguric patients with AKI?
The FENa is diagnostically less useful in non-oliguric AKI. However, FENa can still be checked, but it has to be interpreted in conjunction with the patient's clinical and other laboratory data.
What is your approach to managing AKI secondary to intravenous acyclovir?
First and foremost, obviously, is to stop the acyclovir and switch to something different if indicated. Second, fluid therapy is important if the patient is still urinating. With oliguria, significant saline administration is not possible due to the risk of fluid overload. Of course, like all causes...
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...
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...
Do you recommend captopril for patients with cystine nephrolithiasis given mixed data on its effectiveness?
No. Newer drugs are superior.
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How would you treat a patient with alcoholic cirrhosis and IgA nephropathy with high risk features including nephrotic range proteinuria, microscopic hematuria, and declining eGFR?
Cirrhosis is a well-known cause of secondary IgA nephropathy. Impaired removal of IgA-containing complexes by the Kupffer cells in the liver is thought to predispose to IgA deposition in the kidney (Amore et al., PMID 8302021). As in primary IgAN, polymeric IgA1 appears to be the dominant IgA isofor...
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...