Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you offer peritoneal dialysis to a patient with ESKD who also has a ventriculoperitoneal shunt?
I would not place a PD catheter in an adult ESRD patient who has a ventriculoperitoneal shunt (VPS). I would instead place a hemodialysis vascular access and encourage this patient to do home hemodialysis. However, if the patient had exhausted all vascular access sites and was catheter-dependent, I ...
How would you approach the decision to biopsy a kidney transplant recipient who previously experienced a Page kidney following a kidney biopsy?
The decision to perform a renal biopsy should be made after thorough deliberation regarding the appropriate indications and the potential diagnostic information that the procedure may yield to inform patient management. Under suitable conditions, renal biopsy is considered a safe and well-tolerated ...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
Would you avoid potassium citrate initiation in a pregnant patient with hypocitraturia and recurrent calcium oxalate nephrolithiasis?
Difficult question to answer. There is no clear contraindication; however, if her urine pH is OK, I would likely avoid it. I would make sure she is adequately hydrated and would recommend having fresh squeezed Lemons to help. However, if it appears necessary to use it, I would.
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...
Under what circumstances would you use tenapanor over more frequently prescribed phosphorus binders for managing hyperphosphatemia in CKD patients?
Our current experience has been using tenapanor only as an added medication to oral phosphorus binders when further reduction of serum phosphate is required. We have not used tenapanor as the primary medication to control hyperphosphatemia, but this may change in the future as we learn more about th...
Do you recommend avoiding SGLT2i use for patients with proteinuria from diabetic kidney disease if they have urinary retention requiring catheterization?
I would probably avoid SGLT-2 in such a patient because of the risk of infection. Likely, the risk is not worth the benefit.
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
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...
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...