Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
How do you determine whether medical or surgical intervention is more appropriate for managing abdominal discomfort due to hepatic cysts in patients with ADPKD?
Management depends on the severity of symptoms, liver morphology, and the degree to which symptoms impair quality of life. Initial treatment is generally conservative, with attention to excluding other causes of abdominal pain and optimizing symptom management. In patients with symptomatic polycysti...
Do you pursue genetic testing in a patient with unexplained CKD whose kidney biopsy shows nonspecific tubulointerstitial nephritis without an identifiable toxic, inflammatory, or systemic cause?
Yes. I have seen some interesting diagnoses such as ADTKD. Genetic testing is simple, non-invasive, and relatively inexpensive. I am all for doing more of it.
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I try to review all data related to stone formation in new patients, including 24 hour urine data, stone analysis and imaging studies for stone burden (past and present). If a patient has prior 24 hour urine data, they likely had prior advice on stone prevention, which is relevant to understanding t...
What is the optimal number of days to hold apixaban prior to a kidney biopsy or tunneled dialysis catheter placement?
If the patient has normal or mild renal impairment (≥30 mL/min), I will hold apixaban for 2 days prior to the procedure. If the patient has moderate to severe renal impairment (<30 mL/min), I will hold apixaban for 3 to 4 days prior to the procedure.
Are there instances when you will forgo dialysis catheter placement and instead use an existing AVF/AVG for an ESKD patient who requires CRRT?
Since continuous renal replacement therapy (CRRT) in our institution can run without anyone in the room, we never do CRRT through a fistula or arteriovenous graft (AVG). While the risk of needles coming out is probably low and the acute drop in pressure may (may?) alarm the machine, the potential co...
Do you stop hemodialysis and monitor the patient in clinic, or taper dialysis frequency first, when urine output and lab markers suggest kidney recovery in a hemodynamically stable outpatient with dialysis-requiring AKI?
The absence of interdialytic weight gain is generally the first sign of recovery from acute kidney injury (AKI). However, one thing to avoid getting burned on is the patient with severe heart failure who was previously on high-dose diuretics that were stopped when dialysis began. They may have signi...
How do you manage a patient on peritoneal dialysis who develops a single episode of cloudy effluent with a low cell count and no organisms on Gram stain while remaining clinically well?
There is a relatively broad differential diagnosis for patients presenting with cloudy dialysis fluid that appears to be non-infectious in nature (Rocklin & Teitelbaum, PMID 11208038). While the differential for fluid that is totally acellular is relatively narrow - fibrin or triglycerides are the u...
What is your approach to the use of erythropoiesis-stimulating agents in pregnant patients with anemia and advanced chronic kidney disease?
Anemia in pregnancy with advanced CKD is multifactorial - partly dilutional due to increased intravascular volume, partly due to low erythropoietin levels from CKD, and potentially iron deficiency, depending on dietary intake. Hg levels < 7 g are associated with increased maternal and fetal morbidit...
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...