Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to outpatient antihypertensive therapy after ICH for secondary prevention?
My approach to secondary prevention of ICH depends on the cause.With hypertensive ICH for secondary prevention, the blood pressure goal is less than 130/80 (This is from using the results of the SPS III trial, given the pathological disease mechanisms for both ischemic and hypertensive hemorrhages a...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
What is your approach to an elevated alkaline phosphatase level in an ESKD patient with normal PTH, phosphorus, and calcium levels?
High serum alkaline phosphatase (AlkPhos) is a stronger and more consistent predictor of adverse outcomes, including high mortality, in patients receiving dialysis than parathyroid hormone (PTH) or serum mineral parameters (Ca, Phos). Yet, AlkPhos is rarely emphasized during routine monthly laborato...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How do you evaluate exercise induced hematuria that persists after one week of cessation of exercise?
Exercise-induced hematuria typically resolves within a week. If the hematuria persists after one week of cessation of exercise, further work-up of the hematuria is warranted. First, hematuria should be confirmed by excluding myoglobinuria and march hemoglobinuria. If hematuria is confirmed, then one...
Is there an eGFR or urine output rate for which you would no longer recommend pre- and post-hydration for a patient with AKI who requires liposomal amphotericin B?
I'm not aware of any data to guide recommendations on this. Since it is a simple measure, I err on the side of caution and (barring overt volume overload) recommend hydration in any patient with AKI receiving ampho B, regardless of eGFR and urine output.
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Are there instances when you use diuretics for non-oliguric patients with volume overload in the setting of hepatorenal syndrome who have normal MAPs?
Absolutely. First, since most patients with HRS are oliguric and have low MAPs, I would look for alternative explanations for renal insufficiency. But, yes, if someone like this is volume overloaded, then I do use diuretics, often in conjunction with large volume paracentesis, to manage the volume o...