Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you adjust the hemodialysis bicarbonate bath to match the elevated serum bicarbonate level in ESKD patients with hypercarbia due to COPD?
I do not typically for COPD itself, but I do consider it in circumstances where there is severe resp acidemia with no other options for stabilizing their pH. In a subset of patients on home ventilation/AVAPS, they have little reserve to handle even a little more CO2 retention. I will modulate the di...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
What is your preferred management approach for scleroderma renal crisis in a patient with a history of anaphylaxis to ACE inhibitors?
The important thing is to lower the BP regardless of the how. ACE I were the first medication to show survival benefit in patients with scleroderma renal crisis so they have become the treatment mainstay. Time is kidney so the best treatment is to lower the BP with whatever BP lowering medication yo...
How do you approach selecting a dialysis modality for a patient with advanced CKD who is interested in home therapy but has a history of medication non-adherence and poor attendance at clinic appointments?
Good question. I would like to give them a chance at home dialysis before declaring that they are not candidates but I think it should be evaluated on a case by case basis.
Do you still use the urinary anion gap to estimate renal ammonium excretion in patients with a non-anion gap metabolic acidosis, given its limitations?
Yes, I do, but especially as a teaching tool to help understand the make-up of urine in different clinical scenarios. Of course, a urine NH4+ would make this all so much easier, but I believe that the UAG is usually still of value in the evaluation of a NAGMA. The Achilles heel of it, of course, is ...
Do you temporarily hold ESAs for your patients with kidney disease who have an upcoming surgical procedure with the goal of reducing the risk for DVTs?
I do not routinely recommend this. I think the risk is very small given modern use of ESAs and thromboprophylaxis.
How do you clinically distinguish between pericardial effusion from volume overload versus uremic pericarditis in advanced CKD?
I don't think volume overload by itself can lead to pericardial effusion; rather, there has to be some form of pericardial irritation. I wonder if fluid overload would make the pericardial effusion worse, which is likely the case. Patients on dialysis, if they have pericardial effusion, I would auto...
How would you approach a patient with ESKD on HD who denies a history of abdominal hernias but lifts heavy objects daily as part of work requirements and is desiring to transition to PD?
As a general rule, I instruct patients to lift no more than 15 pounds while they have fluid in the abdomen. Therefore, this patient would need to remain dry during work hours. The ability of a patient such as this to successfully perform PD will depend on his/her muscle mass and residual kidney func...
Would you start allopurinol for a patient with uric acid kidney stones who does not have hyperuricemia or hyperuricosuria?
Definitely not! The main risk factor for uric acid kidney stones is neither hyperuricemia nor hyperuricosuria; it is hyperaciduria. Typically uric acid stone formers have a urine pH below 5.8. Raising urine pH into the mid 6s will not only stop new stone formation and existing stone growth; it will ...