Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to treating hypercalcemia secondary to immobilization?
My first approach is to have the patient become mobile if at all possible, even just increasing mobility in bed by doing leg and arm exercises, which can help, and getting up and walking is preferable if at all possible. Physical therapy is also helpful. I would make sure that the patient is well hy...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
Under what circumstances do you order ambulatory blood pressure monitoring in a patient receiving maintenance hemodialysis?
I have done it when the patient is unable to take their bp meds prior to coming for dialysis, and pre-dialysis BP remains high. Other instances are when there is a large difference between the pre and post-dialysis blood pressure readings.
How would you manage serum sodium monitoring for an asymptomatic outpatient with newly diagnosed SIADH and a serum sodium level of 127 mEq/L, for whom you are initiating treatment with urea?
Based on the current available data, treatment of SIADH with urea is effective with a very low risk of overcorrection. In a meta-analysis of 23 studies involving 537 patients with SIADH, urea increased serum sodium concentration by a mean of 9.6 mmol/L, and the mean increase in serum sodium after 24...
How would you approach de-intensifying antihypertensives in frail older adults with SBP < 130 mmHg who have nephrotic range proteinuria, given the results of the RETREAT-FRAIL trial?
I would withdraw antihypertensive drugs that do not have any significant anti-proteinuric effect: dihydropyridine calcium channel blocker, beta blocker, alpha-1- blocker, hydralazine, and clonidine. Thiazide/loop diuretic may also be withdrawn if it is not needed for control of edema due to the neph...
Do you recommend outpatient dialysis initiation or inpatient admission for dialysis initiation in a CKD Stage 5 patient with stable electrolytes but experiencing nausea and vomiting related to uremia?
For a patient with CKD Stage 5 who has stable electrolytes but is experiencing nausea and vomiting from uremia, the patient can be managed with outpatient dialysis initiation. However, if the patient is at high risk for dialysis disequilibrium syndrome (DDS) due to markedly elevated BUN, I prefer in...
Do you have different 24 hour serum sodium correction targets for patients with severe, moderate, and mild hyponatremia?
It is known that overly rapid correction is significantly more likely to cause osmotic demyelination syndrome (ODS) in patients with more severe hyponatremia, particularly when initial serum sodium is ≤105 mmol/L. Since transcellular water movement is mediated by changes in osmolality across the cel...
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
Would you recommend adjusting the hemodialysis schedule for a TTS dialysis patient who is scheduled for surgery on a Monday?
It depends on the patient. If the patient has no residual renal function, it’s prone to volume overload or hyperkalemia; such a patient would benefit from a dialysis session on Monday before surgery. If the patient is recently initiated on iHD, or has good volume control and electrolytes are fine, y...