Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to timing of the plasma, arterial, and venous urea collections in a patient on hemodialysis for whom you are attempting to calculate arteriovenous fistula recirculation?
I use the two-needle slow blood flow technique to calculate arteriovenous fistula recirculation: After initiation of hemodialysis, turn off ultrafiltration in approximately 30 minutes and then draw urea samples from the arterial and venous ports of the blood lines. Reduce the access blood flow rate...
What is your approach to interpretation of 24 hour urine stone risk studies that persistently demonstrate elevated urinary creatinine excretion despite a reliable patient who denies improper collection?
I would start with a physical examination, looking at muscle mass. Urine creatinine comes from serum creatinine, which in turn comes from muscle mass. Patients with high muscle mass will have high serum and urine creatinine.
Would you add regional citrate anticoagulation to a CRRT prescription for a patient on systemic heparin but who experiences recurrent filter clotting?
Depending on the need for CRRT vs PIRRT, if I could, I would go with PIRRT first depending on when the clotting occurs in the treatment. Our typical PIRRT treatment is 40 liters over 8 hours, and we can do that daily if needed (often at night), and it totally controls the chemistries and usually vol...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
I would try external catheters before internal catheters for this. I would do these only in very select individuals who, despite empiric therapy, continue to have stones and have controlled for infections and other precipitating factors. 24-hour urines are helpful but not very precise and can be ver...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How long do you observe for spontaneous remission after NSAID discontinuation before initiating corticosteroids in a patient with biopsy-confirmed minimal change disease?
The role of steroid treatment in drug-induced acute interstitial nephritis (DI-AIN), including those with MCD, is controversial. There are no large randomized controlled trials, so whether steroids are beneficial or not, and when to give them, is unclear. There have been a number of retrospective st...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...
Is it safe to use acarbose in patients with advanced chronic kidney disease?
Yes, I think so.
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...
How do you approach vitamin D supplementation in patients with chronic kidney disease, given the findings that vitamin D2 supplementation may lead to decreased conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3?
In early 2000, there was a publication suggesting that ingesting vitamin D2 increases the destruction of vitamin D3 and therefore could increase the risk for vitamin D deficiency. Although I had never seen this happen in my clinic, we decided to conduct a study to evaluate what the effect of vitamin...