Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
How do you counsel patients on peritoneal dialysis regarding the safety of engaging in aerobic and resistance exercises, considering the risk of developing abdominal wall complications?
The effect of exercise on intra-abdominal pressure (IAP) while on PD was examined decades ago by Twardowski et al., PMID 3774076. They found that walking, jogging, or using an exercycle resulted in only modest increases in IAP, while jumping or straining (e.g. weight- lifting) resulted in more marke...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
I think there are a few problems or nuances involved in answering this broad question:First, other practitioners may use other IV cephalosporins, but we only use cefazolin, ceftriaxone, cefepime, and ceftazidime (as part of Avycaz).Second, the calculated CrCl often poorly correlates with the patient...
In hospitalized patients with ESKD who develop mechanical hemolysis from high-velocity dialysis, what is your approach to balancing lower ultrafiltration rates to mitigate hemolysis while also optimizing inpatient length of stay and volume management?
To compensate for the lower ultrafiltration rate, I would prolong the dialysis session time. For example, the standard 3-4 hour inpatient dialysis sessions can be extended to 5-6 hours. This lowers the hourly ultrafiltration rate while achieving the same total fluid loss per treatment. I would also ...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
How often do you check fibrinogen levels and when do you administer FFP for patients with AKI requiring plasma exchange?
There is no single universal protocol for monitoring fibrinogen and giving FFP during TPE; the best approach really depends on the patient's bleeding risk. Because fibrinogen recovers slowly, daily albumin-only TPE can drop levels significantly, which has led to the traditional practice of checking ...
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
How long would you wait before performing a kidney biopsy in a patient with nephrotic range proteinuria, a negative PLA2R antibody, a negative anti-THSD7A antibody, and stable renal function who recently started treatment a week ago with a DOAC for a pulmonary embolism?
Since the renal function is stable, and holding the DOAC carries significant risk, I would wait at least 3 months, and if the kidney function is still stable then, possible 6 months before the kidney biopsy.