Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend an overall decrease in daily dietary animal protein intake or focus more on decreasing the actual portion size of animal protein per meal in your patients with recurrent calcium based nephrolithiasis who have hypercalciuria?
I find initiating dietary changes is more difficult for my patients than initiating or changing medications. Regarding reducing dietary animal, protein consumption, I try to work with patient preferences. I have no strong preference of my own.Stephen B. Erickson, MD.
Would you recommend starting finerenone for a patient with diabetic kidney disease who has marked improvement from severely increased albuminuria to moderately increased albuminuria following ARB and SGLT2i initiation?
I would certainly discuss with the patient regarding potential benefits as well as risks. This is a joint decision matter, especially if finerenone leads to the need for potassium binders. Make sure first that the ARB dose is maximized with appropriate use of a diuretic.
Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?
I would go with Tenapanor, it is very effective and can generally significantly decrease the binder dosing. The biggest problem with Tenapanor is an increase in stools, not necessarily overt diarrhea. Counsel the patient, have them stop stool softeners and laxatives, and may want to start with 1 pil...
Are there instances when you continue phosphate binders for patients receiving CRRT?
Would be very unusual. First, continuous renal replacement therapy (CRRT) is so effective in lowering serum phosphorus concentration if done with the right dose that it is almost never needed to add a binder. Second, usually, patients on CRRT are no longer eating meals, and thus binders do not make ...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
Would you recommend temporary transition to hemodialysis in a peritoneal dialysis patient who has risk factors, such as recurrent peritonitis, for the development of encapsulating peritoneal sclerosis?
In summary, yes. However, just like anything in medicine, every patient is different, and risk factors specific to the patient have to be weighed against the benefits of continuing PD.
What is your approach for managing patients with recurrent nephrolithiasis who have elevated urinary cystine levels but calcium oxalate stone composition?
This is usually heterozygous cystinuria, and the urine cystine is in the range of 50 mg. Supersaturation with cystine is absent, and the cystine can be ignored. Rarely, urine cystine is high enough to produce stones, and I treat both stone risk factors. In all cases where urine cystine is above 100 ...
What is your approach to managing patients with suspected osmotic nephrosis from monthly IVIG infusions?
If the patient develops IVIG-induced osmotic nephrosis, the current IVIG therapy should be suspended, and treatment of the AKI is supportive. If IVIG needs to be restarted once the patient’s renal function recovers, there are several preventive strategies that can be tried. The patient should be swi...
Would you support a modified chlorthalidone treatment regimen involving a drug holiday of two days per week for patients with recurrent calcium based nephrolithiasis who have less erectile dysfunction side effects when temporarily off of the thiazide diuretic?
I know of no study data to answer the question. The half-life of chlorthalidone is approximately 40–60 hours. Whether the drug would wear off enough during a 24 hour drug holiday to achieve an erection would be the first question to answer. The second is a risk benefit question: an increased risk of...
Are there instances when you offer dialysis to patients with high-risk hepatorenal syndrome who are not transplant candidates?
Yes. I have done that. Prognosis remains poor but dialysis can sometimes give patients a few more weeks or even months.