Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
At what serum sodium level do you stop desmopressin when using a clamp strategy to prevent overcorrection in hyponatremia?
There is no universally accepted serum sodium threshold above which DDAVP should be stopped. If there is a concern for over-rapid correction of the serum sodium level by more than 8 mmol/L in 24 hours, then DDAVP should be continued. Therefore, urinary output and urine osmolality should be monitored...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Would you offer peritoneal dialysis to a patient with ESKD who also has a ventriculoperitoneal shunt?
I would not place a PD catheter in an adult ESRD patient who has a ventriculoperitoneal shunt (VPS). I would instead place a hemodialysis vascular access and encourage this patient to do home hemodialysis. However, if the patient had exhausted all vascular access sites and was catheter-dependent, I ...
What is your preferred hemodialysis regimen for patients with acute lithium toxicity?
Assuming that renal function is normal or new normal, I would dialyze them in the most rapid way possible, high blood flow, a large dialyzer, and a longer time. Repeat lithium levels and repeat dialysis if levels remain elevated is crucial.
Do you prefer liquid calcium carbonate over other calcium carbonate formulations for patients with recurrent calcium oxalate nephrolithiasis who have persistent hyperoxaluria on 24 hour urine studies?
I would not differentiate between the use of a liquid or tablet form of calcium carbonate based on urine oxalate measurements. The only reason to choose between these two forms would be patient preference or some usual physical limitation with taking the tablet form. Much more commonly, I encounter ...
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
Is there a time frame in which you would no longer consider a prior vein mapping study reliable and thus recommend repeating the test in a patient with advanced chronic kidney disease who requires evaluation for fistula placement?
As a standard, typically 6 months is the longest I’d consider utilizing a vein mapping; however, the caveat here is to repeat after any hospitalization or known line placements/extensive blood draws. Vein mapping is very low risk and relatively easy to repeat vs the risk of a failure to mature fistu...
Would you initiate a SGLT2 inhibitor for a patient on chronic lithium with the goal of preserving kidney function?
I would not be inclined to go to an SGLT-2 inhibitor in this situation. The nephrotoxicity of lithium is tubulointerstitial, not glomerular, primarily. I would not expect an SGLT-2 inhibitor to be nephroprotective and may have other adverse effects, given the other kidney effects of lithium. I do no...