Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you approach managing a patient with ESKD on peritoneal dialysis who has a milky appearance of peritoneal effluent but low peritoneal fluid triglyceride levels?
The key word here is "low" triglyceride (TG) levels. Peritoneal dialysis fluid should ordinarily be devoid of TGs with virtually undetectable levels, < 10 mg/dL. In a case I reported many years ago (Rocklin et al., PMID 10978409), SVC syndrome presented as cloudy dialysate with a TG level just 25 mg...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What criteria do you use to determine if a patient with chronic asymptomatic hyponatremia is safe to proceed with surgery?
A patient with chronic hyponatremia is generally considered safe to proceed with surgery when the serum sodium level is ≥ 125 mmol/L (preferably ≥ 130 mmol/L) if the level is stable and truly chronic and the patient is clinically asymptomatic. In addition, the surgical team should be advised on the ...
What drives you to choose voclospsorin over tacrolimus given the substantially higher cost?
In a discussion of comparing voclosporin versus tacrolimus to treat LN, I would first like to address the issue of cost. As far as any individual patient, out-of-pocket expenses may be similar for these two calcineurin inhibitors since it is often covered by insurance. Additionally, Aurinia has a ve...
Do you ever combine voclosporin and belimumab in the treatment of lupus nephritis?
The combination of these two therapies has not yet been formally tested. Having said that, the combination has an appealing rationale. Immunologically, modulating T cells and B cells in LN seems likely to be efficacious. Beyond the immunology, there are other reasons that favor this combination. Voc...
Do you check carnitine levels for your patients on CRRT?
Our institution doesn’t routinely check Carnitine levels. A few years ago, we did use Carnitor supplements, but in the lack of any major clinical benefit, the practice has since been abandoned, besides many clinical nutrition formulas have carnitine.
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
Can a dihydropyridine calcium channel blocker (CCB) like amlodipine be prescribed in addition to a non-dihydropyridine CCB such as diltiazem or verapamil for treating hypertension?
Yes, with extreme caution. Diltiazem and Verapamil are CYP450 inhibitors, which can interfere with the metabolism of many medications (commonly statins and calcineurin inhibitors), but also can increase levels of nifedipine and presumably other dihydropyridine CCBs, like amlodipine. Diltiazem or ver...