Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you rely on urinalysis testing for microscopic hematuria as a means to assess for a ureteral stone for patients with recurrent nephrolithiasis who report mild potential stone-related pain?
No. I think hematuria is nonspecific as regards ureteral stones. I use imaging, preferably CT, although ultrasound, looking for hydroureter or even KUB, if positive, would suffice.
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
Would you recommend adding a mineralocorticoid receptor antagonist or endothelin receptor antagonist for a patient with bevacizumab-induced proteinuria who is already on an ACEi or ARB?
Unfortunately, we have no data to guide the choice of anti-proteinuric agents in this particular setting. We do have biological plausibility for antagonizing the endothelin pathway, as we know that vascular endothelial growth factor inhibition results in upregulation of endothelin-1, and the resulta...
How do you decide when to stop routine laboratory monitoring in a patient with CKD Stage 5 who has chosen conservative management?
I normally don't as patients often change their mind when they are sick. However, if the patient requests not to monitor labs then I would honor their wishes.
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...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Do you recommend initiating an ACE inhibitor or ARB in a patient with proteinuric CKD Stage 5?
ACE-I’s and ARB’s have been shown to be renal protective, and patients who have stopped these agents do worse than those who continue them. Potassium binders are an excellent option to lower K levels and enable patients to stay on these RAAS inhibitors. I would not take CKD patients off RAAS inhibit...
Would you recommend initiating a SGLT2i for proteinuria secondary to bevacizumab in a patient who has a sub-optimal response to an ACEi or ARB?
We don't have specific data for this scenario, but there is no reason to think that SGLT2i would not have a beneficial role though I agree with Dr. @Dr. First Last that risk/benefit needs to be weighed. At the same time, in this particular scenario, I'd carefully look at the time course of proteinur...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...