Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...
How do you approach deprescribing or continuing statin therapy in older adults with end-stage kidney disease who are initiating dialysis?
My practice in older adults starting dialysis is no different from that of younger patients starting dialysis. If the patient is on a statin, I do not discontinue it. If the patient is not on a statin, I do not start it when they begin dialysis, as there is no strong evidence that it reduces cardiac...
How do you manage Fanconi’s syndrome and polyuria related to ifosfamide?
Treatment of ifosfamide-induced Fanconi syndrome and polyuria is primarily supportive. First, the benefits and risks of discontinuation of ifosfamide should be discussed with the oncologist. Treatment of Fanconi syndrome is aimed at repletion of potassium, bicarbonate, and phosphate. Calcitriol is a...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Would you start potassium citrate in a patient with recurrent nephrolithiasis with only minimal uric acid composition who persistently has acidic urine on 24 hour urine stone risk studies?
In treating stone disease of mixed composition, I pay more attention to the primary component. However, if the primary component is calcium oxalate, which is often the case, I would strongly consider using potassium citrate, as it will alkalinize urine and discourage uric acid nephrolithiasis as wel...
What approaches do you take to avoid further eGFR decline in patients undergoing unilateral nephrectomy for renal cell carcinoma?
The most important/effective intervention by far is good blood pressure control. Secondarily, if there is proteinuria, one should consider ACE/ARB, SGLT-2, etc. The optimal blood pressure target can be uncertain, but I would advocate for a systolic pressure of less than 130 mmHg.
Do you recommend holding metformin in a patient with chronic kidney disease who has an upcoming CT contrast study?
I actually do. Over the years I have seen a number of cases of metformin induced lactic acidosis. Although it is very hard to predict who will have it. I would like to be on the safe side.