Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
At what eGFR would you begin recommending leukoreduced blood products given the potential future need for kidney transplantation in patients with CKD who are not currently listed?
Most states in the US use pre-storage leukoreduction of blood products, done at the time of blood donation. If one is not sure whether the blood is leukoreduced, then a bedside filter can be utilized. Any patient who might be a candidate for transplant in the future and needs a blood transfusion wou...
Do you prefer an isotonic sodium bicarbonate infusion over other isotonic IV fluids when managing those with AKI in the setting of light chain cast nephropathy?
Theoretically, the physiologic rationale for using isotonic sodium bicarbonate over isotonic saline in light chain cast nephropathy is that urine alkalinization reduces the interaction between light chains and Tamm-Horsfall protein and therefore reduces cast formation. However, there are no strong c...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Can contrast instilled through a displaced PEG tube that extravasates into the abdomen cause acute kidney injury?
That's an interesting question. Gastrografin (diatrizoate), used for gastrointestinal (GI) imaging, is poorly absorbed from the GI tract. Nonetheless, low levels of renal excretion of Gastrografin can be seen in some normal individuals and in patients with losses of GI mucosal integrity. Leakage of ...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
Can you safely use a cephalosporin in a patient who previously developed acute interstitial nephritis to amoxicillin?
Amoxicillin-associated interstitial nephritis is most often a type IV hypersensitivity reaction. Cross-reactivity with other beta-lactams is possible but poorly studied. I would try hard to find an alternative.
Would you recommend a diuretic renogram prior to planned unilateral nephrectomy for renal cell carcinoma in a patient with normal kidney sizes bilaterally?
This has not been my practice. As long as there are no imaging findings concerning for obstruction in the kidney that is to remain, I would not see much value in this. Though I’d be interested in the thoughts of others.
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...