Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
Do you prefer starting potassium chloride or amiloride for those with recurrent calcium based nephrolithiasis and hypercalciuria who do not have hypocitraturia but develop hypokalemia following thiazide diuretic initiation?
I prefer going with Potassium citrate.
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...
Would you start potassium citrate for a patient with recurrent calcium oxalate nephrolithiasis who has normal urinary citrate levels but persistent acidic urine?
An excellent, fundamental question!Before starting medical treatment, I want to know if the patient’s stone burden is increasing in volume. That requires, in my opinion, serial CT scans, typically annually.If the stone burden is increasing in volume, it’s time for metabolic (non-surgical) treatment....
What is your approach to an elevated alkaline phosphatase level in an ESKD patient with normal PTH, phosphorus, and calcium levels?
I find that the PTH and alkaline phosphatase levels correlate pretty well in ESRD. Normal PTH for ESRD patients is 150-600 or higher, which is significantly higher than in the general population. I would be hesitant to attribute an elevated alkaline phosphatase level to anything other than bone dise...
In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?
Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate w...
Would you transition a patient with recurrent calcium nephrolithiasis and hypercalciuria from chlorthalidone to indapamide if they report sexual dysfunction side effects?
Yes. Indapamide is a thiazide-like diuretic that decreases urinary calcium excretion by increasing renal tubular reabsorption of calcium. In my experience, it is less likely to create sexual dysfunction than a true thiazide diuretic. Stephen B. Erickson, MD
Would you increase the delivered dose to more than 25 ml/kg/hr in a patient on CKRT if a prolonged interruption for a procedure is planned for the day?
Guidelines, all guidelines have to be taken with a grain of salt. The Ronco CVVH trial found 35 ml/kg/hr was the goal, definitively. It was questioned because it was a single center with too many surgical patients. Is that really such a valid criticism? Not to be ignored, his study was pure post-dil...
Do you check a fractional excretion of sodium in nonoliguric patients with AKI?
The FENa is diagnostically less useful in non-oliguric AKI. However, FENa can still be checked, but it has to be interpreted in conjunction with the patient's clinical and other laboratory data.
What is your approach to managing AKI secondary to intravenous acyclovir?
First and foremost, obviously, is to stop the acyclovir and switch to something different if indicated. Second, fluid therapy is important if the patient is still urinating. With oliguria, significant saline administration is not possible due to the risk of fluid overload. Of course, like all causes...