Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
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...
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
How would you counsel a patient with CKD Stage 5 and prediabetes who is concerned about their risk of developing diabetes if they start peritoneal dialysis?
History of diabetes is certainly an important consideration to have when providing dialysis education to patients with advanced CKD. We don't contraindicate any modality, including peritoneal dialysis, when patients have a history of prediabetes or diabetes. However, I will acknowledge that uncontro...
What is your approach to treating IgA nephropathy in patients who also have IgA vasculitis?
In a patient with known IgA Vasculitis [IgAV], IgA dominant pattern of injury in the kidney biopsy reflects IgA Vasculitis with Nephritis [IgAV-N]. Thus, it would not be appropriate to call it IgA nephropathy [IgAN] in IgAV. Though the histological features in IgAN and IgAV-N can be common in the ki...
Do you recommend scheduled potassium phosphate dosing during PIRRT to avoid hypophosphatemia in patients with acute kidney injury requiring renal replacement therapy?
I would only do this once it has been documented that the patient developed hypophosphatemia with PIRRT. If hyperphosphatemic to start, certainly not.
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...