Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
When do you refer for peritoneal dialysis catheter placement in a patient with advanced chronic kidney disease who does not currently have dialysis needs but does have a progressive decline in eGFR?
The question, of course, is whether to place the catheter early, when the patient does not yet require dialysis and then need to provide catheter care (e.g., weekly flushes), or to delay catheter placement and risk needing to start urgently, or, much worse, risk placement of a tunneled dialysis cath...
Would you recommend delaying a 24 hour urine stone risk study until a patient is off of antibiotics if they are on a short course for an upper respiratory infection but are experiencing no medication side effects?
If the patient is eating and drinking as usual, I would have no reservation collecting a 24-hour urine supersaturation study during the illness. I am not aware that antibiotics would affect the volume or mineral content of the specimen.Stephen B Erickson, MD
When transitioning a patient with recurrent calcium based nephrolithiasis from one thiazide diuretic to another, do you typically recommend a washout period?
Yes. But since the half-lives of thiazide diuretics differ dramatically, from 1.5 to 2 hours for chlorothiazide to 40 to 60 hours for chlorthalidone, the washout period should be tailored to the specific drugs in question. Checking an electrolyte panel during the transition seems very appropriate to...
Do you favor peritoneal dialysis over hemodialysis in patients with an LVAD who have ESKD?
Yes, I prefer peritoneal dialysis (PD) over hemodialysis (HD) in suitable patients with a left ventricular assist device (LVAD) due to its hemodynamic stability. PD provides slow, continuous ultrafiltration over 24 hours rather than the rapid, intermittent fluid shifts seen with ultrafiltration in a...
Do you prefer to have your patients with recurrent nephrolithiasis who have completed a 24 hour urine stone risk study drop off the entire collection to the respective lab for processing or personally mix and aliquot a representative sample prior to submitting to the lab for processing?
We prefer to get the entire 24-hour urine sample to avoid measurement errors.
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 proactively convert stable kidney transplant recipients from twice-daily immediate release tacrolimus to once-daily extended release tacrolimus to improve long-term adherence?
Yes, we convert to once-daily tacrolimus whenever possible. If we cannot get insurance approval, we work with our pharmacy and the company to try to get the medication for the patient. We expect improved adherence and fewer side effects (due to lack of peak level) for our patients.
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I do but the issue is complex. Interpreted in context - life events, surgeries, meds etc - they tell me the range of behaviors for a patient in chemistry terms. But it takes a lot of time, and is not a good idea unless you are prepared to take that time.