Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
Do you recommend patients temporarily hold cilostazol prior to and after a kidney biopsy?
Kidney biopsy is considered a high-risk bleeding procedure by SIR (Society of Interventional Radiology).Cilostazol is a PDE inhibitor leading to the inhibition of platelet aggregation. The Drug has a half-life of 10 hours. In the past, it was recommended to stop the drug at least 24 hours before a p...
Would you recommend immediately exchanging a peritoneal dialysis catheter, or waiting until the completion of antibiotics with transition to HD, if a PD patient presents with peritonitis and a nonfunctional PD catheter?
Optimally, peritonitis should be completely resolved before placing a new (and hence sterile) foreign body into the peritoneum. That said, all attempts to restore PD catheter function without invasive measures (non-surgical) should be attempted first. If the PD catheter can be restored with minimall...
Do you apply manual pressure around the kidney biopsy site immediately post-procedure and prior to supine positioning to help prevent perinephric bleeding?
Yes, I do apply 3-4 minutes of manual pressure immediately at the site of a kidney biopsy while the patient is prone or supine if doing a transplant biopsy. I also apply a pressure dressing and have the patient lie down on it for 2 hours (for native kidney biopsies). This helps in a thin person.
How much proteinuria would warrant consideration of native kidney nephrectomies at the time of a kidney transplant?
We don't typically consider native nephrectomies unless the proteinuria is > 5-6 grams. We rarely end up doing native nephrectomies, though. The main problem, besides the complications associated with heavy proteinuria, is the inability to assess for recurrent disease post-transplant. This can be pa...
Do you recommend first consulting interventional radiology or vascular surgery if you lack access to interventional nephrology in a patient with ESKD who is suspected of having a clotted fistula and is unable to receive hemodialysis?
Yes. Not all institutions have access to Interventional Nephrology. Anyone with the required skill, expertise, and availability would need to be consulted urgently to manage the clotted AV access - especially if it is indeed a fistula (as opposed to a graft). The longer the fistula remains clotted, ...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Would you recommend avoiding intravesical (bladder) tobramycin administration in a patient with advanced chronic kidney disease?
Guess fear is absorption, build up, and toxicity. A single loading dose of an aminoglycoside is not to toxic level. Maintaining the level of risks ototoxicity, build up also nephrotoxicity. Would depend on absorption and residual GFR. Try a single loading dose, check levels after 12 or 24 hours to g...
Do you recommend prophylactically adding heparin to the dialysate in patients hospitalized for peritoneal dialysis associated peritonitis given higher incidence of fibrin-associated catheter issues?
We do not prophylactically add heparin to dialysate in patients with peritonitis. We have that as a "prn" order, if necessary, but the frequency with which it is needed is low, no more than 10% of the time. As each addition to a dialysate bag is associated with a small possibility of introducing inf...
When would you consider using amiloride over spironolactone for treatment-resistant hypertension (not reaching goal BP on 3 agents, including a diuretic)?
In male patients, because of the high incidence of gynecomastia...