Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
Do you use SGLT2 inhibitors in the management of SIADH?
The osmotic diuresis induced by SGLT2 inhibitors results in the urinary excretion of water in excess of Na+ and K+ excretion, thereby resulting in an increase in the serum sodium concentration. However, SIADH is a clinical disorder characterized by an increase in TBW in the setting of relatively nor...
Do you avoid low-dose radiation CT stone scans in obese patients with recurrent nephrolithiasis given concerns for inadequate stone detection?
Given about 55% sensitivity of US, I am fine with the reduced sensitivity of low dose CT in obese patients. It is better than the alternative. I do not know off hand if trials have estimated the loss of counting accuracy in the obese, and I suspect it will depend a lot on details of patient selectio...
Do you recommend checking urine sodium 2 hours after loop diuretic administration to determine the need for dose adjustment in a patient with acute decompensated heart failure?
I know that is maybe a more physiologic way, but I can tell if it is working just by the urine output. The urine output is not going to increase following a loop diuretic without a natriuresis. And what good id an increased urine Na if the volume of urine is insufficient? If I am diuresing in decom...
Would you start an SGLT2 inhibitor in patients with diabetic kidney disease who also have a history of prior toe amputation?
I would. I think the risk with SGLT2 and vascular disease is very low. Thus, I would give them if there are no other contraindications.
Do you initiate peritoneal dialysis with an incremental strategy to ease patients into their treatment, even though it might lead to frequent lab monitoring and the risk of underdialysis?
The benefits of incremental peritoneal dialysis, in patients who have residual kidney function, cannot be overstated. In addition to "easing into treatment" as suggested in this question, other benefits include: reduced exposure to dialysate and glucose in dialysate, potentially preserving the perit...
Do you recommend cholestyramine for your patients with recurrent nephrolithiasis secondary to enteric hyperoxaluria?
Although it is reasonable to use it, my experience has been mixed. Sometimes, I have found a reliable fall in urine oxalate; other times, no. I have not published any research on this topic, but have reviewed the literature and in it find more or less the same as in my practice. So I can see no reas...
What is your approach to patients with recurrent nephrolithiasis and low urine volumes who struggle with increasing fluid intake following a sleeve gastrectomy procedure?
This is a difficult situation for both the patient and the provider. I think the best solution is for them to drink small quantities of fluid frequently. This creates a compliance problem. I encourage patients to have fluid regularly available, meaning that they may have to take it with them to work...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
How many days after an AVF clots do you determine that attempting a declot procedure is no longer worthwhile?
Fistulas behave differently than grafts. As time goes by, the clot organizes and makes it difficult to pass the wire across the clot in the fistula. The volume of the clot tends to be large in the fistula as well. For these reasons, fistulas need to be declotted asap. I would say that the chance of ...