Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
In elderly patients with underlying CNS disease, renal dysfunction and prior history of cephalosporin neurotoxicity, I would avoid the use of Cephalosporin therapy if possible. If there are not other alternatives, I would strive to give the lowest possible therapeutic dose of the antibiotic to dimin...
How do you advise a patient with CKD who wants to take an herbal medication that is not known to be nephrotoxic, given that herbal medications are not regulated?
Dr. @Dr. First Last' answer is spot on. We just don't know what these drugs do in CKD. We have been fooled many times in the past, thinking it was safe, and they were not. But not all supplements are the same, and you have to look at the bottle; many are just homeopathic nonsense and can be taken.
How would you approach a patient with class III and V lupus nephritis, already on HCQ, MMF, voclosporin and losartan, but has continued proteinuria not yet attaining complete renal response?
Few things are more complicated than lupus nephritis, and this question is not answered easily. It depends on hematuria, Cr, proteinuria, C3, C4, dsDNA, and systemic symptoms. So, it depends on what I think is causing the incomplete clinical response. If I believe it is the class V lesion, I would g...
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Is there any way to safely treat patients with mCRPC with 177-Lu PSMA who are on hemodialysis?
For the most part, no. Not unless you're a big academic medical center with a robust multidisciplinary team willing to tackle the significant logistical challenges associated with this scenario.I'm aware of no literature in this scenario specifically for Pluvicto, but we can look at the radiopharmac...
Would you recommend adding a daytime dwell over an additional nighttime exchange to achieve volume and clearance targets for an ESKD patient who recently stopped making urine and has been receiving only nighttime automated peritoneal dialysis?
Regardless of fluid removal needs, once a patient on automated peritoneal dialysis (APD) has lost their residual kidney function, they should have a long dwell added to their PD regimen sometime during the day in order to facilitate peritoneal clearance of phosphorus and middle molecules.The native ...
Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?
In short, no. I think the recent studies tell me two things: We need to better discriminate correction rates based on the risk of osmotic demyelination (ODS). Perhaps, do not worry so much about over-correction. They do not tell me to start rapidly correcting patients, and I guess I will summarize m...
How do you utilize Cystatin-C as a marker of renal dysfunction in patients with chronic liver disease?
Liver disease is definitely one of those circumstances that results in lower creatinine production. As such, cystatin-C is likely a better marker than creatinine for renal function in those patients, even more than usual.
What approaches do you take to prevent worsening kidney function for patients with chronic kidney disease who have an upcoming outpatient CT scan with iodinated contrast?
If CT is really necessary, if not very high risk just encourage moderate oral hydration before and after. May hold diuretics if this can be done safely. If very high risk try to get IV saline for a few hours prior.