Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
Would you perform a kidney biopsy to rule out other etiologies before diagnosing Loin Pain Hematuria Syndrome in a patient with persistent microscopic hematuria, left flank pain, no proteinuria, normal renal function, normal cystoscopy, and normal imaging?
Probably not unless something changes.
Is there a role for cinacalcet in the management of PTHrP-mediated hypercalcemia?
Cinacalcet is a calcimimetic, meaning that it mimics calcium and interacts with the calcium sensor in the parathyroid glands, which is a signal to decrease the production of PTH. Cinacalcet will not decrease the production of PTHRP in cancer cells. However, cinacalcet will decrease the production of...
How would you manage suspected MGRS in a patient refusing a kidney biopsy?
To diagnose MGRS, a biopsy is necessary. If a patient has M protein on serum protein electrophoresis (SPEP) but shows no evidence of paraprotein-mediated kidney disease, this indicates MGUS. In contrast, conditions like PGNMID are also paraprotein-mediated but can be caused by a small clone that is ...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
How do you approach checking an aldosterone to renin ratio in an outpatient with hypertension and hypokalemia that is difficult to correct with oral potassium replacement?
It is well known that hypokalemia can affect the aldosterone-renin ratio (ARR). Since hypokalemia directly inhibits aldosterone production, this can lead to false negative results when using ARR to screen for primary aldosteronism. If it is difficult to correct hypokalemia with oral potassium repla...
Is there a role for early GLP-1 therapy for weight loss in patients with early-stage ADPKD and obesity, given the association between obesity and the risk of progression to ESKD?
Indeed, maintaining a healthy BMI is an important evidence-based guideline in ADPKD, but no data exist for early GLP-1 therapy and early-stage ADPKD at this time. Weight loss has not yet been shown to be protective of eGFR in ADPKD, although of course, conceptually, we believe that to be true. That ...
In a hospitalized patient who undergoes a MRI with gadolinium contrast study, would you perform hemodialysis if they have AKI with prior dialysis requirements but do not currently otherwise meet criteria for dialysis?
I would not. Although gadolinium contrast has been associated with nephrogenic systemic fibrosis in patients with advanced CKD or AKI, the risk is much lower for the newer generation contrast agents with more tightly chelated Gd. That said, the risk is not zero, as reviewed in a recent CJASN perspec...
Can contrast instilled through a displaced PEG tube that extravasates into the abdomen cause acute kidney injury?
That's an interesting question. Gastrografin (diatrizoate), used for gastrointestinal (GI) imaging, is poorly absorbed from the GI tract. Nonetheless, low levels of renal excretion of Gastrografin can be seen in some normal individuals and in patients with losses of GI mucosal integrity. Leakage of ...