Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
When would you pursue a kidney biopsy for patients with inflammatory bowel disease who have non-proteinuric progressive CKD of unknown etiology?
I have done kidney biopsies in patients in this setting. Helpful to know what is going on in the kidneys.
Will you implement the conservative dialysis strategy from the LIBERATE-D trial for patients with dialysis-requiring acute kidney injury, or will you continue dialysis on a schedule until recovery based on creatinine and urine output?
I think I have always dialyzed patients with AKI on an as-needed basis. The question is whether to follow the parameters set by the LIBERATE-D study (bun >112, etc.). I am not yet sure what my practice will look like in the future as far as the parameters. It is likely the case, though, that I would...
Are there circumstances in which you would check a serum copeptin level when evaluating patients for possible SIADH?
I would check a serum copeptin level in a patient suspected of having nephrogenic syndrome of inappropriate antidiuresis (nephrogenic SIAD). Since the vasopressin 2 receptor is constitutively activated, these patients present with hyponatremia, low serum osmolality, high urinary sodium, and elevated...
What do you feel are the potential barriers to widespread use of obinutuzumab in proliferative lupus nephritis?
1. Insurance Coverage: Oh, easy one! Since it is not FDA-approved yet for lupus nephritis (I bet it will be though... great data so far), insurance will unlikely cover it, except for a few (like Tricare, which is sometimes easier to get off-label drugs). I am fortunate to have the NIH Lupus Center c...
Would you make any dialysis prescription modifications for an ESKD patient who develops tachycardia during a hemodialysis session?
Arrhythmias that initiate during dialysis treatment are almost always due to hypokalemia. Unfortunately, changing the potassium bath after an arrhythmia has already started will likely not help. The answer to the question depends on the circumstances of the patient. If unstable, would stop dialysis....
Do you postpone hemodialysis for a period of time after stem cell transplantation in a hospitalized patient with ESKD?
No. In fact, some patients may require extra HD sessions to manage volume overload post SCT. All ESKD patients are assessed daily for HD and continue to receive thrice-weekly dialysis per routine. If they are persistently hypotensive, they are considered for transition to CRRT.
Do you avoid potassium citrate in patients with recurrent nephrolithiasis and hypocitraturia if they also take antihistamine medications?
I know of no data showing effects of antihistamine meds on urine citrate or on the effects of potassium citrate on urine citrate. I made a Perplexity search which also found no evidence - this is not a topic I have personally researched because I have never encountered clinical issues about it. So -...
Is azilsartan superior to other angiotension receptor blockers in regard to cardiorenal outcome data?
In short, there are no data. There are very few head-to-head comparisons of ARBs on hard outcomes. Azilsartan was used in SPRINT (alongside losartan and valsartan), though the secondary analyses focused on class effect as opposed to specific med-to-med comparisons within a class (DeCarolis et al., P...