Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach selecting a dialysis modality for a patient with advanced CKD who is interested in home therapy but has a history of medication non-adherence and poor attendance at clinic appointments?
Good question. I would like to give them a chance at home dialysis before declaring that they are not candidates but I think it should be evaluated on a case by case basis.
Do you still use the urinary anion gap to estimate renal ammonium excretion in patients with a non-anion gap metabolic acidosis, given its limitations?
Yes, I do, but especially as a teaching tool to help understand the make-up of urine in different clinical scenarios. Of course, a urine NH4+ would make this all so much easier, but I believe that the UAG is usually still of value in the evaluation of a NAGMA. The Achilles heel of it, of course, is ...
Do you temporarily hold ESAs for your patients with kidney disease who have an upcoming surgical procedure with the goal of reducing the risk for DVTs?
I do not routinely recommend this. I think the risk is very small given modern use of ESAs and thromboprophylaxis.
How do you clinically distinguish between pericardial effusion from volume overload versus uremic pericarditis in advanced CKD?
I don't think volume overload by itself can lead to pericardial effusion; rather, there has to be some form of pericardial irritation. I wonder if fluid overload would make the pericardial effusion worse, which is likely the case. Patients on dialysis, if they have pericardial effusion, I would auto...
Would you start allopurinol for a patient with uric acid kidney stones who does not have hyperuricemia or hyperuricosuria?
Definitely not! The main risk factor for uric acid kidney stones is neither hyperuricemia nor hyperuricosuria; it is hyperaciduria. Typically uric acid stone formers have a urine pH below 5.8. Raising urine pH into the mid 6s will not only stop new stone formation and existing stone growth; it will ...
Would you pursue temporary dialysis catheter placement followed by hemodialysis in a hospitalized patient with ESKD who is not able to undergo urgent fistula repair for a non-functioning fistula and receives gadolinium for a MRI study?
There is no role for hemodialysis following the GAD preparations we use these days.
Do you recommend transitioning elderly patients from thiazide diuretics to alternative agents when managing hypertension given the increased concern for hyponatremia in this patient population?
In short, no.If hyponatremia from a thiazide occurs, which is rare (~2% among individuals in the intensive treatment arm of SPRINT), it is more likely to be in the first month after thiazide initiation. Hyponatremia occurring in an individual with chronic thiazide use very likely represents the pres...
Do you prefer allopurinol or febuxostat for patients with chronic kidney disease who are receiving treatment for asymptomatic hyperuricemia?
Allopurinol. For my Asian and sometimes African American patients, I consider HLA testing to make sure they are not at risk for allopurinol hypersensitivity. In which case, I will prescribe febuxostat. Most often, I find the insurance will not even cover febuxostat unless I have tried allopurinol fi...
Under what circumstances would you consider doing a furosemide stress test in the workup of AKI?
Furosemide stress test may be performed early in the course of Stage 1 or 2 AKI to evaluate the likelihood of progression to Stage 3 AKI or the need for renal replacement therapy. A urine output of <200 ml over 2 hours after furosemide administration is predictive of progression to Stage 3 AKI and t...
Do you use a profile with high ultrafiltration rates interrupted by UF pauses to manage ESKD patients prone to intradialytic hypotension?
After exhausting lowering the dialysis bath temperature, extending the time of dialysis (including extra treatments), pure ultrafiltration treatment, and I have tried the UF profile options with varying success.