Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When transitioning a patient with recurrent calcium based nephrolithiasis from one thiazide diuretic to another, do you typically recommend a washout period?
Yes. But since the half-lives of thiazide diuretics differ dramatically, from 1.5 to 2 hours for chlorothiazide to 40 to 60 hours for chlorthalidone, the washout period should be tailored to the specific drugs in question. Checking an electrolyte panel during the transition seems very appropriate to...
Do you prefer to have your patients with recurrent nephrolithiasis who have completed a 24 hour urine stone risk study drop off the entire collection to the respective lab for processing or personally mix and aliquot a representative sample prior to submitting to the lab for processing?
We prefer to get the entire 24-hour urine sample to avoid measurement errors.
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
What is your approach to determining the ideal starting dose of sodium chloride tablets when transitioning a patient with hyponatremia from a 3% sodium chloride infusion?
In the treatment of hyponatremia, the volume of an infusate necessary to induce a given change in plasma sodium concentration differs between hypovolemic hyponatremia and SIADH. In hypovolemic hyponatremia, the infused sodium and water are retained due to the volume depletion, resulting in positive ...
Do you routinely switch an ESKD patient from a NOAC to warfarin to allow for deceased donor kidney transplant listing?
We typically ask patients to switch from DOAC to warfarin when we think they are in range of deceased donor offers. We have a median waiting time for B and O candidates around 5.5 years, so we switch at 4 years of waiting/dialysis time. For ABO A candidates, we switch at 2 years. Of course, urgency ...
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 an overall decrease in daily dietary animal protein intake or focus more on decreasing the actual portion size of animal protein per meal in your patients with recurrent calcium based nephrolithiasis who have hypercalciuria?
I find initiating dietary changes is more difficult for my patients than initiating or changing medications. Regarding reducing dietary animal, protein consumption, I try to work with patient preferences. I have no strong preference of my own.Stephen B. Erickson, MD.
Would you recommend starting finerenone for a patient with diabetic kidney disease who has marked improvement from severely increased albuminuria to moderately increased albuminuria following ARB and SGLT2i initiation?
I would certainly discuss with the patient regarding potential benefits as well as risks. This is a joint decision matter, especially if finerenone leads to the need for potassium binders. Make sure first that the ARB dose is maximized with appropriate use of a diuretic.