Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When showing lab results to patients who have chronic kidney disease, do you prefer to use the absolute creatinine value or eGFR?
I look at both. It is easier to follow the creatinine over time, but the eGFR is likely a better measure of the actual kidney function.
What is your approach for minimizing volume intake for patients on dialysis who are receiving total parenteral nutrition (TPN)?
I would use concentrated TPN formulations by using higher concentrations of dextrose and amino acids to deliver more calories and protein per mL. I would adjust the dialysis prescription to account for TPN-related fluid gains. For example, ultrafiltration targets on dialysis days can be increased to...
How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?
This is not exactly a rare problem! I have a number of comments: Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because: a) patients really don't under...
Would you add tolvaptan to manage difficult to treat SIADH in a patient who is already on high doses of sodium chloride tablets and urea but fails to reach adequate serum sodium levels?
First of all, I am NOT a fan of salt tablets for SIADH; it takes a bit over 7 one-gram salt tablets to equal the mmol supplied by a single 15-gram packet of urea. And that many (large) pills can be nauseating, much more so than urea. By far, I would prefer tolvaptan over urea, but tolvaptan is often...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...
What is the role of APOL1 genotyping in the evaluation of a living kidney donor?
Testing for APOL-1 in living donors is controversial and a topic of much discussion and debate. There are not standardized guidelines of who and when to test. Some centers incorporate testing into their protocols while others individualize the decision regarding testing. There are a couple aspects t...
How do you counsel patients about the likelihood of improvement in kidney disease after anti-cancer treatment is initiated in a patient with malignancy associated membranous nephropathy?
There are numerous case reports to support that if the patient has a paraneoplastic MN then the expectation is that the renal lesion will respond to cancer directed therapy.
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
When would you consider referring a patient with resistant hypertension for renal denervation?
I consider renal denervation in patients who have 2 kidneys without renal artery pathology, eGFR > 40, a negative secondary workup (including exclusion of primary aldosteronism), uncontrolled BP, and who can return for follow-up monitoring after the procedure. Some of my referrals have been in patie...