Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?
The short answer is to add a binder. The best case for this is with Ca-based binders, for which many experts recommend a maximum daily dose of 1 gm of elemental Ca. (That’s only 6 CaAc tabs -169 mg of Ca per 667 mg). Another limit that is supported by some data is for sevelamer. The binding per 800 ...
Are there instances when you continue phosphate binders for patients receiving CRRT?
Would be very unusual. First, continuous renal replacement therapy (CRRT) is so effective in lowering serum phosphorus concentration if done with the right dose that it is almost never needed to add a binder. Second, usually, patients on CRRT are no longer eating meals, and thus binders do not make ...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
Would you recommend temporary transition to hemodialysis in a peritoneal dialysis patient who has risk factors, such as recurrent peritonitis, for the development of encapsulating peritoneal sclerosis?
In summary, yes. However, just like anything in medicine, every patient is different, and risk factors specific to the patient have to be weighed against the benefits of continuing PD.
What is your approach to managing patients with suspected osmotic nephrosis from monthly IVIG infusions?
If the patient develops IVIG-induced osmotic nephrosis, the current IVIG therapy should be suspended, and treatment of the AKI is supportive. If IVIG needs to be restarted once the patient’s renal function recovers, there are several preventive strategies that can be tried. The patient should be swi...
Would you support a modified chlorthalidone treatment regimen involving a drug holiday of two days per week for patients with recurrent calcium based nephrolithiasis who have less erectile dysfunction side effects when temporarily off of the thiazide diuretic?
I know of no study data to answer the question. The half-life of chlorthalidone is approximately 40–60 hours. Whether the drug would wear off enough during a 24 hour drug holiday to achieve an erection would be the first question to answer. The second is a risk benefit question: an increased risk of...
Are there instances when you offer dialysis to patients with high-risk hepatorenal syndrome who are not transplant candidates?
Yes. I have done that. Prognosis remains poor but dialysis can sometimes give patients a few more weeks or even months.
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
At what serum sodium level do you stop desmopressin when using a clamp strategy to prevent overcorrection in hyponatremia?
There is no universally accepted serum sodium threshold above which DDAVP should be stopped. If there is a concern for over-rapid correction of the serum sodium level by more than 8 mmol/L in 24 hours, then DDAVP should be continued. Therefore, urinary output and urine osmolality should be monitored...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.