Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend avoiding morphine in patients with ESKD?
I would not recommend using other than for a few doses for acute severe pain but not for more prolonged use other than in the setting of terminal illness/hospice.
How do you approach recommending an AVF for a patient with advanced CKD who is concerned about the cosmetic appearance of the fistula?
My approach is usually 2-fold. First, I try to emphasize the medical benefits of an AVF over a catheter. Second, I point out that the catheter is also the most aesthetically appealing option to have. I then go over possible solutions of covering the AVF (sleeves, etc.). This could also be a good ...
What is your approach to using intraperitoneal sodium thiosulfate for a patient with ESKD on peritoneal dialysis who develops calciphylaxis?
I believe if the patient has calciphylaxis, PD should not be continued, and more efficient IHD or HHD with the addition of sodium thiosulfate is better.
Do you have your patients with recurrent calcium phosphate nephrolithiasis and hypocitraturia avoid high citrate containing foods if they have alkaline urine?
A good question, and I don’t think we have hard evidence to answer it. Most kidney stones are a mixture of calcium oxalate and calcium phosphate, the oxalate content usually predominating. Pure oxalate stones should prompt a search for one of the hyperoxalurias. Pure phosphate stones (apatite/brushi...
What is your approach to managing patients with recurrent nephrolithiasis who consistently fail to adhere to recommended dietary changes including animal protein and sodium restriction and remain at elevated stone risk due to hypercalciuria despite thiazide diuretic use?
I typically repeat the prior recommendations and discuss potential barriers to better compliance with the patient in follow-up to try to encourage better compliance. I do point out that they might compensate for some dietary indiscretions in salt and protein by drinking extra fluid, since "dilution ...
Do you recommend SGLT2 inhibitors for patients with Fabry disease and proteinuria despite ACEi/ARB use?
Like most other nephrologists, I have had very little experience with Fabry's disease (1 patient for a couple of months over the last 26 years). If enzyme replacement is indicated and given, and an ACE-ARB is already instituted, I don't see a problem with starting SGLT-2 in addition.
What is your approach to waiting period for an ESKD patient getting a kidney transplant after just being treated for bacteremia?
In general, I would like a waiting period of at least 6-8 weeks. I would review the clinical course of the hospital admission to ensure that the patient has recovered well physically and that the source of bacteremia has been adequately addressed, e.g., any lines/abscesses. If this is a living donor...
How have you incorporated donor-derived cell-free DNA to help with the diagnosis of rejection or monitoring of the treatment response to rejection?
I typically use it in lieu of an allograft biopsy in patients on surveillance, particularly if there are reasons to avoid a biopsy (antiplatelet agents, bleeding risk, difficult anatomy). Serial cf-DNA levels that improve following treatment of rejection have been helpful as well to give us an idea ...
What adjustments to total parenteral nutrition (TPN) do you recommend for hospitalized patients with hyponatremia?
In patients on TPN, the sodium concentration can be increased by either increasing the sodium content or reducing the volume of TPN to limit the electrolyte-free water content in the TPN. As the concentration of Na + K approaches 154 mmol/L, the electrolyte-free water content in the TPN decreases.
How should PPIs or H2 blockers be managed in peritoneal dialysis patients with a history of peritonitis and peptic ulcer disease, considering the potential infection risk?
This question should probably be rephrased, with the words "a history of peritonitis and" removed. I am not aware of any literature indicating that the risk of peritonitis with the use of gastric acid suppressants (GAS), either H2 blockers (H2Bs) or proton pump inhibitors (PPIs), is modified by a pr...