Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you add amiloride for patients with recurrent calcium nephrolithiasis who have hypercalciuria despite adherence to maximum dose thiazide, low sodium dietary intake, and low animal protein dietary intake?
Amiloride does not lower urine calcium on a chronic basis. In one set of experiments, acute loading lowered urine calcium, but the effect was very brief. I use amiloride to prevent potassium wasting from thiazides and on and off in primary hyperaldosteronism, but it will not lower urine calcium in t...
How do you advise your patients with recurrent nephrolithiasis to avoid consuming more than usual fluid volume on the day of a scheduled 24 hour urine stone risk study?
I tell them to collect on a day that represents their life as lived - how things are in general. I tell them not to show off. I tell them that if the day does not reflect their usual life, I will be misled and may make mistakes in how I treat them for stone prevention.
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I do but the issue is complex. Interpreted in context - life events, surgeries, meds etc - they tell me the range of behaviors for a patient in chemistry terms. But it takes a lot of time, and is not a good idea unless you are prepared to take that time.
What is your recommended sequence of therapies for achieving optimal proteinuria reduction in IgA nephropathy, especially in light of the recent approvals of sparsentan, delayed-release budesonide, and iptacopan?
I am actually quite persistent with conservative therapies first - I push an ARB or ACE inhibitor in an effort to get the proteinuria under 1 gram per day, or ideally 0.75 gram per day. I favor stronger ARBs such as olmesartan or azilsartan over weaker ones such as losartan or valsartan, and really ...
Would you start a mineralocorticoid receptor antagonist or aprocitentan first in a patient with resistant hypertension and advanced CKD?
My cut offs for prescribing a new mineralocorticoid receptor antagonist are eGFR < 30 (for spironolactone and eplerenone) and eGFR < 25 (for finerenone). I will, however, continue these meds down to an eGFR of 15 if they have been taking them without a history of hyperkalemia, which is often the cas...
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What is your approach to managing patients with recurrent ammonium urate kidney stones?
Pure ammonium urate stones are very unusual, and, to my knowledge, there are no studies to guide us in their treatment. Much more common are magnesium ammonium urate stones, commonly known as "struvite". These are caused by urease-producing bacteria, usually Proteus or Klebsiella. I would first chec...
Do you dose ESAs via an intravenous or subcutaneous route for hospitalized patients with ESKD and anemia?
ESAs are dosed IV at our hospital. No good reason aside from patient comfort probably. I personally think giving ESAs to hospitalized patients is largely a waste due to their inflammation, infection, etc.
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...