Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you offer peritoneal dialysis to a patient with ESKD who also has a ventriculoperitoneal shunt?
I would not place a PD catheter in an adult ESRD patient who has a ventriculoperitoneal shunt (VPS). I would instead place a hemodialysis vascular access and encourage this patient to do home hemodialysis. However, if the patient had exhausted all vascular access sites and was catheter-dependent, I ...
What is your preferred hemodialysis regimen for patients with acute lithium toxicity?
Assuming that renal function is normal or new normal, I would dialyze them in the most rapid way possible, high blood flow, a large dialyzer, and a longer time. Repeat lithium levels and repeat dialysis if levels remain elevated is crucial.
Do you prefer liquid calcium carbonate over other calcium carbonate formulations for patients with recurrent calcium oxalate nephrolithiasis who have persistent hyperoxaluria on 24 hour urine studies?
I would not differentiate between the use of a liquid or tablet form of calcium carbonate based on urine oxalate measurements. The only reason to choose between these two forms would be patient preference or some usual physical limitation with taking the tablet form. Much more commonly, I encounter ...
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
Is there a time frame in which you would no longer consider a prior vein mapping study reliable and thus recommend repeating the test in a patient with advanced chronic kidney disease who requires evaluation for fistula placement?
As a standard, typically 6 months is the longest I’d consider utilizing a vein mapping; however, the caveat here is to repeat after any hospitalization or known line placements/extensive blood draws. Vein mapping is very low risk and relatively easy to repeat vs the risk of a failure to mature fistu...
Would you initiate a SGLT2 inhibitor for a patient on chronic lithium with the goal of preserving kidney function?
I would not be inclined to go to an SGLT-2 inhibitor in this situation. The nephrotoxicity of lithium is tubulointerstitial, not glomerular, primarily. I would not expect an SGLT-2 inhibitor to be nephroprotective and may have other adverse effects, given the other kidney effects of lithium. I do no...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
When would you pursue a kidney biopsy for patients with inflammatory bowel disease who have non-proteinuric progressive CKD of unknown etiology?
I have done kidney biopsies in patients in this setting. Helpful to know what is going on in the kidneys.
How would you approach organ harvesting in an ambulatory patient with ALS who wishes to transition to comfort measures and to be an organ donor?
Data is very limited. If the patient is deemed safe to undergo general anesthesia, it would be reasonable for the patient to be a living donor, either as a direct donation or non-directed/altruistic. There is some theoretical risk of transmission of ALS (based on the potential that some ALS is due t...