Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
Do you advise your patients with CKD to consume a set amount of fluids daily in an attempt to prevent disease progression?
No. I advise them to limit fluid intake and drink only according to thirst. There 3 caveats to this.Patients with a history of kidney stones need to drink more water.Patients with hypernatremia need to drink more water. Whether drinking more water will prevent bladder cancer has been debated, but I ...
Would you offer peritoneal dialysis to a patient with ESKD who also has dementia but lives with family who can assist with dialysis treatments?
The key words in this question are "can assist". Change it to "WILL assist" and the answer is an unequivocal "yes". But I would not leave it optional.
What is your preferred blood flow rate for a patient with ESKD who has an AVF but is only undergoing an ultrafiltration session?
I see no reason to limit the blood flow. Clearly, if you are just UF, the blood will "thicken" as you remove protein and cell-free water component of the blood, and the higher the blood flow, the lower the filtration fraction (FF) and the less "thick" the blood will get. If your UF says 3 liters ove...
Do you recommend checking a serum phosphorus level in patients with recurrent nephrolithiasis?
For patients with pure calcium phosphate or mixed calcium phosphate/oxalate nephrolithiasis, l routinely check serum phosphorus as part of a panel that also contains serum calcium, PTH, creatinine, and 25-vitamin D, looking for primary hyperparathyroidism, a surgically curable cause of these stones....
Do you recommend 24 hour urine stone risk studies for patients with no history of nephrolithiasis who are undergoing evaluation as potential kidney donors?
We ask all donors if they have had a history of kidney stones. All donors also get a CT angiogram of the abdomen. Patients with a stone history will need a 24-hour urine stone risk profile. If a donor has an incidental single stone, we may still allow donation, but we would ask for a 24 stone profil...
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Would you opt to start IV iron load, maintenance iron therapy, or no iron at all in a patient with ESKD on hemodialysis who has a stable hemoglobin level at around 12.0 g/dL but also has low iron stores as evidenced by a low transferrin saturation and ferritin?
I routinely give an IV iron load to such patients. Iron is required for metabolic functions other than hemoglobin production and, for example, studies in non-anemic iron-deficient patients with heart failure consistently demonstrate improved outcomes with IV iron administration. If the patient is no...
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...