Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend immediately exchanging a peritoneal dialysis catheter, or waiting until the completion of antibiotics with transition to HD, if a PD patient presents with peritonitis and a nonfunctional PD catheter?
Optimally, peritonitis should be completely resolved before placing a new (and hence sterile) foreign body into the peritoneum. That said, all attempts to restore PD catheter function without invasive measures (non-surgical) should be attempted first. If the PD catheter can be restored with minimall...
How much proteinuria would warrant consideration of native kidney nephrectomies at the time of a kidney transplant?
We don't typically consider native nephrectomies unless the proteinuria is > 5-6 grams. We rarely end up doing native nephrectomies, though. The main problem, besides the complications associated with heavy proteinuria, is the inability to assess for recurrent disease post-transplant. This can be pa...
Do you recommend first consulting interventional radiology or vascular surgery if you lack access to interventional nephrology in a patient with ESKD who is suspected of having a clotted fistula and is unable to receive hemodialysis?
Yes. Not all institutions have access to Interventional Nephrology. Anyone with the required skill, expertise, and availability would need to be consulted urgently to manage the clotted AV access - especially if it is indeed a fistula (as opposed to a graft). The longer the fistula remains clotted, ...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Would you recommend avoiding intravesical (bladder) tobramycin administration in a patient with advanced chronic kidney disease?
Guess fear is absorption, build up, and toxicity. A single loading dose of an aminoglycoside is not to toxic level. Maintaining the level of risks ototoxicity, build up also nephrotoxicity. Would depend on absorption and residual GFR. Try a single loading dose, check levels after 12 or 24 hours to g...
Do you recommend prophylactically adding heparin to the dialysate in patients hospitalized for peritoneal dialysis associated peritonitis given higher incidence of fibrin-associated catheter issues?
We do not prophylactically add heparin to dialysate in patients with peritonitis. We have that as a "prn" order, if necessary, but the frequency with which it is needed is low, no more than 10% of the time. As each addition to a dialysate bag is associated with a small possibility of introducing inf...
When would you consider using amiloride over spironolactone for treatment-resistant hypertension (not reaching goal BP on 3 agents, including a diuretic)?
In male patients, because of the high incidence of gynecomastia...
Do you prefer to simultaneously start an ACEi/ARB and SGLT2i or initiate one prior to the other in a patient with proteinuria secondary to diabetic kidney disease?
I would start ACE/ARB first. If, after 4-5 months the proteinuria is not within goal, then would add SGLT-2. Also, this will ensure that blood pressure does not drop too much.
Do you prefer using the delta ratio or corrected bicarbonate formula when further evaluating a patient with high anion gap metabolic acidosis?
I use the delta AG/delta HCO3 ratio in evaluating a patient with high anion gap metabolic acidosis. It is important to recognize that the delta AG/delta HCO3 ratio in lactic acidosis averages approximately 1.6, whereas the delta AG/delta HCO3 ratio in ketoacidosis averages approximately 1. The reaso...
How do you approach chronic T cell mediated rejection when patient is intolerant to steroids?
I would really want to know in what way the patient is intolerant to steroids. Depending on the degree of activity, I would also consider thymoglobulin and maximize the mycophenolate. CNI dosing would depend on the degree of chronicity, but in general, I would aim for a tacrolimus level of 6-8 ng/ml...