Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach for ESKD patients on peritoneal dialysis who request to do their own exchanges during a hospitalization?
I am very fortunate in that the University of Colorado Hospital has PD nurses on call 24/7. When patients are hospitalized, they are all, even those who usually do CAPD at home, treated with APD performed by the on-call PD nurse. For liability reasons, all machines are set up by the PD nurses. I rea...
Would you avoid fistula placement in patients with ESKD secondary to scleroderma?
I do not have any direct experience with this, but I would be very reluctant to place a fistula in someone with scleroderma.
What is your preferred method for latent tuberculosis screening prior to outpatient hemodialysis initiation for a patient with new dialysis requirements?
Definitely Quantiferon testing. It can be done at the same time as the hepatitis B blood test. The patient does not have to come back and have it read a couple of days later.
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...
How do you time 24-hour urine collections when calculating creatinine clearance for patients receiving thrice-weekly hemodialysis?
Great question. I think no matter how one does it there is bound to be some inaccuracies but it would still be helpful. My routine is to do the urine collection starting the morning after dialysis and ending the morning of dialysis. Then to check serum creatinine before dialysis. Of course, the seru...
Would you initiate urgent start peritoneal dialysis for a patient with uremic symptoms who plans to pursue long-term hemodialysis but currently lacks an AV access, to avoid using a temporary dialysis catheter until they can obtain a functioning AV access?
Interesting question. My answer is no. Although generally I prefer PD, I would not go that route in this case. An AVF could be created now, and it may be ready to use in 2-3 months. Although a PD catheter could potentially be inserted and used even within the next 48 hours, the patient will need to ...
What factors influence your decision to start salt tablets, urea, or a vaptan first in the management of a patient diagnosed with SIADH?
In patients with SIADH, free water intake has to be less than the urinary electrolyte-free water clearance in order for the serum sodium level to increase, assuming no significant extra-renal fluid losses. Therefore, if urinary electrolyte-free water clearance is very low, then free fluid restrictio...