Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How often do you check serum glucose and lipid levels after starting a thiazide diuretic for patients with recurrent calcium based nephrolithiasis?
I think checking serum glucose, electrolytes, and lipids about one month after starting a thiazide is reasonable. If levels are normal, I would revert to annual monitoring. Stephen B. Erickson, MD.
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
How do you advise patients with recurrent nephrolithiasis and polyuria who require more than one 24 hour collection jug and need to adequately mix the specimens prior to aliquoting for mail-off lab analysis?
My understanding of methods for dealing with large volume collections (more than 1 container) is that each container is sampled and tested separately, and the results are combined by the processing laboratory to provide the actual 24-hour totals. While one could envision methods for mixing the conte...
What is your approach to managing patients with recurrent nephrolithiasis and hypercalciuria who develop sun photosensitivity following thiazide diuretic initiation?
Sun avoidance and/or protection are my first thoughts. Failing that, I would recommend more intense dietary modification and look for other metabolic abnormalities amenable to pharmaceutical treatment. Treatment follow-up is critically important, preferably with CT scanning, looking to see if there ...
How do you determine the optimal time to restart a diuretic in a patient with cirrhosis, ascites, and lower extremity edema who presented with acute kidney injury that resolved with IV albumin and holding diuretics?
Good question. It is tricky. Spironolactone can be resumed fairly quickly. With loop diuretics it is harder to resume them. If necessary, I would resume at lower dose and slowly uptitrate as needed with close monitoring. Ideally, it is better to do frequent paracentesis with albumin infusion than gi...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
Do you prefer starting potassium chloride or amiloride for those with recurrent calcium based nephrolithiasis and hypercalciuria who do not have hypocitraturia but develop hypokalemia following thiazide diuretic initiation?
I prefer potassium citrate, even with normal urinary citrate levels, in urolithiasis patients with hypokalemia. Citrate can be therapeutic for some patients with calcium urolithiasis, and I am not aware of any harm from high urinary citrate levels. Stephen B. Erickson, MD
In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?
Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate w...
Would you transition a patient with recurrent calcium nephrolithiasis and hypercalciuria from chlorthalidone to indapamide if they report sexual dysfunction side effects?
Yes. Indapamide is a thiazide-like diuretic that decreases urinary calcium excretion by increasing renal tubular reabsorption of calcium. In my experience, it is less likely to create sexual dysfunction than a true thiazide diuretic. Stephen B. Erickson, MD
Would you increase the delivered dose to more than 25 ml/kg/hr in a patient on CKRT if a prolonged interruption for a procedure is planned for the day?
Guidelines, all guidelines have to be taken with a grain of salt. The Ronco CVVH trial found 35 ml/kg/hr was the goal, definitively. It was questioned because it was a single center with too many surgical patients. Is that really such a valid criticism? Not to be ignored, his study was pure post-dil...