Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
Is there any way to safely treat patients with mCRPC with 177-Lu PSMA who are on hemodialysis?
For the most part, no. Not unless you're a big academic medical center with a robust multidisciplinary team willing to tackle the significant logistical challenges associated with this scenario.I'm aware of no literature in this scenario specifically for Pluvicto, but we can look at the radiopharmac...
Would you recommend adding a daytime dwell over an additional nighttime exchange to achieve volume and clearance targets for an ESKD patient who recently stopped making urine and has been receiving only nighttime automated peritoneal dialysis?
Regardless of fluid removal needs, once a patient on automated peritoneal dialysis (APD) has lost their residual kidney function, they should have a long dwell added to their PD regimen sometime during the day in order to facilitate peritoneal clearance of phosphorus and middle molecules.The native ...
Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?
In short, no. I think the recent studies tell me two things: We need to better discriminate correction rates based on the risk of osmotic demyelination (ODS). Perhaps, do not worry so much about over-correction. They do not tell me to start rapidly correcting patients, and I guess I will summarize m...
How do you utilize Cystatin-C as a marker of renal dysfunction in patients with chronic liver disease?
Liver disease is definitely one of those circumstances that results in lower creatinine production. As such, cystatin-C is likely a better marker than creatinine for renal function in those patients, even more than usual.
What approaches do you take to prevent worsening kidney function for patients with chronic kidney disease who have an upcoming outpatient CT scan with iodinated contrast?
If CT is really necessary, if not very high risk just encourage moderate oral hydration before and after. May hold diuretics if this can be done safely. If very high risk try to get IV saline for a few hours prior.
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
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.
Will you implement the conservative dialysis strategy from the LIBERATE-D trial for patients with dialysis-requiring acute kidney injury, or will you continue dialysis on a schedule until recovery based on creatinine and urine output?
I think I have always dialyzed patients with AKI on an as-needed basis. The question is whether to follow the parameters set by the LIBERATE-D study (bun >112, etc.). I am not yet sure what my practice will look like in the future as far as the parameters. It is likely the case, though, that I would...
Are there circumstances in which you would check a serum copeptin level when evaluating patients for possible SIADH?
I would check a serum copeptin level in a patient suspected of having nephrogenic syndrome of inappropriate antidiuresis (nephrogenic SIAD). Since the vasopressin 2 receptor is constitutively activated, these patients present with hyponatremia, low serum osmolality, high urinary sodium, and elevated...