Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
How do you approach checking an aldosterone to renin ratio in an outpatient with hypertension and hypokalemia that is difficult to correct with oral potassium replacement?
It is well known that hypokalemia can affect the aldosterone-renin ratio (ARR). Since hypokalemia directly inhibits aldosterone production, this can lead to false negative results when using ARR to screen for primary aldosteronism. If it is difficult to correct hypokalemia with oral potassium repla...
Is there a role for early GLP-1 therapy for weight loss in patients with early-stage ADPKD and obesity, given the association between obesity and the risk of progression to ESKD?
Indeed, maintaining a healthy BMI is an important evidence-based guideline in ADPKD, but no data exist for early GLP-1 therapy and early-stage ADPKD at this time. Weight loss has not yet been shown to be protective of eGFR in ADPKD, although of course, conceptually, we believe that to be true. That ...
In a hospitalized patient who undergoes a MRI with gadolinium contrast study, would you perform hemodialysis if they have AKI with prior dialysis requirements but do not currently otherwise meet criteria for dialysis?
I would not. Although gadolinium contrast has been associated with nephrogenic systemic fibrosis in patients with advanced CKD or AKI, the risk is much lower for the newer generation contrast agents with more tightly chelated Gd. That said, the risk is not zero, as reviewed in a recent CJASN perspec...
Are you comfortable using low molecular weight heparin as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis?
Low molecular weight heparin may be used as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis. However, its use requires close monitoring and careful management. Unlike unfractionated heparin, which is fully reversible with protamine, LMWH is only partially re...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
How do you decide which patients with asymptomatic hyperkalemia and CKD warrant inpatient admission versus expedited outpatient management?
I would imagine that there is no EKG available as the patient is outpatient. I prefer not to admit patients as much as possible. I would not admit patients with potassium levels less than 6. For those between 6 and 6.5, I would try to treat medically and recheck potassium the next day. If potassium ...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
Can contrast instilled through a displaced PEG tube that extravasates into the abdomen cause acute kidney injury?
That's an interesting question. Gastrografin (diatrizoate), used for gastrointestinal (GI) imaging, is poorly absorbed from the GI tract. Nonetheless, low levels of renal excretion of Gastrografin can be seen in some normal individuals and in patients with losses of GI mucosal integrity. Leakage of ...