Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Do you prefer maximizing fluid removal during dialysis or starting new antihypertensive medications for patients with ESKD on intermittent hemodialysis who are chronically hypertensive?
Fluids, fluids, and fluids are the most crucial first step. Challenging dry weight is the most important part in controlling blood pressure, and then adding more blood pressure medications is the next step. The only "exception" is high dose diuretics to reduce intradialytic weight gain. Additionall...
When showing lab results to patients who have chronic kidney disease, do you prefer to use the absolute creatinine value or eGFR?
I look at both. It is easier to follow the creatinine over time, but the eGFR is likely a better measure of the actual kidney function.
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
What is your approach for minimizing volume intake for patients on dialysis who are receiving total parenteral nutrition (TPN)?
I would use concentrated TPN formulations by using higher concentrations of dextrose and amino acids to deliver more calories and protein per mL. I would adjust the dialysis prescription to account for TPN-related fluid gains. For example, ultrafiltration targets on dialysis days can be increased to...
How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?
This is not exactly a rare problem! I have a number of comments: Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because: a) patients really don't under...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Would you add tolvaptan to manage difficult to treat SIADH in a patient who is already on high doses of sodium chloride tablets and urea but fails to reach adequate serum sodium levels?
First of all, I am NOT a fan of salt tablets for SIADH; it takes a bit over 7 one-gram salt tablets to equal the mmol supplied by a single 15-gram packet of urea. And that many (large) pills can be nauseating, much more so than urea. By far, I would prefer tolvaptan over urea, but tolvaptan is often...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...