Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
In patients with lupus nephritis, and MAHA with positive anti-phospholipid autoantibodies, what are the considerations to use or not use anti-coagulation therapy?
I support anticoagulation and C5 inhibition for such patients if they are not adequately responding.
Is the combination of SGLT2i and GLP 1 R agonist therapy contraindicated in patients who develop an episode of euglycemic DKA?
Therapy always needs to be individualized, but in most cases, SGLT2 inhibitors should be stopped in patients who have had euglycemic DKA. Such individuals likely have low endogenous insulin production. GLP1R agonists could further increase the risk of recurrent euglycemic DKA, and I agree with Mehta...
Does vitamin D supplementation in primary hyperparathyroidism increase the risk of kidney stones?
Hyperparathyroidism does increase the risk of developing kidney stones. A study in New England Journal of Medicine, Broadus et al., PMID 7351950, reported that patients with elevated concentrations of 1,25-dihydroxyvitamin D are at increased risk for kidney stones. The reason is that 1,25-dihydroxyv...
Do you recommend transitioning elderly patients from thiazide diuretics to alternative agents when managing hypertension given the increased concern for hyponatremia in this patient population?
In short, no.If hyponatremia from a thiazide occurs, which is rare (~2% among individuals in the intensive treatment arm of SPRINT), it is more likely to be in the first month after thiazide initiation. Hyponatremia occurring in an individual with chronic thiazide use very likely represents the pres...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...