Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a serum potassium level for when you would recommend discontinuing potassium citrate in a patient with recurrent nephrolithiasis, hypocitraturia, and hyperkalemia?
I take hyperkalemia seriously, as cardiac effects do not correlate closely with serum levels. If evaluation does not reveal a correctable cause, I would decrease potassium citrate dosage to keep serum potassium below 5.0. Stephen B. Erickson, MD
How do you manage polyuria and polydipsia from lithium?
My first step is to confirm that the symptoms, including polydipsia and polyuria, are due to NDI and not other reasons. Other potential causes that should be excluded are: Psychogenic polydipsia other substance-induced, such as caffeine, diuretics primary DM pituitary related CKD Lowering the dose...
Would you avoid a 24 hour urine collection for creatinine clearance measurement in a patient who is on fluid restriction?
No. The creatinine clearance should still be accurate if done correctly. The only problem may be if the urine output is lower, minor mistakes in urine collection will lead to bigger inaccuracies.
What is your preferred iron loading strategy for patients with anemia of chronic kidney disease?
I prefer to give ferumoxytol 510 mg X 2 doses of available.
How often do you recommend basic metabolic panel checks in a hospitalized ESKD patient on thrice weekly hemodialysis and for whom hyperkalemia is not of major concern?
The ease (usually no venipuncture), cost (miniscule relative to the overall cost of hospitalization), blood loss (not much) and utility (varying from little to significant depending on the clinical setting) indicate at least thrice weekly BMPs. A very ill, ICU patient will need a daily BMP while an ...
What is your approach to nephrology referral for patients with lupus nephritis?
The answer to this question "depends" on many factors.I had the luxury of learning under some lupus nephritis greats in the 1990s (John "Jack" Klippel, H Austin, and J Balow... the high-dose NIH CYC regimen guys). Therefore, I am fortunate to feel confident in my abilities to care for LN better than...
What is your approach to treating antibody-mediated rejection in a pregnant patient with a kidney transplant?
This is a very difficult situation. Presumably, this is late AMR, and to begin with, we would have very few treatment options. I would first optimize immunosuppression and consider IVIG and solumedrol, and defer further treatment until after delivery. We have not used rituximab in pregnancy. Rituxim...
How do you approach the management of a patient with nonoliguric ESKD, massive proteinuria, and hypoalbuminemia who is already on an ACE inhibitor?
This situation does not come up often, but I think there should be serious consideration of attempting to decrease kidney function by measures such as NSAID administration. Severe proteinuria has detrimental effects way beyond any benefit one may obtain from preserving residual renal function. The p...
What is your approach to discharge planning for a patient with chronic SIADH who is admitted with asymptomatic acute-on-chronic hyponatremia?
An acceptable baseline serum sodium level in chronic SIADH is based on both clinical status and risk of complications. Based on literature, in the absence of severe symptoms, the target is a gradual correction to a level that minimizes neurocognitive and physical impairment, typically aiming for a s...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.