Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
Do you advise your patients with CKD to consume a set amount of fluids daily in an attempt to prevent disease progression?
No. I advise them to limit fluid intake and drink only according to thirst. There 3 caveats to this.Patients with a history of kidney stones need to drink more water.Patients with hypernatremia need to drink more water. Whether drinking more water will prevent bladder cancer has been debated, but I ...
Would you offer peritoneal dialysis to a patient with ESKD who also has dementia but lives with family who can assist with dialysis treatments?
The key words in this question are "can assist". Change it to "WILL assist" and the answer is an unequivocal "yes". But I would not leave it optional.
What is your preferred blood flow rate for a patient with ESKD who has an AVF but is only undergoing an ultrafiltration session?
I see no reason to limit the blood flow. Clearly, if you are just UF, the blood will "thicken" as you remove protein and cell-free water component of the blood, and the higher the blood flow, the lower the filtration fraction (FF) and the less "thick" the blood will get. If your UF says 3 liters ove...
Do you recommend checking a serum phosphorus level in patients with recurrent nephrolithiasis?
For patients with pure calcium phosphate or mixed calcium phosphate/oxalate nephrolithiasis, l routinely check serum phosphorus as part of a panel that also contains serum calcium, PTH, creatinine, and 25-vitamin D, looking for primary hyperparathyroidism, a surgically curable cause of these stones....
Would you opt to start IV iron load, maintenance iron therapy, or no iron at all in a patient with ESKD on hemodialysis who has a stable hemoglobin level at around 12.0 g/dL but also has low iron stores as evidenced by a low transferrin saturation and ferritin?
I routinely give an IV iron load to such patients. Iron is required for metabolic functions other than hemoglobin production and, for example, studies in non-anemic iron-deficient patients with heart failure consistently demonstrate improved outcomes with IV iron administration. If the patient is no...
What is your approach for ESKD patients on peritoneal dialysis who request to do their own exchanges during a hospitalization?
I am very fortunate in that the University of Colorado Hospital has PD nurses on call 24/7. When patients are hospitalized, they are all, even those who usually do CAPD at home, treated with APD performed by the on-call PD nurse. For liability reasons, all machines are set up by the PD nurses. I rea...
Would you avoid fistula placement in patients with ESKD secondary to scleroderma?
I do not have any direct experience with this, but I would be very reluctant to place a fistula in someone with scleroderma.
What is your preferred method for latent tuberculosis screening prior to outpatient hemodialysis initiation for a patient with new dialysis requirements?
Definitely Quantiferon testing. It can be done at the same time as the hepatitis B blood test. The patient does not have to come back and have it read a couple of days later.
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...