Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Would you recommend adding a mineralocorticoid receptor antagonist or endothelin receptor antagonist for a patient with bevacizumab-induced proteinuria who is already on an ACEi or ARB?
Unfortunately, we have no data to guide the choice of anti-proteinuric agents in this particular setting. We do have biological plausibility for antagonizing the endothelin pathway, as we know that vascular endothelial growth factor inhibition results in upregulation of endothelin-1, and the resulta...
How do you decide when to stop routine laboratory monitoring in a patient with CKD Stage 5 who has chosen conservative management?
I normally don't as patients often change their mind when they are sick. However, if the patient requests not to monitor labs then I would honor their wishes.
Do you recommend initiating an ACE inhibitor or ARB in a patient with proteinuric CKD Stage 5?
ACE-I’s and ARB’s have been shown to be renal protective, and patients who have stopped these agents do worse than those who continue them. Potassium binders are an excellent option to lower K levels and enable patients to stay on these RAAS inhibitors. I would not take CKD patients off RAAS inhibit...
Would you recommend initiating a SGLT2i for proteinuria secondary to bevacizumab in a patient who has a sub-optimal response to an ACEi or ARB?
We don't have specific data for this scenario, but there is no reason to think that SGLT2i would not have a beneficial role though I agree with Dr. @Dr. First Last that risk/benefit needs to be weighed. At the same time, in this particular scenario, I'd carefully look at the time course of proteinur...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
How often do you check serum glucose and lipid levels after starting a thiazide diuretic for patients with recurrent calcium based nephrolithiasis?
I think checking serum glucose, electrolytes, and lipids about one month after starting a thiazide is reasonable. If levels are normal, I would revert to annual monitoring. Stephen B. Erickson, MD.
How do you advise patients with recurrent nephrolithiasis and polyuria who require more than one 24 hour collection jug and need to adequately mix the specimens prior to aliquoting for mail-off lab analysis?
My understanding of methods for dealing with large volume collections (more than 1 container) is that each container is sampled and tested separately, and the results are combined by the processing laboratory to provide the actual 24-hour totals. While one could envision methods for mixing the conte...
How do you determine the optimal time to restart a diuretic in a patient with cirrhosis, ascites, and lower extremity edema who presented with acute kidney injury that resolved with IV albumin and holding diuretics?
Good question. It is tricky. Spironolactone can be resumed fairly quickly. With loop diuretics it is harder to resume them. If necessary, I would resume at lower dose and slowly uptitrate as needed with close monitoring. Ideally, it is better to do frequent paracentesis with albumin infusion than gi...
Do you prefer starting potassium chloride or amiloride for those with recurrent calcium based nephrolithiasis and hypercalciuria who do not have hypocitraturia but develop hypokalemia following thiazide diuretic initiation?
I prefer going with Potassium citrate.