Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you would prescribe a phosphate binder to an ESKD patient on hemodialysis who has a phosphorus level in the target range of less than 5.5 mg/dL?
Yes. If the serum phosphorus is increasing and the trend would suggest >5.5 soon. If the patient has history of calciphylaxis. I am sure there are other instances also.
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
Do you modify the albumin level below which you would prophylactically anticoagulate a pregnant patient with nephrotic-range proteinuria, given that hypoalbuminemia is expected in pregnancy?
I wouldn't anticoagulate for nephrotic syndrome unless the albumin was <2.5, and that is too low for pregnancy. Besides, "any" pregnant patient with "any" renal disease should be on ASA for preeclampsia prophylaxis. So, all pregnant patients with proteinuria need ASA (not without anticoagulation pro...
Do you recommend buttonhole cannulation for arteriovenous fistulas?
No, I do not recommend routine buttonhole cannulation of arteriovenous fistulas. RCTs have shown a high risk of infections with S aureus bacteremia with buttonhole cannulation and no difference in AV fistula survival, surgical and endovascular interventions or patient comfort when compared to rope l...
Do you routinely recommend decreasing dietary animal protein intake in patients with recurrent calcium oxalate nephrolithiasis who are found to have hyperoxaluria on 24 hour urine studies?
This is an interesting question. I focus more on total protein intake rather than which type in my initial assessment and make sure that the patients are meeting guidelines there first (0.8-1g protein/Kg of lean body weight). I address hyperoxaluria in my review primarily through addressing the usua...
What specific precautions or restrictions do you recommend when prescribing home hemodialysis for a patient with ESKD who lives alone?
Have done a few times, many many years ago, never slept well given monitoring available in 70’s. Leg shunt, or if fistula, Sears wee alert, tried a computer-monitored system with dial-up modem and memory on floppies. Decided never to do it again, now retired, even with current technologies, would no...
What is your preferred potassium binder for patients with CKD and hyperkalemia that persists despite dietary potassium restriction?
This is mainly determined by the patient's insurance preferences. I have a slight preference with Veltassa as compared to Lokelma due to the low sodium content. However, I am ok using both.
How would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
Proceed with coronary angiogram and dialysis after the procedure.
How do you determine when it is appropriate to transition a patient back to peritoneal dialysis after they were switched to hemodialysis due to PD catheter removal for refractory peritonitis, once the infection has been treated?
I am not aware of any data/evidence to guide this. I generally wait for two weeks after the completion of treatment to be sure that the infection has indeed been eradicated. I think it's OK to try PD catheter placement at any time after that.
Are there instances where you may transiently transition a perioperative ESKD on PD inpatient from peritoneal dialysis to hemodialysis if they are likely to receive a large volume of fluid?
Most peritoneal dialysis patients should be able to continue with PD while in the hospital. For patients with acute volume overload, hypertonic dextrose solutions can be used. However, there may be special circumstances where patients on peritoneal dialysis will need a temporary transition to hemodi...