Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?
Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate w...
Would you transition a patient with recurrent calcium nephrolithiasis and hypercalciuria from chlorthalidone to indapamide if they report sexual dysfunction side effects?
Yes. Indapamide is a thiazide-like diuretic that decreases urinary calcium excretion by increasing renal tubular reabsorption of calcium. In my experience, it is less likely to create sexual dysfunction than a true thiazide diuretic. Stephen B. Erickson, MD
Would you increase the delivered dose to more than 25 ml/kg/hr in a patient on CKRT if a prolonged interruption for a procedure is planned for the day?
Guidelines, all guidelines have to be taken with a grain of salt. The Ronco CVVH trial found 35 ml/kg/hr was the goal, definitively. It was questioned because it was a single center with too many surgical patients. Is that really such a valid criticism? Not to be ignored, his study was pure post-dil...
Do you check a fractional excretion of sodium in nonoliguric patients with AKI?
The FENa is diagnostically less useful in non-oliguric AKI. However, FENa can still be checked, but it has to be interpreted in conjunction with the patient's clinical and other laboratory data.
What is your approach to managing AKI secondary to intravenous acyclovir?
First and foremost, obviously, is to stop the acyclovir and switch to something different if indicated. Second, fluid therapy is important if the patient is still urinating. With oliguria, significant saline administration is not possible due to the risk of fluid overload. Of course, like all causes...
Do you recommend captopril for patients with cystine nephrolithiasis given mixed data on its effectiveness?
No. Newer drugs are superior.
What is your approach to the management of patients with recurrent nephrolithiasis who continue to have elevated stone risk parameters in the setting of dietary factors despite receiving education from a dedicated stone clinic dietician?
Diets are notoriously difficult to follow. Once it is apparent that the patient is not going to get satisfactory control of metabolic stone disease (an increase in stone number or size as opposed to the passage of pre-existing stones, unchanged in size or number), it is time to start preventative me...
Do you taper steroids more aggressively to decrease the risk of developing new-onset diabetes after transplantation in kidney transplant recipients who had pretransplant impaired fasting glucose?
Steroids are given after any transplant (kidney, heart, lung, bone marrow, etc.,) to reduce risk of rejection of the transplanted organ. Preservation of organ function is the number one concern for the transplant team. Steroid free regimens for anti-rejection are always a goal but the transition to ...
Would you consider making a diagnosis of hepatorenal syndrome-associated acute kidney injury with a one-day diagnostic fluid challenge instead of a two-day challenge to expedite vasoconstrictor therapy if needed?
Depending on the circumstances, of course. If the patient is already significantly fluid overloaded, even one day of fluids may not be necessary. The main issue is renal vasoconstriction, as these patients are never truly total-body fluid depleted. The key question is whether the renal vasoconstrict...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...