Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When do you decide to initiate potassium binders for patients with hyperkalemia in the setting of CKD?
This is a complicated question and requires a lot of thought. In brief, first, I will determine if the serum potassium is high enough (usually around 5.3-5.5) and if it is increasing rapidly. Then I will determine if the patient is on a drug that will worsen hyperkalemia (mainly ACE/ARB/MRB). Then I...
Do you prefer kidney ultrasound or a non-contrast CT scan to evaluate for nephrolithiasis in an asymptomatic patient with primary hyperparathyroidism?
I first order an ultrasound due to the lack of concern for radiation exposure and if it is equivocal then follow-up with a CT scan. Ultrasound is not as sensitive as a CT scan especially for very small stones.
In a patient with severe hyponatremia and acute kidney injury in the setting of hypovolemic shock, would fluid resuscitation take precedence over the rate at which sodium is corrected?
Normal saline, or a balanced fluid, e.g., Lactated Ringers or Plasmalye, if you are believers in balanced fluids. Shock trumps ANY concerns over rate of Na rise. Also if someone is in shock they are not going to have a water diuresis from volume.
What are the factors that you would consider for the use of ESA in patients with anemia of CKD with a history of stroke or TIA?
Large clinical trials of ESA have indicated increased stroke risk with these medications with TREAT reporting the highest stroke incidence. In this study, "baseline history of cerebrovascular disease was a strong predictor of experiencing a stroke during follow-up; patients with a history of stroke ...
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
Would you recommend initiation of cinacalcet in a patient with hypercalcemia and recurrent nephrolithiasis attributed to an atypical presentation of familial hypocalciuric hypercalcemia?
I would really like to know the level of the patient’s parathyroid hormone. If it is low, cinacalcet would probably not be helpful. Stephen B Erickson, MD
Do you recommend restricting alcohol use in patients with recurrent nephrolithiasis?
No. Clearly excess alcohol use is to be avoided. I much prefer water or citrate containing beverages for stone prevention. Beer has some oxalate content and is better avoided. Stephen B. Erickson, MD
Are there instances when you recommend initiation of hemodialysis for patients with severe symptomatic hypercalcemia?
In reality, there are so many treatments for hypercalcemia nowadays that the answer to the question is no. However, I can imagine if a patient is already on the cusp of needing dialysis and is hypercalcemic then I may initiate dialysis a little earlier to fix the hypercalcemia sooner.
How do you approach the management of a patient with an ileostomy who has recurrent prerenal AKI episodes that improve with IV fluids but worsen with each attempt to transition to oral fluids alone?
This can be a difficult problem to deal with. In addition to electrolyte losses and volume depletion, these patients can have problems with caloric and micronutrient/vitamin depletion, so close collaboration with a nutritionist and gastroenterologist is important. Assuming the ileostomy can't be rev...
How do you choose between the different vitamin D analogs for patients with CKD, an elevated PTH, and a normal 25-hydroxy vitamin D level?
In patients with pre dialysis CKD and elevated PTH, I would recommend using ER Calcifediol, which is a 25 D compound. It has been shown to be more effective than Vit D and it does not result in hypercalcemia, hyperphosphatemia, or FGF23 as is seen with VDRAs, calcitriol, paricalcitol, or doxercalcif...