Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
Do you plan to initiate combination therapy with an SGLT-2 inhibitor and finerenone, instead of an SGLT-2 inhibitor alone, when treating patients with proteinuric chronic kidney disease and type 2 diabetes in light of the CONFIDENCE trial findings?
I would start one (typically the SGLT-2 inhibitor), then add finerenone potentially later. If both are started simultaneously and there is an AE, then both may have to be stopped. I prefer to see that one is tolerated, then start another.
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
Under what circumstances do you order ambulatory blood pressure monitoring in a patient receiving maintenance hemodialysis?
I have done it when the patient is unable to take their bp meds prior to coming for dialysis, and pre-dialysis BP remains high. Other instances are when there is a large difference between the pre and post-dialysis blood pressure readings.
How would you manage serum sodium monitoring for an asymptomatic outpatient with newly diagnosed SIADH and a serum sodium level of 127 mEq/L, for whom you are initiating treatment with urea?
Based on the current available data, treatment of SIADH with urea is effective with a very low risk of overcorrection. In a meta-analysis of 23 studies involving 537 patients with SIADH, urea increased serum sodium concentration by a mean of 9.6 mmol/L, and the mean increase in serum sodium after 24...
How would you approach de-intensifying antihypertensives in frail older adults with SBP < 130 mmHg who have nephrotic range proteinuria, given the results of the RETREAT-FRAIL trial?
I would withdraw antihypertensive drugs that do not have any significant anti-proteinuric effect: dihydropyridine calcium channel blocker, beta blocker, alpha-1- blocker, hydralazine, and clonidine. Thiazide/loop diuretic may also be withdrawn if it is not needed for control of edema due to the neph...
Do you recommend outpatient dialysis initiation or inpatient admission for dialysis initiation in a CKD Stage 5 patient with stable electrolytes but experiencing nausea and vomiting related to uremia?
For a patient with CKD Stage 5 who has stable electrolytes but is experiencing nausea and vomiting from uremia, the patient can be managed with outpatient dialysis initiation. However, if the patient is at high risk for dialysis disequilibrium syndrome (DDS) due to markedly elevated BUN, I prefer in...
Do you have different 24 hour serum sodium correction targets for patients with severe, moderate, and mild hyponatremia?
It is known that overly rapid correction is significantly more likely to cause osmotic demyelination syndrome (ODS) in patients with more severe hyponatremia, particularly when initial serum sodium is ≤105 mmol/L. Since transcellular water movement is mediated by changes in osmolality across the cel...
Do you recommend patients with ESKD time their daily B complex multivitamin to after hemodialysis on hemodialysis days?
Yes. B vitamins do get removed some with dialysis but their removal is limited. Vitamin C on the other hand seems to be removed better. I don't see any harm of taking them after dialysis.