Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What is your approach to managing patients with recurrent ammonium urate kidney stones?
Pure ammonium urate stones are very unusual, and, to my knowledge, there are no studies to guide us in their treatment. Much more common are magnesium ammonium urate stones, commonly known as "struvite". These are caused by urease-producing bacteria, usually Proteus or Klebsiella. I would first chec...
Do you dose ESAs via an intravenous or subcutaneous route for hospitalized patients with ESKD and anemia?
ESAs are dosed IV at our hospital. No good reason aside from patient comfort probably. I personally think giving ESAs to hospitalized patients is largely a waste due to their inflammation, infection, etc.
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
Do you advise your patients with CKD to consume a set amount of fluids daily in an attempt to prevent disease progression?
No. I advise them to limit fluid intake and drink only according to thirst. There 3 caveats to this.Patients with a history of kidney stones need to drink more water.Patients with hypernatremia need to drink more water. Whether drinking more water will prevent bladder cancer has been debated, but I ...
Do you recommend checking a serum phosphorus level in patients with recurrent nephrolithiasis?
For patients with pure calcium phosphate or mixed calcium phosphate/oxalate nephrolithiasis, l routinely check serum phosphorus as part of a panel that also contains serum calcium, PTH, creatinine, and 25-vitamin D, looking for primary hyperparathyroidism, a surgically curable cause of these stones....
Would you opt to start IV iron load, maintenance iron therapy, or no iron at all in a patient with ESKD on hemodialysis who has a stable hemoglobin level at around 12.0 g/dL but also has low iron stores as evidenced by a low transferrin saturation and ferritin?
I routinely give an IV iron load to such patients. Iron is required for metabolic functions other than hemoglobin production and, for example, studies in non-anemic iron-deficient patients with heart failure consistently demonstrate improved outcomes with IV iron administration. If the patient is no...
What is your approach for ESKD patients on peritoneal dialysis who request to do their own exchanges during a hospitalization?
I am very fortunate in that the University of Colorado Hospital has PD nurses on call 24/7. When patients are hospitalized, they are all, even those who usually do CAPD at home, treated with APD performed by the on-call PD nurse. For liability reasons, all machines are set up by the PD nurses. I rea...
Would you avoid fistula placement in patients with ESKD secondary to scleroderma?
I do not have any direct experience with this, but I would be very reluctant to place a fistula in someone with scleroderma.