Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
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 ...