Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you decide when to treat hypocalcemia in hospitalized patients?
When I think about when to treat hypocalcemia in hospitalized patients, I anchor the decision on three things: symptoms, the absolute calcium level, and the trajectory. First, it’s important to confirm true hypocalcemia: either a serum calcium <8 mg/dL or an ionized calcium <1.1 mmol/L, and to consi...
Do you add an SGLT2 inhibitor to mineralocorticoid receptor antagonist therapy in a patient with primary aldosteronism who is not a surgical candidate, given retrospective data showing significantly lower mortality and cardiorenal events with the combination?
I have expanded the use of SGLT2-INHs beyond the core indications of HFrEF, DM2, and proteinuric CKD to include CV risk reduction for those at higher risk. Patients with primary aldosteronism often have a high ASCVD risk by PREVENT risk calculator, and would benefit from SGLT2-INH use.
How do you determine whether medical or surgical intervention is more appropriate for managing abdominal discomfort due to hepatic cysts in patients with ADPKD?
Management depends on the severity of symptoms, liver morphology, and the degree to which symptoms impair quality of life. Initial treatment is generally conservative, with attention to excluding other causes of abdominal pain and optimizing symptom management. In patients with symptomatic polycysti...
Do you use biomarkers to improve risk prediction in patients with ADPKD during early disease stages?
Yes. The most important validated prognostic biomarker in early ADPKD is height-adjusted total kidney volume (htTKV), typically measured by MRI and interpreted using the Mayo Imaging Classification. KDIGO recommends htTKV as the preferred imaging biomarker for predicting disease progression and iden...
Do you pursue genetic testing in a patient with unexplained CKD whose kidney biopsy shows nonspecific tubulointerstitial nephritis without an identifiable toxic, inflammatory, or systemic cause?
Yes. I have seen some interesting diagnoses such as ADTKD. Genetic testing is simple, non-invasive, and relatively inexpensive. I am all for doing more of it.
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I try to review all data related to stone formation in new patients, including 24 hour urine data, stone analysis and imaging studies for stone burden (past and present). If a patient has prior 24 hour urine data, they likely had prior advice on stone prevention, which is relevant to understanding t...
What is the optimal number of days to hold apixaban prior to a kidney biopsy or tunneled dialysis catheter placement?
If the patient has normal or mild renal impairment (≥30 mL/min), I will hold apixaban for 2 days prior to the procedure. If the patient has moderate to severe renal impairment (<30 mL/min), I will hold apixaban for 3 to 4 days prior to the procedure.
Are there instances when you will forgo dialysis catheter placement and instead use an existing AVF/AVG for an ESKD patient who requires CRRT?
Since continuous renal replacement therapy (CRRT) in our institution can run without anyone in the room, we never do CRRT through a fistula or arteriovenous graft (AVG). While the risk of needles coming out is probably low and the acute drop in pressure may (may?) alarm the machine, the potential co...
What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?
This is an important topic in which terminology and associated definitions are critical because they directly influence management. Historically, hypertensive crisis has served as an umbrella term encompassing both hypertensive emergency and hypertensive urgency. However, accumulating evidence has d...