Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Do you initiate peritoneal dialysis with an incremental strategy to ease patients into their treatment, even though it might lead to frequent lab monitoring and the risk of underdialysis?
The benefits of incremental peritoneal dialysis, in patients who have residual kidney function, cannot be overstated. In addition to "easing into treatment" as suggested in this question, other benefits include: reduced exposure to dialysate and glucose in dialysate, potentially preserving the perit...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
Do you recommend an overall decrease in daily dietary animal protein intake or focus more on decreasing the actual portion size of animal protein per meal in your patients with recurrent calcium based nephrolithiasis who have hypercalciuria?
I find initiating dietary changes is more difficult for my patients than initiating or changing medications. Regarding reducing dietary animal, protein consumption, I try to work with patient preferences. I have no strong preference of my own.Stephen B. Erickson, MD.
Would you recommend starting finerenone for a patient with diabetic kidney disease who has marked improvement from severely increased albuminuria to moderately increased albuminuria following ARB and SGLT2i initiation?
I would certainly discuss with the patient regarding potential benefits as well as risks. This is a joint decision matter, especially if finerenone leads to the need for potassium binders. Make sure first that the ARB dose is maximized with appropriate use of a diuretic.
Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?
I would go with Tenapanor, it is very effective and can generally significantly decrease the binder dosing. The biggest problem with Tenapanor is an increase in stools, not necessarily overt diarrhea. Counsel the patient, have them stop stool softeners and laxatives, and may want to start with 1 pil...
What is your approach to intracatheter alteplase use for hospitalized ESKD patients who are experiencing tunneled dialysis catheter issues?
I do use it in stable patients who do not have any bleeding issues. In others, it would be better to manipulate or exchange the catheter.
Are there instances when you continue phosphate binders for patients receiving CRRT?
Would be very unusual. First, continuous renal replacement therapy (CRRT) is so effective in lowering serum phosphorus concentration if done with the right dose that it is almost never needed to add a binder. Second, usually, patients on CRRT are no longer eating meals, and thus binders do not make ...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...