Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
Would you recommend initiation of cinacalcet in a patient with hypercalcemia and recurrent nephrolithiasis attributed to an atypical presentation of familial hypocalciuric hypercalcemia?
I would really like to know the level of the patient’s parathyroid hormone. If it is low, cinacalcet would probably not be helpful. Stephen B Erickson, MD
Do you recommend restricting alcohol use in patients with recurrent nephrolithiasis?
No. Clearly excess alcohol use is to be avoided. I much prefer water or citrate containing beverages for stone prevention. Beer has some oxalate content and is better avoided. Stephen B. Erickson, MD
Are there instances when you recommend initiation of hemodialysis for patients with severe symptomatic hypercalcemia?
In reality, there are so many treatments for hypercalcemia nowadays that the answer to the question is no. However, I can imagine if a patient is already on the cusp of needing dialysis and is hypercalcemic then I may initiate dialysis a little earlier to fix the hypercalcemia sooner.
How do you approach the management of a patient with an ileostomy who has recurrent prerenal AKI episodes that improve with IV fluids but worsen with each attempt to transition to oral fluids alone?
This can be a difficult problem to deal with. In addition to electrolyte losses and volume depletion, these patients can have problems with caloric and micronutrient/vitamin depletion, so close collaboration with a nutritionist and gastroenterologist is important. Assuming the ileostomy can't be rev...
How do you choose between the different vitamin D analogs for patients with CKD, an elevated PTH, and a normal 25-hydroxy vitamin D level?
In patients with pre dialysis CKD and elevated PTH, I would recommend using ER Calcifediol, which is a 25 D compound. It has been shown to be more effective than Vit D and it does not result in hypercalcemia, hyperphosphatemia, or FGF23 as is seen with VDRAs, calcitriol, paricalcitol, or doxercalcif...
What is your hemoglobin target for patients with nondialysis chronic kidney disease who are receiving ESA therapy?
I again shoot for a hemoglobin of 10-11 g/dL. This will help decrease risk of needing transfusion while minimizing risk of elevated blood pressure.
Do you rely on CT Hounsfield Units to determine stone composition in your patients with recurrent nephrolithiasis who have yet to submit a stone for laboratory based composition testing?
It is somewhat helpful if the value is low, consistent with Uric Acid stones, if higher, not specifically differentiate the calcium stone type. However, since it is part of routine CT stone protocol, it may add some useful information.
Would you consider a BRCA carrier patient for kidney transplantation?
I would certainly consider a potential recipient who is a BRCA carrier. Would involve genetic counseling as well as informed consent regarding the risk of malignancy post-transplant. The mortality risk, depending on co-morbidities, of remaining on dialysis is high and should certainly be considered ...
Would you start a vaptan or monitor an asymptomatic patient with reset osmostat and an average sodium of 126 meq/L?
No therapy is required if the patient has hyponatremia due to a reset osmostat, since the patient will regulate the serum sodium concentration around this new baseline level. The key question is whether or not the patient actually has a reset osmostat. A patient with hyponatremia due to a reset osmo...