Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...
How do you advise your patients to optimally store a recently passed kidney stone to ensure it can later undergo composition testing?
I am not aware that kidney stone composition changes significantly ex vivo. Calcium oxalate dihydrate will gradually change to monohydrate, but that does not influence my treatment recommendations. The more challenging problem is capturing the stone for analysis. For patients with colic, I send them...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
In a patient with acute stroke/ICH/SDH/hyperammonemia at risk for rebound edema with new onset renal failure, do you prefer CRRT versus low and slow HD?
In the acute period (first 72-96 hours after ictus), my personal preference is CRRT due to the theoretical advantage of hourly titration of ultrafiltrate. I don't know if it really matters though. As for the frequency of laboratory evaluations, I don't find more frequent than q4 hours to be useful, ...
How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?
For those with a history of skin cancers prior to transplant would recommend every 6 months. For those with no history of skin cancer I recommend skin checks every 6 months starting 1-2 years after transplant. Those at highest risk are the Latino and Caucasian propulations but even those in the less...
Do you recommend a kidney ultrasound to evaluate for microcystic changes when caring for a patient with chronic kidney disease suspected secondary to chronic lithium use?
Not sure if the ultrasound will add to management beyond lab values and routine ultrasound for patients with CKD. The question comes if someone has microcystic changes and normal creatinine levels, would that indicate a need for a change of therapy? In the past, lithium has been a very effective (ma...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Do you transition to non-tablet formulations of potassium citrate in patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia who are noticing intact tablets in their stool?
Wax matrix slow release tablets release their contents but need not dissolve and are often seen by patients. I never change meds just because of signs of the tablets, I watch the 24 hour urine K, citrate, pH, and the balance between ammonia and sulfate. If the pills are working K and pH and citrate ...