Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend malic acid supplementation for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
F. Malic acid, like citric acid, is metabolized as a protonated acid and used as a metabolite—it produces no alkali. Malate is metabolized as an acid and in doing so takes up a proton—just as citrate does—producing new bicarbonate, and so is an alkali.Rodgers et al., PMID 24059642 reports malic acid...
What is your approach to intensifying the hemodialysis prescription for patients found to have dialysis-related amyloidosis?
These are the patients in whom hemodiafiltration would be the most useful. If not available then using the most high flux dialyzer, longer dialysis times are other options to remove more b2 microglobulin.
Would you recommend against starting SGLT2 inhibitors in patients with a history of struvite nephrolithiasis who also have proteinuria and chronic kidney disease?
Yes! Although SGLT2 inhibitors are helpful in most patients with proteinuric chronic kidney disease, they can also exacerbate some coexistent conditions. Increasing glycosuria predisposes patients to UTIs. For patients with struvite stones, SGLT2s would likely exacerbate the infection and increase s...
Are there situations when you recommend initiating dialysis in patients with advanced chronic kidney disease, even if their symptoms are minimal and electrolytes are well controlled with medical management?
Not many, but yes. If a patient had an AV graft placed for dialysis, and it has been longer than a month since the surgery, then using it if eGFR is less than 10 seems appropriate. Also, very low eGFR is probably an indication by itself. Usually, patients have symptoms before that occurs. One has to...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
How would you manage hemodialysis for an ESKD patient who presents with a phosphorus of 1.6 mg/dl and potassium of 6.5 mEq/L without ECG changes?
Don’t panic. EKG changes correlate not with plasma K but with intra/extra cell K ratio, that ratio is what determines arrhythmias and muscle weakness, so while agreeing with dialysis with usual bath K (2.0?), check Hb and occult blood stools, review diet and recounsel, is the patient underdualized? ...
Do you increase the frequency of hemodialysis for patients with calciphylaxis?
Optimally I would: Stop or change warfarin Stop any Vit D or analogs Dialyze on lower Ca Bath (dialysate) Stop CA-based PO4 binders Give Vit K Increase the frequency of HD Give sodium thiosulfate as tolerated by patient's [HCO3] but I would prefer to increase HD than cut the dose
Do you perform a kidney ultrasound in patients following a kidney biopsy to evaluate for post-procedural complications?
I agree with Dr. @Dr. First Last. There is a high incidence of hematoma formation post-kidney biopsy when evaluated by ultrasound (70%) or CT scan (90%). This will result in unnecessary ultrasounds leading to stress for patients and physicians. I usually get a hemoglobin level 4-8 hours after the bi...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...