Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
Do you target specific Kt/V values or specific duration of hemodialysis sessions for hospitalized patients who you are planning several consecutive and progressive hemodialysis initiation sessions?
We do not target a specific Kt/V, but employ an incremental initiation protocol for new ESRD patients for the first 3 treatments to avoid dysequilibrium syndrome: day 1 - 2 hours at Qb of 200ml/min, Day 2 - 2.5 hour at Qb of 250 and Day 3 - 3 hour at Qb of 300. The treatments are performed daily if ...
Do you recommend any CRRT prescription changes for optimal clearance for patients with AKI who are on a reduced blood flow rate due to concurrent regional citrate anticoagulation?
In distinction to conventional HD, solute clearance in CRRT is limited by dialysate/replacement solution flow, not blood flow. So, no, I do not make changes in the CRRT just because of a decrease in blood flow rate.
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
Is there a BMI cutoff for which you would refer a patient needing a native kidney biopsy to interventional radiology?
I refer all my patients who require a kidney biopsy irrespective of BMI to our in-hospital Interventional Nephrology service. They evaluate the depth of the kidney from the skin surface with ultrasound and decide whether they will be able to obtain adequate renal tissue for diagnosis. If the kidney ...
Does your treatment strategy differ when managing patients with recurrent calcium oxalate monohydrate versus calcium oxalate dihydrate stones?
I manage calcium oxalate monohydrate and calcium oxalate dihydrate stones the same way. Based on my laboratory studies of calcium oxalate crystallization, the differentiating feature between these two stone types is likely related to differing inhibitor properties of urinary proteins; forming the di...
Do you recommend stopping triamterene in patients with recurrent kidney stones who have stone composition results consistent with calcium based stone disease?
No. Decades ago, some triamterene containing kidney stones were reported. However, I have not seen one in many years. Typically, when I start a thiazide-type diuretic for the treatment of hypercalciuria, I do not add a potassium blocker since my patients have been instructed in a sodium-restricted d...
Do you have a preferential 24-hour urine lab test between urine urea nitrogen, urine protein catabolic rate, and urine sulfate when evaluating a recurrent calcium based stone former who has hypercalciuria presumed secondary to excess animal protein intake?
Urine urea nitrogen and urine protein catabolic rate are functionally equivalent measures of protein intake (simple calculation to convert urea to protein catabolic rate). The generally accepted protein catabolic rate target is 0.8 - 1.0 g/Kg, though I do subjectively adjust my patient goals for bod...
What is your approach to dosing sodium thiosulfate for a patient with ESKD who is receiving CRRT?
It seems a bit oxymoronic, mutually exclusive, contradictory, - not sure if any of those are the right words. But if a patient needs CRRT, I dont think STS is something I am worrying about. It is not something that works right away, not even close. It can be missed for a while until patient is back ...