Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
Are there any special considerations you take with ESA use in hospitalized patients with ESKD who undergo stem cell transplantation?
There really are no guidelines for the use of ESAs in this population. Generally, these patients receive PRBC support for severe and/or symptomatic anemia. We do not prescribe ESAs int this setting because we suspect that the response will be suboptimal given the inflammatory state of these patients...
For outpatients undergoing a kidney biopsy, do you routinely recommend an overnight admission for continued hemoglobin monitoring?
If I perform an uneventful kidney biopsy in the morning on a patient with well-controlled BP and normal hemoglobin, I can observe the patient all day. If vitals are stable and the repeat hemoglobin at 8 hours is stable, I would discharge the patient. However, if I did the biopsy later in the day or ...
Under what circumstances would you consider a bone biopsy in the workup of renal osteodystrophy?
I am always in favor of doing more diagnostic tests. The problem is that it is often practically hard to get a bone biopsy. I would suggest it anytime there a question of what is happening with the bone disease.
How do you approach managing patients with recurrent nephrolithiasis who have low supersaturation profiles due to polyuria and stable stone disease on imaging but do have persistent urinary abnormalities such as hyperoxaluria, hypercalciuria, and hypocitraturia?
If the stone disease is metabolically stable (no change in stone size or increase in number by serial CT imaging), I do not treat urinary chemical abnormalities. Presumably these patients have high levels of urinary inhibitors of crystallization. I encouraged them to continue their successful stone ...
Would you obtain an abdominal non-contrast CT study for further routine evaluation of stone burden in a patient with recurrent nephrolithiasis who recently completed an abdominal iodinated contrast CT study for non-stone purposes?
Often, there is no pre-contrast imaging, and stones cannot be counted well once contrast enters the kidneys. So, unless there was a pre-contrast phase, the contrast CT cannot be considered adequate for determining stone burden and new stone activity. So if either is at issue, I would obtain a non-co...
Would you add amiloride for patients with recurrent calcium nephrolithiasis who have hypercalciuria despite adherence to maximum dose thiazide, low sodium dietary intake, and low animal protein dietary intake?
Amiloride does not lower urine calcium on a chronic basis. In one set of experiments, acute loading lowered urine calcium, but the effect was very brief. I use amiloride to prevent potassium wasting from thiazides and on and off in primary hyperaldosteronism, but it will not lower urine calcium in t...
How do you advise your patients with recurrent nephrolithiasis to avoid consuming more than usual fluid volume on the day of a scheduled 24 hour urine stone risk study?
I tell them to collect on a day that represents their life as lived - how things are in general. I tell them not to show off. I tell them that if the day does not reflect their usual life, I will be misled and may make mistakes in how I treat them for stone prevention.
Would you start a mineralocorticoid receptor antagonist or aprocitentan first in a patient with resistant hypertension and advanced CKD?
My cut offs for prescribing a new mineralocorticoid receptor antagonist are eGFR < 30 (for spironolactone and eplerenone) and eGFR < 25 (for finerenone). I will, however, continue these meds down to an eGFR of 15 if they have been taking them without a history of hyperkalemia, which is often the cas...
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...