Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend temporarily holding SGLT2 inhibitors in patients with CKD who are undergoing CT imaging with intravenous contrast?
Probably should hold the morning dose before giving contrast. The risk I would assume is very low, likely lower than giving lasix prior to the contrast which we normally do not hold.
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
Are there instances when you recommend kidney stone disorder gene testing in patients suspected of having cystinuria?
If the patient has a stone analysis showing pure cystine, I consider that proof positive of homozygous cystinuria and do not recommend genetic testing for the patient. However, I suggest that first degree relatives get genetic testing for cystinuria, and, if homozygous, I recommend preventive treatm...
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