Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your preferred initial imaging choice for a patient suspected of having renal artery stenosis who does not have any contraindications to imaging contrast media?
If the suspicion is for atherosclerotic-related renal artery stenosis (>55 years old, history of systemic atherosclerosis, tobacco use), then I start with a renal duplex ultrasound. Importantly, I do not get a renal duplex ultrasound on all patients with resistant hypertension. If the suspicion is f...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Do you recommend avoiding combination vancomycin and piperacillin-tazobactam in patients with acute kidney injury?
Personally, I don't think the risk is that high and I won't necessarily recommend against it. If a patient develops worse renal function while on the drugs though, I would have a low threshold of switching to something different. I would also try to avoid vancomycin levels over 30.
What is your approach to anticoagulation in a patient with AKI and cirrhosis who has frequent filter clotting on CRRT?
A meta-analysis (Qi et al., PMID 37186766) compared 348 patients from 9 studies receiving RCA to 127 patients from 5 studies receiving heparin anticoagulation. Among the RCA recipients, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis was 5.3%, 26.4%, and 1.8%, resp...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
How do you address patient concerns regarding the necessity of REMS monitoring when prescribing sparsentan?
I point out to patients that sparsentan itself did not have an increased incidence of liver function abnormalities in trials, and that this REMS monitoring is required out of an abundance of caution because of liver function abnormalities seen with other anti-endothelin drugs like bosentan. Of cours...
Do you use the same hemoglobin target as an ESKD patient for an outpatient with AKI-D who has been receiving dialysis for more than 30 days and is prescribed an ESA?
Yes. The real question is whether Hgb between 10-11 g/dL is better than Hgb between 12-14 g/dL for just ESRD patients or even the General population. My guess is the latter. Lower Hgb is likely to be associated with lower bp and less stroke/CV disease. The benefit that the general population will de...
How do you titrate midodrine in your patients with ESKD who suffer from intradialytic hypotension?
I start out with 10 mg an hour before coming to dialysis and go up at high at 20 mg depending on the response.
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...