Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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?
No. I refer most of my stone patients to the stone clinic dietitian who takes an accurate history of dietary nutrient intakes, including protein, and makes recommendations accordingly. Stephen B. Erickson, MD
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 ...
Are there instances when you recommend oral phosphate for patients with recurrent nephrolithiasis?
Yes. There have been two studies both done long ago looking at the effectiveness of oral phosphates in preventing kidney stones. The first using K Phos Neutral was done at Mayo and showed a decrease in the frequency of stone passage. The second, done in a California system, used K Phos Acid and show...
How long do you wait to repeat a 24 hour urine stone risk study after stopping topiramate in patient with recurrent calcium based kidney stones attributed to the medication?
Assuming normal or near normal GFR, topiramate should be effectively eliminated after approximately 5 days, and urine pH should have returned to its pretreatment level. If more data is desired, a 24-hour urine supersaturation could be collected then. Topiramate predisposes to kidney stones by inhib...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
Are there situations when you a 1K dialysis bath as a long-term outpatient prescription for patients with ESKD?
I cannot think of a situation where this would be needed, and based on available data I recommend against it.In the hospital setting, there is some data that doing dialysis with a 1K bath is beneficial and can reduce mortality, see Singh et al., PMID 34476092.The same cannot be said for long-term di...
Do you wait until serum anti-GBM antibody titers are undetectable before hospital discharge in a patient with anti-GBM antibody disease with renal involvement who is receiving daily plasmapheresis, cyclophosphamide, and steroids?
If such a patient is responding to treatment, titers are declining, is otherwise doing well, and does not have extra-renal issues that would require hospitalization, for example, an ongoing oxygen requirement for lung involvement, they could be managed as an outpatient if pheresis can be arranged. I...
What are the best practices for preparing blood for transfusion in a patient with a kidney transplant to minimize complications?
HLA sensitization via blood transfusions could present problems with transplant candidates (diminishing the chance of finding a compatible donor) and for transplant recipients (greater hazards for deceased censored graft loss, Massicotte-Azarnioch et al., PMID 33912754). Scornik & Meier-Kriesche, PM...