Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...
Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?
The short answer is to add a binder. The best case for this is with Ca-based binders, for which many experts recommend a maximum daily dose of 1 gm of elemental Ca. (That’s only 6 CaAc tabs -169 mg of Ca per 667 mg). Another limit that is supported by some data is for sevelamer. The binding per 800 ...
Do you have different 24 hour serum sodium correction targets for patients with severe, moderate, and mild hyponatremia?
It is known that overly rapid correction is significantly more likely to cause osmotic demyelination syndrome (ODS) in patients with more severe hyponatremia, particularly when initial serum sodium is ≤105 mmol/L. Since transcellular water movement is mediated by changes in osmolality across the cel...
Under what circumstances do you order ambulatory blood pressure monitoring in a patient receiving maintenance hemodialysis?
I have done it when the patient is unable to take their bp meds prior to coming for dialysis, and pre-dialysis BP remains high. Other instances are when there is a large difference between the pre and post-dialysis blood pressure readings.
What is your approach to treating hypercalcemia secondary to immobilization?
My first approach is to have the patient become mobile if at all possible, even just increasing mobility in bed by doing leg and arm exercises, which can help, and getting up and walking is preferable if at all possible. Physical therapy is also helpful. I would make sure that the patient is well hy...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
How would you manage serum sodium monitoring for an asymptomatic outpatient with newly diagnosed SIADH and a serum sodium level of 127 mEq/L, for whom you are initiating treatment with urea?
Based on the current available data, treatment of SIADH with urea is effective with a very low risk of overcorrection. In a meta-analysis of 23 studies involving 537 patients with SIADH, urea increased serum sodium concentration by a mean of 9.6 mmol/L, and the mean increase in serum sodium after 24...
How would you approach de-intensifying antihypertensives in frail older adults with SBP < 130 mmHg who have nephrotic range proteinuria, given the results of the RETREAT-FRAIL trial?
I would withdraw antihypertensive drugs that do not have any significant anti-proteinuric effect: dihydropyridine calcium channel blocker, beta blocker, alpha-1- blocker, hydralazine, and clonidine. Thiazide/loop diuretic may also be withdrawn if it is not needed for control of edema due to the neph...
Do you recommend outpatient dialysis initiation or inpatient admission for dialysis initiation in a CKD Stage 5 patient with stable electrolytes but experiencing nausea and vomiting related to uremia?
For a patient with CKD Stage 5 who has stable electrolytes but is experiencing nausea and vomiting from uremia, the patient can be managed with outpatient dialysis initiation. However, if the patient is at high risk for dialysis disequilibrium syndrome (DDS) due to markedly elevated BUN, I prefer in...
Do you take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...