Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you stop hemodialysis and monitor the patient in clinic, or taper dialysis frequency first, when urine output and lab markers suggest kidney recovery in a hemodynamically stable outpatient with dialysis-requiring AKI?
The absence of interdialytic weight gain is generally the first sign of recovery from acute kidney injury (AKI). However, one thing to avoid getting burned on is the patient with severe heart failure who was previously on high-dose diuretics that were stopped when dialysis began. They may have signi...
How do you manage a patient on peritoneal dialysis who develops a single episode of cloudy effluent with a low cell count and no organisms on Gram stain while remaining clinically well?
There is a relatively broad differential diagnosis for patients presenting with cloudy dialysis fluid that appears to be non-infectious in nature (Rocklin & Teitelbaum, PMID 11208038). While the differential for fluid that is totally acellular is relatively narrow - fibrin or triglycerides are the u...
What is your approach to the diagnosis of acute kidney injury suspected secondary to renal infarction from thromboembolic disease?
Renal infarction should be suspected in a patient with acute flank/abdominal pain, hematuria, and elevated LDH with normal AST and ALT, especially in the setting of atrial fibrillation, left ventricular thrombus, dilated cardiomyopathy, prosthetic heart valve, renal artery injury/dissection or hyper...
What is your approach to the use of erythropoiesis-stimulating agents in pregnant patients with anemia and advanced chronic kidney disease?
Anemia in pregnancy with advanced CKD is multifactorial - partly dilutional due to increased intravascular volume, partly due to low erythropoietin levels from CKD, and potentially iron deficiency, depending on dietary intake. Hg levels < 7 g are associated with increased maternal and fetal morbidit...
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...
Would you start potassium citrate for a patient with normal urine citrate levels, but who suffers from recurrent calcium oxalate nephrolithiasis and no identifiable risk factors on 24 hour urine studies, as a method of increasing urine citrate levels to further prevent stone formation?
No. I am not aware of data that raising urinary citrate levels above normal is helpful in the prevention of calcium-based kidney stones. My next step would be to encourage the patient to improve dietary and fluid consumption compliance. If the patient cannot comply, my last option would be to go to ...
How do you decide in older adults with newly diagnosed stage 2 hypertension when to start with two antihypertensive agents versus taking a more cautious approach due to concerns about potential orthostasis, frailty, or polypharmacy?
Starting Dual Therapy vs. a Staged Approach in Older Adults with Newly Diagnosed Stage 2 HypertensionThe core question isn't just how high blood pressure is; it's how much treatment this patient can safely absorb.In geriatric cardiology, cardiovascular risk reduction and treatment-related harm are t...
Do you recommend temporarily holding hydroxyurea prior to and after a native kidney biopsy to prevent procedure related bleeding complications?
I would recommend temporarily holding hydroxyurea prior to a native kidney biopsy if the patient has hydroxyurea-induced thrombocytopenia, provided that the hematologist believes a brief interruption is safe.
For a renal transplant patient on chronic immunosuppression with resolved esophageal symptoms (epigastric pain and intermittent dysphagia), does the presence of minimal CMV-positive cells on esophageal biopsy warrant preemptive antiviral therapy, or is clinical monitoring sufficient?
All things equal, in the average patient, if a patient has rare/minimal CMV-positive cells, it could occasionally represent a minimal infection or an incidental finding. However, in a transplant patient who is on immunosuppression, and especially one who has had recent symptoms (such as dysphagia in...
When do you refer for peritoneal dialysis catheter placement in a patient with advanced chronic kidney disease who does not currently have dialysis needs but does have a progressive decline in eGFR?
The question, of course, is whether to place the catheter early, when the patient does not yet require dialysis and then need to provide catheter care (e.g., weekly flushes), or to delay catheter placement and risk needing to start urgently, or, much worse, risk placement of a tunneled dialysis cath...