Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
Would you recommend temporary transition to hemodialysis in a peritoneal dialysis patient who has risk factors, such as recurrent peritonitis, for the development of encapsulating peritoneal sclerosis?
In summary, yes. However, just like anything in medicine, every patient is different, and risk factors specific to the patient have to be weighed against the benefits of continuing PD.
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
What is your approach for managing patients with recurrent nephrolithiasis who have elevated urinary cystine levels but calcium oxalate stone composition?
This is usually heterozygous cystinuria, and the urine cystine is in the range of 50 mg. Supersaturation with cystine is absent, and the cystine can be ignored. Rarely, urine cystine is high enough to produce stones, and I treat both stone risk factors. In all cases where urine cystine is above 100 ...
What is your approach to managing patients with suspected osmotic nephrosis from monthly IVIG infusions?
If the patient develops IVIG-induced osmotic nephrosis, the current IVIG therapy should be suspended, and treatment of the AKI is supportive. If IVIG needs to be restarted once the patient’s renal function recovers, there are several preventive strategies that can be tried. The patient should be swi...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
Would you support a modified chlorthalidone treatment regimen involving a drug holiday of two days per week for patients with recurrent calcium based nephrolithiasis who have less erectile dysfunction side effects when temporarily off of the thiazide diuretic?
I know of no study data to answer the question. The half-life of chlorthalidone is approximately 40–60 hours. Whether the drug would wear off enough during a 24 hour drug holiday to achieve an erection would be the first question to answer. The second is a risk benefit question: an increased risk of...
Are there instances when you offer dialysis to patients with high-risk hepatorenal syndrome who are not transplant candidates?
I never say never. The diagnosis of HRS is not 100% accurate. Particularly in a young person, but in others as well, if it seemed like there was an acute event, I might offer a time limited period of dialysis.
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Mother treatment for remembrance GN is very important, and monitoring your protein as well as PLA2R are extremely important as well.