Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What are the factors that you would consider for the use of ESA in patients with anemia of CKD with a history of stroke or TIA?
Large clinical trials of ESA have indicated increased stroke risk with these medications with TREAT reporting the highest stroke incidence. In this study, "baseline history of cerebrovascular disease was a strong predictor of experiencing a stroke during follow-up; patients with a history of stroke ...
Would you recommend initiation of cinacalcet in a patient with hypercalcemia and recurrent nephrolithiasis attributed to an atypical presentation of familial hypocalciuric hypercalcemia?
I would really like to know the level of the patient’s parathyroid hormone. If it is low, cinacalcet would probably not be helpful. Stephen B Erickson, MD
Do you recommend restricting alcohol use in patients with recurrent nephrolithiasis?
No. Clearly excess alcohol use is to be avoided. I much prefer water or citrate containing beverages for stone prevention. Beer has some oxalate content and is better avoided. Stephen B. Erickson, MD
Are there instances when you recommend initiation of hemodialysis for patients with severe symptomatic hypercalcemia?
In reality, there are so many treatments for hypercalcemia nowadays that the answer to the question is no. However, I can imagine if a patient is already on the cusp of needing dialysis and is hypercalcemic then I may initiate dialysis a little earlier to fix the hypercalcemia sooner.
How do you approach the management of a patient with an ileostomy who has recurrent prerenal AKI episodes that improve with IV fluids but worsen with each attempt to transition to oral fluids alone?
This can be a difficult problem to deal with. In addition to electrolyte losses and volume depletion, these patients can have problems with caloric and micronutrient/vitamin depletion, so close collaboration with a nutritionist and gastroenterologist is important. Assuming the ileostomy can't be rev...
How do you choose between the different vitamin D analogs for patients with CKD, an elevated PTH, and a normal 25-hydroxy vitamin D level?
In patients with pre dialysis CKD and elevated PTH, I would recommend using ER Calcifediol, which is a 25 D compound. It has been shown to be more effective than Vit D and it does not result in hypercalcemia, hyperphosphatemia, or FGF23 as is seen with VDRAs, calcitriol, paricalcitol, or doxercalcif...
What is your hemoglobin target for patients with nondialysis chronic kidney disease who are receiving ESA therapy?
I again shoot for a hemoglobin of 10-11 g/dL. This will help decrease risk of needing transfusion while minimizing risk of elevated blood pressure.
Would you consider a BRCA carrier patient for kidney transplantation?
I would certainly consider a potential recipient who is a BRCA carrier. Would involve genetic counseling as well as informed consent regarding the risk of malignancy post-transplant. The mortality risk, depending on co-morbidities, of remaining on dialysis is high and should certainly be considered ...
Would you start a vaptan or monitor an asymptomatic patient with reset osmostat and an average sodium of 126 meq/L?
No therapy is required if the patient has hyponatremia due to a reset osmostat, since the patient will regulate the serum sodium concentration around this new baseline level. The key question is whether or not the patient actually has a reset osmostat. A patient with hyponatremia due to a reset osmo...
How do you tailor protein intake recommendations for older patients with stages 3-5 non-dialysis dependent CKD, considering the unique metabolic and physiologic factors that influence protein metabolism in this population?
Personally, I would not restrict their protein intake. I would encourage good protein source intake such as eggs, chicken and fish. If serum BUN is very elevated, then it may be worthwhile discussing lower protein intake. If patient become uremic then dialysis should be discussed if indicated.