Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
What advice do you offer to patients with recurrent nephrolithiasis who are on a tube feeding diet and seeking stone prevention guidance?
As always, it is important to know their stone composition, so that you tailor the invention appropriately. Regardless, I have seen many such patients with calcium oxalate stones. It is important to get detailed information about their tube feeding formula and dosing, because tube feedings can vary ...
Would you consider treating hypercalcemia with CRRT and regional citrate anticoagulation for a dialysis dependent patient who does not respond to bisphosphonate therapy and low calcium dialysate bath?
Although CRRT with citrate anticoagulation may be effective in treating significant hypercalcemia, this is only a temporary solution if the underlying etiology of hypercalcemia persists. The underlying cause of hypercalcemia should be addressed, if possible. If the underlying etiology cannot be easi...
Do you recommend holding metformin in a patient with chronic kidney disease who has an upcoming CT contrast study?
I actually do. Over the years I have seen a number of cases of metformin induced lactic acidosis. Although it is very hard to predict who will have it. I would like to be on the safe side.
Do you have a higher threshold regarding when to hold bevacizumab for proteinuria in patients who had known baseline proteinuria from diabetic nephropathy?
This is an interesting question. It’s not uncommon to have patients with cancer who have other underlying conditions that may lead to proteinuria. I don’t have a higher or lower threshold to recommend holding VEGF inhibitors, but in all patients who are on them who develop proteinuria, the degree of...
What is your approach to exit-site prophylaxis in patients receiving peritoneal dialysis who are unable to tolerate gentamicin or mupirocin due to allergic reactions?
There are a number of other antibacterial regimens that have been proposed, most of which are either ineffective or actually pose a higher risk of fungal infections (at least in diabetic patients). These include polysporin triple antibiotic ointment and medical-grade antibacterial honey. The only ag...
What are your management strategies for patients with recurrent uric acid nephrolithiasis and chronic kidney disease who have persistent hypocitraturia and acidic urine pH?
This is a good question. The primary goal is to correct the urine pH to at least 6 and preferably 6.5, regardless of renal function. Hypocitraturia is not a critical issue in uric acid stones disease, though it will likely respond to therapies listed below. Concurrent chronic kidney disease does not...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
What is the minimum eGFR at which we should avoid initiating SGLT2i therapy?
The minimum eGFR to avoid initiating SGLT2i is different depending on the medication. Canagliflozin or Invokana is less than 30 ml/min. Dapagliflozin or Farxiga is less than 25 ml/min. Empagliflozin or Jardiance is less than 20 ml/min. With recent study suggests you still can continue the therapy wi...
Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?
I understand the physiology upon which the cinacalcet suppression test is based. However, I have not used it in my practice. Once I see a discordant result between a parathyroid hormone level and its main determinants: serum calcium, phosphorus, and vitamin D (or 1, 25-vitamin-D), I use a sestamibi ...