Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
Do you recommend any specific testing for patients with recurrent nephrolithiasis and suspected absorptive hypercalciuria?
I would consider genetic testing in this situation, although it would not alter my recommendations for diet and thiazide diuretic treatment. I would also look for primary hyperparathyroidism. Counterintuitively, parathyroid hormone increases absorption of urinary calcium; that’s why HPT patients are...
Are there instances when you recommend using sevelamer for patients with recurrent calcium phosphate nephrolithiasis?
Basically no. The main drivers of calcium phosphate stones are mildly alkaline urine and hypercalciuria. Primarily, I am looking for the causes of these conditions. Urine volume is always important. If urine phosphate is elevated, my first intervention in that regard is dietary. Stephen B. Erickson...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...
Are there instances when you recommend against a kidney biopsy in a patient with a single kidney who otherwise has indications for a biopsy, consents, and has no medical contraindications for the procedure?
I don't think so. These days the risks of having to do nephrectomy after kidney biopsy is very small and having a single kidney is a weak argument for not doing kidney biopsies. In my practice, a patient with a single kidney would get biopsied by interventional radiology to minimize the risk as much...
Do you prefer sodium bicarbonate or sodium citrate in your chronic kidney disease patients with metabolic acidosis?
I have always used sodium bicarbonate in this scenario. The easiest/cheapest way to prescribe it is to advise patients to use Arm & Hammer baking soda, which is essentially sodium bicarbonate. I gm of sodium bicarbonate provide 11.9 mEq of bicarbonate; therefore one half of a teaspoon (about 2.5 gm)...
Do you offer home administration of ESAs for your patients with anemia of chronic kidney disease?
Yes, it the patient's prescription drug plan allows it. Traditional Medicare does not allow home administration of ESAs since they are covered under part B rather than part D. However, many Medicare Advantage and commercial insurers do allow for home administration of ESAs, so I offer that option to...
How do you approach consults regarding clearance of patients with chronic kidney disease for surgery?
I never provide "clearance" for surgeries. I comment whether kidney disease is stable and whether there are any contraindications to surgery, medications, etc. based on the kidney disease.
Would you avoid SGLT2 inhibitors in patients with nephrostomy tubes?
I probably would unless a compelling reason to use. I worry about risk of infection and would imagine that depending on the reason for the nephrostomy tubes might limit the potential upside of using these agents. Maybe in future years as we gain more experience in non-study populations my answer wil...