Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to intensifying the hemodialysis prescription for patients found to have dialysis-related amyloidosis?
These are the patients in whom hemodiafiltration would be the most useful. If not available then using the most high flux dialyzer, longer dialysis times are other options to remove more b2 microglobulin.
Would you recommend against starting SGLT2 inhibitors in patients with a history of struvite nephrolithiasis who also have proteinuria and chronic kidney disease?
Yes! Although SGLT2 inhibitors are helpful in most patients with proteinuric chronic kidney disease, they can also exacerbate some coexistent conditions. Increasing glycosuria predisposes patients to UTIs. For patients with struvite stones, SGLT2s would likely exacerbate the infection and increase s...
Are there situations when you recommend initiating dialysis in patients with advanced chronic kidney disease, even if their symptoms are minimal and electrolytes are well controlled with medical management?
I try to leave a lot of the decision-making to my patients if there is no absolute need to initiate dialysis. There would have to be a good reason... an upcoming transplant or other surgery, minimal symptoms that still are negatively impacting QoL/ability to work or exercise, etc.
How would you manage hemodialysis for an ESKD patient who presents with a phosphorus of 1.6 mg/dl and potassium of 6.5 mEq/L without ECG changes?
Don’t panic. EKG changes correlate not with plasma K but with intra/extra cell K ratio, that ratio is what determines arrhythmias and muscle weakness, so while agreeing with dialysis with usual bath K (2.0?), check Hb and occult blood stools, review diet and recounsel, is the patient underdualized? ...
Do you increase the frequency of hemodialysis for patients with calciphylaxis?
Optimally I would: Stop or change warfarin Stop any Vit D or analogs Dialyze on lower Ca Bath (dialysate) Stop CA-based PO4 binders Give Vit K Increase the frequency of HD Give sodium thiosulfate as tolerated by patient's [HCO3] but I would prefer to increase HD than cut the dose
Do you perform a kidney ultrasound in patients following a kidney biopsy to evaluate for post-procedural complications?
I agree with Dr. @Dr. First Last. There is a high incidence of hematoma formation post-kidney biopsy when evaluated by ultrasound (70%) or CT scan (90%). This will result in unnecessary ultrasounds leading to stress for patients and physicians. I usually get a hemoglobin level 4-8 hours after the bi...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
Do you target specific Kt/V values or specific duration of hemodialysis sessions for hospitalized patients who you are planning several consecutive and progressive hemodialysis initiation sessions?
We do not target a specific Kt/V, but employ an incremental initiation protocol for new ESRD patients for the first 3 treatments to avoid dysequilibrium syndrome: day 1 - 2 hours at Qb of 200ml/min, Day 2 - 2.5 hour at Qb of 250 and Day 3 - 3 hour at Qb of 300. The treatments are performed daily if ...
Do you recommend any CRRT prescription changes for optimal clearance for patients with AKI who are on a reduced blood flow rate due to concurrent regional citrate anticoagulation?
In distinction to conventional HD, solute clearance in CRRT is limited by dialysate/replacement solution flow, not blood flow. So, no, I do not make changes in the CRRT just because of a decrease in blood flow rate.