Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
Do you recommend holding ACE inhibitors, ARBs, and SGLT2 inhibitors for patients with chronic kidney disease and malignancy who are about to start high-dose intravenous methotrexate?
This is obviously an opinion-based question since there are no clinical data on this topic. If a patient has risk factors for AKI (underlying CKD, advanced age, low body mass) then it may be reasonable to hold RAAS blockers prior to treatment and resume following the completion of that cycle of high...
Do you recommend dosing potassium citrate three times or two times daily for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I recommend twice daily dosing to help with compliance. I monitor 24-hour urine citrate and increase the dose rather than frequency if adequate urine levels are not achieved. Stephen B. Erickson, MD
Between mean arterial pressure (MAP) and blood pressure (BP), which do you use when prescribing hemodialysis to instruct a hold on additional ultrafiltration should the value become too low?
I believe the data on systolic blood pressure and outcomes is better than the other values of blood pressure measurement. As such I use the systolic blood pressure mainly to decide on ultrafiltration, medications and other therapy. Of course patient symptoms are also very important.
Do you preferentially avoid use of piperacillin-tazobactam for empiric anti-pseudomonal coverage in hospitalized patients due to risk of nephrotoxicity?
The bulk of published data indicates that the onset of nephrotoxicity in patients receiving piperacillin-tazobactam plus vancomycin seldom occurs before 3 days of the combination. Thus, I do not object to initiation of this combination empiric therapy, but, as in all cases, therapy must be reevaluat...
Do you recommend avoiding ESAs in ESKD patients with heart failure who require a left ventricular assist device?
I have not had such a patient as of yet but my sense would be to give them ESAs. We want to keep the Hgb above a certain level and avoid blood transfusions. The most logical way to accomplish that would be an ESA.
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
How do you approach prevention of kidney stones in patients with an ileal diversion and recurrent nephrolithiasis?
My first step, is to perform a kidney stone analysis. Kidney stones are not a "monolithic" disorder; rather they are "symptoms" of a diverse group of renal mineral metabolism and acid-base disorders. my next step in this case would be to obtain a 24-hour urine supersaturation study. I would be parti...
Do you recommend genetic testing for patients with a family history of polycystic kidney disease and who meet the imaging criteria, but the specific genetic variant in the family is unknown?
This is an interesting and evolving area. I think this is somewhat dependent on a patient's own interest after discussing the following things: In some cases, even with family history and imaging criteria, a genetic diagnosis may not be available from testing (due to inability to detect or perhaps i...
Do you restrict topical diclofenac use in your patients with chronic kidney disease?
It is a great question. I normally don't but I always do it with a touch of hesitation. I believe the absorption is minimal but it also depends of the degree of use. At this time, when narcotics are in restricted use and oral NSAIDs are not a good option in patients with CKD, topical NSAIDs may be t...