Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to establishing a dry weight in a pregnant patient with ESKD on hemodialysis given the expectation of weight increase and pregnancy-related edema?
I think there is a lot of nuance managing weight in pregnant patients with ESRD. Pregnant patients have better fetal and maternal outcomes when clearance is increased. Outcomes are best with >36 hours of dialysis per week. Adjustment of dry weight should include assessment of volume status, blood pr...
Would you recommend proceeding with a kidney biopsy for patients' with Waldenström's macroglobulinemia who have hematuria and normal kidney function?
The answer to this question would certainly depend on the clinical scenario.As we are aware, there are many different etiologies of hematuria. If the patient were to have gross hematuria, then I would start with cross-sectional imaging to ensure there is no nephrolithiasis or tumor and even consider...
How do you approach treatment for patients with proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) with end-stage renal disease who are considering kidney transplant?
Monoclonal gammopathy of renal significance includes a variety of renal pathologies: MIDD (LCDD, LHCDD, HCDD). Monoclonal immunotactoid glomerulonephritis or type 1 cryoglobulinemic glomerulonephritis. Light chain proximal tubulopathy or crystal-storing histiocytosis. C3 glomerulopathy with monoclon...
Does vitamin D supplementation in primary hyperparathyroidism increase the risk of kidney stones?
Hyperparathyroidism does increase the risk of developing kidney stones. A study in New England Journal of Medicine, Broadus et al., PMID 7351950, reported that patients with elevated concentrations of 1,25-dihydroxyvitamin D are at increased risk for kidney stones. The reason is that 1,25-dihydroxyv...
At what serum bicarbonate level do you initiate alkali therapy for patients with chronic kidney disease?
I find that there is a lot of variability between different laboratories in their serum CO2 levels. As such, I don't think this is a one-size-fits-all all situation. At my lab, which tends to have higher CO2 levels, I start bicarbonate therapy once the serum CO2 level is at or below 20 mEq/L.
What is your blood pressure or mean arterial pressure goal in a critically ill patient with acute kidney injury?
The current surviving sepsis guidelines recommend targeting a mean arterial pressure (MAP) of 65 mm Hg with no benefit of targeting a higher MAP in septic shock patients.
Do you avoid performing urine microscopy in patients with AKI who have COVID-19 given concern for potential aerosolization?
No. The risk is very low to non-existent. At the beginning of the epidemic we were doing that but the evidence now is not supporting that practice.
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...
Do you recommend a daily B complex multivitamin for patients with end stage kidney disease who are receiving peritoneal dialysis?
When it comes to Vitamin management in my dialysis patients I defer to my RD, Diane Mettler, who has decades of experience and knows this material better than I ever will. Diane says “I recommend a daily renal vitamin on PD, due to the losses of B-vitamins with dialysis. That being said, if the pati...
How do you approach increasing urinary citrate levels in a patient with recurrent calcium nephrolithiasis who has hypocitraturia, non-acidic urine, and normal serum bicarbonate levels?
For the patient you describe, I would start Moonstone and monitor serum electrolytes and 24 hour supersaturation as I increase the Moonstone dose to optimize treatment. I have no financial interest in this product. Stephen B. Erickson, MD