Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
How frequently do you check serum electrolytes for patients on CRRT?
When starting out CVVH and with unstable patients who have very abnormal electrolytes, as often as even every 6 hours. In patients who have been on stable dose of cvvh and electrolytes are within goal, even twice a day may be enough.
What is your approach to weight loss interventions for patients with recurrent nephrolithiasis and obesity?
Obesity tends to be a little more common in stone formers. Integrating weight loss with stone prevention features can be tricky. We are fortunate to have a dietitian dedicated to our Stone Clinic and I rely heavily upon her expertise. More fluid, preferably water, and a diet tailored to the patient’...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
How do you choose between eculizumab and ravulizumab for patients with acute kidney injury from complement mediated thrombotic microangiopathy?
For atypical HUS (aka complement-mediated TMA), both eculizumab and ravalizumab are FDA-approved therapies and are technically equivalent.The main advantage of ravulizumab is that it is a re-engineered form of eculizumab that extends its half-life to 51.8 days vs 11.3 days for eculizumab.Of note, me...
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...