Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to interpreting urine studies in patients hospitalized for hyponatremia who have recently received intravenous fluids containing sodium chloride?
Regardless of whether or not the patient receives intravenous saline infusion, a low urinary sodium concentration is still suggestive of reduced tissue perfusion (hypovolemia, CHF, cirrhosis).
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
How do you approach a patient request to decrease hemodialysis time when Kt/V values are above target but serum phosphorus remains poorly controlled?
Reducing time is the wrong approach, phosphorus control is a long-term problem and we all know it will go up and down. I only accept time reduction when approaching end of life to make the patient more comfortable. By then, I would have already started palliative care conversations.
How do you approach the management of persistent hyperphosphatemia in ESKD patients who are non-adherent to phosphate binders?
This is not easy. The first thing I usually do is try and find out why they are non-adherent. Is it due to side effects, cost, etc? Are there social reasons? For example, are they "embarrassed" to take binders if they are out eating with friends? Often, I find that I need to switch binders to see if...
Would you recommend normal saline for pre- and post-LHC hydration in patients with CKD stage III to IV with reduced LV systolic function, and if so, what is a reasonable amount of volume?
The POSEIDON trial, or Prevention of Contrast Renal Injury with Different Hydration Strategies, was a randomized controlled trial that found a personalized hydration strategy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. The tria...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
Do you routinely obtain serum anti-THSD7A and anti-NELL1 tests in your patients with nephrotic syndrome suspected secondary to membraneous nephropathy?
I usually follow up on serum anti-THSD7A titers in patients with kidney biopsy-proven THSD7A (+) Membranous Nephropathy. The Serum NELL-1 titer is not yet commercially available and is available only in the research setting that needs further validation.
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...
Do you recommend daily topical exit site antibiotic use for patients with a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
No. When PD catheters are being accessed only once weekly for flushes, we keep the exit site under a sterile dressing with a chlorhexidine-gluconate-impregnated disc surrounding the exit site. The catheter is accessed only by the PD nurse at the time of flushing, and we do not have the patient perfo...
Do you assess for podocyte detachment in addition to effacement when considering the degree of glomerular injury and potential treatment options following a native kidney biopsy in a patient with proteinuria?
Yes. This is very important in non-minimal change lesions including FSGS, membranous nephropathy, Immunoglobulin A Nephropathy, and the spectrum of Lupus related kidney manifestations.