Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you transition patients with recurrent nephrolithiasis and hypercalciuria off of hydrochlorothiazide in favor of an alternative thiazide diuretic?
No. Assuming the patient tolerates HCTZ well, and it is effective in lowering hypercalciuria, I continue it. Most of the thiazide research has been done using this agent. Stephen B. Erickson, MD
What is your approach to managing acidic urine in patients with recurrent uric acid nephrolithiasis who have normal urinary citrate levels?
After appropriate dietary advice from our Stone Clinic dietitian, I preferentially prescribe sodium bicarbonate tablets, teaching the patient how to adjust the dose using pH strip testing to reach the desired urinary pH. pH testing should be done frequently, as urine pH is in part dietary dependent ...
Do you routinely use markers or tests other than serum creatinine when estimating GFR to determine if patients with liver failure, not on dialysis, meet criteria for a simultaneous liver-kidney transplant?
This is a good question as eGFR cutoffs of 25ml/min (AKI) and 30ml/min (CKD) are used as criteria for SLK eligibility and yet the accuracy of the creatinine-based equations is known to be sub-optimal in patients with liver cirrhosis. UNOS does not specify the type of equation that should be used.In ...
Do you recommend using vitamin D analogs for patients with CKD and a high PTH but a normal 25-hydroxy vitamin D level?
The answer is that it depends on how high the PTH level is. KDIGO guidelines originally recommended targeting PTH between 65 and 130 for patients with non-dialysis CKD by using nutritional vitamin D if the 25-OH vitamin D level is low and using active vitamin D if the 25-OH vitamin D level is normal...
Below what ejection fraction would you avoid referral for AV access creation in a patient with advanced CKD and heart failure with reduced ejection fraction?
I would not refer a patient with advanced CKD and heart failure with an ejection fraction less than 30-35% for a hemodialysis vascular access for fear of worsening the heart failure. In addition, in my experience, if an arteriovenous fistula is placed in such a patient, it usually does not mature du...
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
Is reduction in proteinuria with SGLT2i dose dependent?
My understanding of dosing with empagliflozin, in particular, is that it is not dose-dependent, thus a dose of 10 mg versus 25 mg will lead to a similar reduction in proteinuria. This is based on data from the EMPA REG OUTCOME trial published in NEJM in 2016. The composite outcome of incident or wor...
Is there a kidney length for which you would no longer recommend attempting a kidney biopsy due to safety concerns and lack of diagnostic yield?
Yes. I definitely do not biopsy very small kidneys. Where you draw the line is the question. I think it is not only the size of the kidney but also the height of the patient. It may be OK to biopsy a patient with a 7.5 cm kidney who is 4 feet 8 but not OK to biopsy an 8 cm kidney in a patient who is...
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...