Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Under what circumstances would you initiate hemodialysis for fetal protection in a pregnant patient with CKD Stage 4 who does not have any usual indications to start dialysis?
There is no one-size-fits-all approach. You do want to make sure the BUN does not get too high, which can be achieved with dialysis. Note that studies looking at very long dialysis times and treatment hours were for established dialysis patients. In patients with AKI or CKD stage 4, there is still s...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What is your approach to timing of the plasma, arterial, and venous urea collections in a patient on hemodialysis for whom you are attempting to calculate arteriovenous fistula recirculation?
I use the two-needle slow blood flow technique to calculate arteriovenous fistula recirculation: After initiation of hemodialysis, turn off ultrafiltration in approximately 30 minutes and then draw urea samples from the arterial and venous ports of the blood lines. Reduce the access blood flow rate...
What is your approach to interpretation of 24 hour urine stone risk studies that persistently demonstrate elevated urinary creatinine excretion despite a reliable patient who denies improper collection?
I would start with a physical examination, looking at muscle mass. Urine creatinine comes from serum creatinine, which in turn comes from muscle mass. Patients with high muscle mass will have high serum and urine creatinine.
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
Would you add regional citrate anticoagulation to a CRRT prescription for a patient on systemic heparin but who experiences recurrent filter clotting?
Depending on the need for CRRT vs PIRRT, if I could, I would go with PIRRT first depending on when the clotting occurs in the treatment. Our typical PIRRT treatment is 40 liters over 8 hours, and we can do that daily if needed (often at night), and it totally controls the chemistries and usually vol...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
A practical question! My answer is nuanced. If serial imaging, preferably CT, shows an increase in stone volume on their current treatment program (metabolic stone activity), yes. I think the benefit of controlling their stone formation outweighs the risks and inconvenience of a urinary catheter. I ...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...