Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
Do you routinely discontinue SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease due to concern for volume depletion?
I would temporarily hold SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease if they are at risk of volume depletion (i.e. reduced oral intake, vomiting or diarrhea, high fevers with insensible fluid losses). Holding SGLT2 inhibitors in these acutely i...
Do you temporarily hold diuretics when measuring 24-hour urine calcium levels in the evaluation of primary hyperparathyroidism?
It is mandatory to stop diuretics at least 2 weeks before evaluating a patient for PHPT. One should have a fasting blood sample on the morning of the end of the collection for calcium phosphate and PTH to complement the urine collection. Thiazide-type diuretics raise serum calcium and lower urine ca...
What are your management strategies for patients with bradycardia post-kidney biopsy who received lidocaine for local anesthesia?
In the management of patients with bradycardia post-kidney biopsy who received lidocaine for local anesthesia, one must distinguish between vasovagal reaction and Local Anesthetic Systemic Toxicity (LAST). Vasovagal reaction is typically characterized by bradycardia with hypotension, lightheadedness...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
Do you treat persistent microscopic hematuria as a clinically meaningful sign of ongoing disease activity in a patient with IgA nephropathy whose proteinuria is well controlled on current therapy?
The KDIGO 2025 guidelines still regard proteinuria (ideally <300 mg) as the validated early biomarker for IgA nephropathy (IgAN), but persistent hematuria is an independent risk factor for disease progression and should be monitored closely as the marker for glomerular inflammation. Depending upon e...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
How do you decide when to refer for an access angiogram in a patient on hemodialysis with a drop in Kt/V but no other signs of access dysfunction?
In a JASN study (Coyne et al., PMID 9259360), the 3 comment causes of low Kt/V were: 42%- from poor blood cleaning due to low blood flow or shortened HD time 25% - due to recirculation from access dysfunction or reversed needles 33% - no cause identified, but on subsequent monthly testing, it normal...