Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
Will you use vadadustat in place of an ESA in treating anemia of chronic kidney disease?
Vadadustat is approved by the FDA only for patients who have been on dialysis for at least 3 months. It is not approved for patients with CKD not on dialysis. Its efficacy and safety are comparable to that of ESAs. I would consider using vadadustat in two patient populations: those on home dialysis ...
When do you recommend genetic testing prior to kidney transplantation for a patient with ESKD secondary to FSGS?
Agree with Dr. @Dr. First Last's assessment. If a transplant candidate has clear evidence of secondary causes of FSGS (weight-based, medications, infections, autoimmune) and biopsy showed only patchy podocyte effacement, then I do not think the genetic testing would add much. The post-transplant mon...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Is there a role for vadadustat in addition to an ESA in ESKD patients who are hyporesponsive to ESA’s alone?
I am not aware of any published studies of HIF-PHIs such as vadadustat used in combination with ESAs in ESKD patients who are hyporesponsive to ESAs alone. The vadadustat label recommends pausing vadadustat treatment for patients receiving ESA rescue for Hb <9 during the transition phase from ESAs, ...
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?
I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is...