Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How early do you involve palliative care in the management of a CKD Stage 5 patient who does not wish to pursue renal replacement therapy?
I tend to refer as soon as they are clear that they do not want to pursue renal replacement therapy for a couple of reasons: (1) By CKD 5, even if they do not have uremic symptoms, it is nice to establish longitudinal care with palliative care so that there is a strong relationship with trust when p...
Do you use potassium phosphate for patients with recurrent nephrolithiasis to acidify the urine and prevent certain types of stones?
Short answer: No. That study was done about 40 years ago, I think by the Kaiser group, and was negative. That said, they used a suboptimal dose of 250 mg bid and measured success by stone passages rather than stone growth. However, studies using neutral phosphates (K Phos Neutral) were done by my me...
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
Do you use terlipressin for patients with hepatorenal syndrome who also have elevated blood pressures?
There are those who would question HRS as a diagnosis if the patient had an elevated BP. Regardless, I believe its effect is related to BP so I would not use it in this situation.
How do you approach the decision to use terlipressin in a patient with hepatorenal syndrome type 1, AKI, and a history of heart failure given its potential cardiovascular effects?
I usually do a full workup to make sure the etiology of AKI is type 1 HRS. Would also make sure bleeding or infection not complicating the clinical scenario. This is not as simple as it seems, especially in the setting of primary heart failure as a complicating factor, and requires thorough thinking...
Do you recommend ligation of a functional arteriovenous fistula after kidney transplantation?
The decision to ligate a functional arteriovenous fistula (AVF) after kidney transplantation should be based on several factors. Generally, it is not recommended to ligate a functional AVF post successful kidney transplantation, as it can provide valuable vascular access for hemodialysis in case of ...
What is your approach to achieving hypernatremia in a patient on CRRT for whom increasing the rate of a post-filter 3% sodium chloride infusion is insufficient?
Good question. First, we can always increase the rate of the 3% saline more. Eventually, the increased amount of salt will lead to an increase in serum sodium concentration. It has to be a gradual process though to make sure one does not overshoot. Second, if the patient does not require more dialys...
Do you hospitalize patients with newly diagnosed lupus nephritis and nephrotic syndrome if you are able to provide pulse steroids outpatient and follow them closely?
Usually not. I suspect it all depends upon one's ancillary support situation. We are able to do in-house labs, give immediate in-house IV pulse steroids, and I can call interventional radiology and get an ASAP renal biopsy. If there were complications, such as infection, thrombosis, need for dialysi...
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who are unable to tolerate thiazide diuretics due to hyperglycemia?
I think it is a risk-benefit analysis. The answer depends on the severity of the stone disease and the severity of the hyperglycemia. Obviously, controlling hyperglycemia would have multiple benefits, and I would certainly proceed along that route. But if the calcium-based kidney stone disease is se...
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...