Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you manage unintended hypercalciuria that results from an increase in dietary calcium intake as recommended to patients with recurrent calcium oxalate nephrolithiasis attributed to enteric hyperoxaluria?
I find this to be a common concern. As you know, the idea of treating enteric hyperoxaluria with supplemental oral calcium is to bind dietary oxalate in the gut before it can be absorbed systematically. In addition to arranging an appointment with our stone clinic (not general) dietitian to discuss...
Do you still consider hepatorenal syndrome in patients with renal impairment and liver disease who are found to have rare muddy brown casts on urine microscopy?
I personally do. While the traditional teaching is to try to differentiate ATN versus pre-renal versus HRS using the urine sodium, history, and urine microscopy. While sometimes one diagnosis is compelling, often the clinical picture is not clear cut, and at times there is a component of ATN on some...
Do you recommend a ketogenic diet for patients with autosomal dominant polycystic kidney disease?
So far, what we know based on pilot studies is that the keto diet "doesn't not work" in PKD. I tell this to patients and some are motivated to pursue it, which should be done in a supervised way and focus on fat from salmon and avocado rather than super high saturated fat options where possible. Som...
Are there instances when you recommend performing a kidney biopsy in patients with presumed acute interstitial nephritis who are already on steroids and have improving renal function?
The decision to perform renal biopsy in a patient with presumed allergic interstitial nephritis on steroids, who is demonstrating improvement depends on the magnitude and rate of improvement. In a patient whose magnitude and rate of improvement, I suggest that the prior acute kidney injury baseline ...
Do you recommend using methionine to acidify the urine in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
I have not used it. Many of these patients have a partial renal tubular acidosis and will develop a metabolic acidemia if so treated. I suggest checking a urinary acidification test before prescribing it. Stephen B. Erickson, MD
How frequently do you monitor anti-PLA2R antibody titers in patients with stable renal function/proteinuria and a past diagnosis of PLA2R-associated membranous nephropathy?
Serum anti-PLA2R antibody levels measured by ELISA are valuable in informing initial treatment decisions when used in combination with clinical and laboratory parameters. However, there are no clear guidelines on how frequently we should measure it. Insufficient data to guide the use of anti-PLA2R a...
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
Do you prefer performing a kidney biopsy on the left or right kidney if both kidneys appear similar on pre-biopsy imaging?
At my institution, we have been biopsying almost exclusively the left kidney per the radiologist's preference. My teaching has been that we should prefer to biopsy the right kidney as if the spleen is enlarged then stabbing that with a needle is more risky than stabbing the liver. These days, with m...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...