Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
What is your approach to ESA use in patients with ESKD and active malignancy on treatment?
Patients can receive ESA’s and keep hgb goal at 10. Would discuss this with an oncologist and get clearance and after a hematological workup is also attained.
Do you add a separate dose of losartan for patients with heart disease and proteinuric kidney disease who are on maximal doses of sacubitril/valsartan but continue to experience proteinuria?
There is data in studies of proteinuric kidney disease to suggest that combining an ACEi and an ARB confers a little additional benefit in proteinuria management but confers a significant risk of hyperkalemia. I would presume the same risk/benefit ratio when using 2ARBs and I would not opt for that ...
Would you recommend genetic testing to determine if there is a potential underlying primary process in a patient with congenital solitary kidney who is presumed to have secondary FSGS?
I do recommend genetic testing more frequently especially at our institution in which the cost to the patient is minimal to none. I would imagine very rarely one finds a positive genetic test result but one never knows what we find until we do the testing.
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who take daily calcium supplements?
Calcium-based stone disease and osteopenia/porosis commonly occur together in postmenopausal women. Calcium supplements are the basic treatment for osteopenia/porosis but may aggravate stone disease in hypercalciuric patients. My approach is first to ask our Stone Clinic dietitian to estimate the pa...
Do you prefer monitoring creatinine over cystatin C levels in patients with lymphoma and chronic kidney disease given the potential for cystatin C levels to be increased with certain malignancies?
My default is to monitor creatinine, not cystatin C, in all patients with malignancies except: if patients have had weight loss and down-trending creatinine, patients are at eGFR cutoffs for chemotherapy drug dosing, leading to concern for potential over/under-dosing, there is concern for pseudo-AKI...
Do you recommend stopping a SGLT2i indefinitely if a patient with chronic kidney disease and diabetes develops euglycemic diabetic ketoacidosis?
I would. In my opinion, the risk of ketoacidosis will outweigh the possible benefit from SGLTs.
Do you recommend dietary protein restriction in your patients with chronic kidney disease?
Not really. I let the serum BUN be the guide. If the serum BUN is very high and otherwise patient does not need dialysis then it may be helpful to decrease the protein intake. This is more often observed in inpatients (with some degree of AKI) than outpatients.
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.