Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you check EPO levels in patients with anemia of chronic kidney disease?
No, I never check EPO levels in patients with anemia of CKD since they're uninterpretable. Patients with CKD have inadequate EPO synthesis for their degree of anemia, so their EPO levels may be greater than normal yet still not sufficient to correct the anemia. We now understand the role of inflamma...
Do you obtain spot urine protein or 24 hour urine protein quantification studies in pregnant patients who are found to have proteinuria on a standard urinalysis test?
If a patient has a positive dipstick for protein, I would do a 24-hour collection, just to get the most accurate answer to the question of whether there is truly abnormal proteinuria or not, and taking into account the physiologic protein increase that happens during pregnancy. I generally check a b...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
How often do you monitor plasma oxalate levels for patients with ESKD secondary to primary hyperoxaluria who are on hemodialysis and receiving lumasiran?
There is no absolute correct answer. Largely, it depends on how the patient is doing and how stable their oxalate status has been. Typically, we had like a predialysis plasma oxalate at a minimum once per month in a stable patient. I typically would do this on a Monday so that is the absolute highes...
What strategies have you used to help patients with advanced kidney disease who are asymptomatic understand the severity of their condition?
It is not unusual for patients with advanced kidney disease (stage 4, for example) to be asymptomatic or for the symptoms to be so insidious that the patient doesn't notice them or denies them. That's why it's very useful for such patients to be seen with a significant other or relative who can prov...
What is your blood pressure threshold to hold an ESA for patients with ESKD, anemia, and hypertension?
I will hold ESA for BP 170 or higher.
How long do you wait before reassessing a 24 hour urine calcium level in patients with recurrent nephrolithiasis, hypercalciuria, and osteoporosis who are initiated on bisphosphonate therapy?
Thank you for your excellent question. This is a relatively common concern, and yet I am aware of very little hard data. Opinions will differ; here is mine: In this scenario, it is my practice to have the patient visit with our Stone Clinic dietitian regarding dietary recommendations for calcium, so...
How do you decide between CT and ultrasound imaging tests for surveillance imaging for patients with recurrent nephrolithiasis?
I much prefer non-contrast renal CT scanning compared to ultrasound to determine metabolic stone activity (an increase in size or number of stones from previous imaging). Although more expensive, radiation exposure is low and sensitivity is high. Determining metabolic activity is important; if activ...
What approaches do you take for your patients with nephrolithiasis who undergo intermittent fasting for cultural, religious, or personal reasons?
Assuming "fasting" does not prohibit the intake of water, I encourage my patients to continue drinking water frequently, ideally at least 2 L daily, as that is the minimum amount shown in previous studies to decrease kidney stone passage. If fasting is intermittent and includes all fluids, I encoura...
What instances will you start outpatient steroids in patients with nephrotic syndrome of unknown etiology prior to obtaining a kidney biopsy?
It is Friday, your patient presents with classic acute nephrotic syndrome, your biopsy Friday won't have results (if not longer if you need EMs which you need for MCD) until Tuesday. I never think a few days of steroids is a big deal, so I can see doing it.