Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you recommend femoral vein dialysis catheter placement in patients newly started on hemodialysis in an effort to preserve upper extremity future fistula options?
I do not recommend tunneled femoral lines for patients who will need dialysis through the catheter for more than a week or so. Temporary femoral catheters are useful at times if unable to place tunneled line expeditiously.
What is your approach to determining which patients with ESKD and pruritis should be started on difelikefalin?
Since difelikefalin is a restricted formulary item at my dialysis units, I am required to reserve its use for patients who have failed antihistamines and neuroleptics. If the patient doesn't have traditional Medicare, there may be issues with difelikefalin reimbursement by Medicare Advantage and com...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
Would you recommend initiating a SGLT2i for proteinuria secondary to bevacizumab in a patient who has a sub-optimal response to an ACEi or ARB?
Obviously, SGLT2i were not studied in this setting. If the patient otherwise meets the criteria for approved uses of SGLT2i then it is reasonable to consider. The prescriber should make a careful assessment of the risk and risk factors for infections and monitor the Cr closely. An initial increase i...
What is your approach to managing intradialytic cramping that recurs despite multiple dry weight adjustments in a patient with ESKD?
This is a great question and there is no easy answer. As always, try and make sure the patient is following fluid restriction in between treatments as having less fluid to remove during a session may reduce cramping. I also try gabapentin 100mg prior to treatment for cramping. If they treat early in...
Do you consider Randall's plaque as a form of nephrocalcinosis necessitating genetic testing for monogenic kidney stone disorders?
No. Randall's plaque is the infrastructure of all calcium oxalate kidney stones. It is formed beneath the uroepithelium, due to (according to preliminary research) excess reabsorption of calcium in the thick ascending limb of Henley's loop. it is composed of calcium phosphate and somehow induces the...
Do you recommend decreasing the loop diuretic dose when starting an SGLT2 inhibitor in a CKD patient given its natriuretic and osmotic diuretic effects?
The decision to continue or not a loop diuretic when starting an SGLT2 inhibitor should be individualized based on the patient's blood pressure/volume status.In general, if a patient's blood pressure/volume status is high, like in the setting of heart failure, SGLT2 inhibitors, and loop diuretics ar...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
Is there a role for vascular intervention in patients with renal artery stenosis found during work up of resistant hypertension?
The ASTRAL, STAR, and CORAL trials all attempt to this question in different patient populations. A portion of CORAL participants met the diagnostic criteria for resistant hypertension. What I have taken away from the data is that renal artery intervention can be helpful in fibromuscular dysplasia i...
What is the next best anti-hypertensive medication to start after mineralocorticoid receptor antagonists in patients with primary aldosteronism?
I have had a good experience with calcium channel blockers and combined alpha/beta-blockers such as carvedilol in patients with PA. They are my first and second choices after MRA. If tolerated, pushing the MRA dose to get a PRA> 1 ng/ml/hr is important. I check for proteinuria, and if present, I add...