Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What are some considerations to make when managing patients with recurrent nephrolithiasis who are found to have nephrocalcinosis on imaging?
Nephrocalcinosis is generally defined as calcification of the renal parenchyma, especially the medulla and papillary tips, as opposed to nephrolithiasis which refers to calcification in the urinary space. The two often coexist. Nephrocalcinosis, and its accompanying nephrolithiasis, are typically pr...
What is your preferred therapy to raise urinary citrate in a patient with recurrent calcium based stone disease and hypocitraturia?
I prefer potassium citrate tablets. For those who have trouble swallowing tablets, it also comes in liquid form. There used to be a powder packet that you could tear open and mix in liquid, but it is my understanding that is no longer available. These products require a prescription. For those on a ...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.
What is your approach to determining the need for continued isolation in the dialysis unit for an ESKD patient who had a positive hepatitis B surface antigen one year ago but who now has a negative HbsAg in the absence of treatment?
I have not encountered this situation before. Assuming that both checks are accurate and not the result of vaccination, then I would continue to isolate for another 6 months, repeat Hep BsAg and viral load. If still negative would take off isolation.
Do you consider hyperuricemia as a potential etiology of an anion gap metabolic acidosis in patients with elevated uric acid levels and no other readily explainable causes of acidosis?
Urate has a molecular weight of ~166 mg/mmole and the valence of the anion is -1. Hence, let us say we have severe hyperuricemia with 16 mg/dl. That will provide an "anion gape" of only 1! So, by itself, urate cannot increase the anion gap. Could hyperuricemia be a "biomarker" of other causes of met...
What is your approach to safely performing hemodialysis in a patient with a fistula who is hospitalized for altered mental status and unable to remain still?
First, I would try to delay performing dialysis if possible and give the patient a chance to be more alert. Second, if there is a way to perform dialysis safely through meds or very close supervision, then I would try to use the fistula for dialysis. If the above is not possible, then the patient wo...
What considerations do you take when managing a patient with end stage kidney disease on peritoneal dialysis who is planning on undergoing PEG tube placement?
This is a somewhat difficult question to address, as there is more opinion and conventional “wisdom” than there is data. Let me begin with the “easy” part: notwithstanding reports of caregivers confusing the PD catheter for the PEG tube and instilling enteral feeding solutions intraperitoneally, pla...
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Do you use mannitol when initiating patients on intermittent hemodialysis?
This is a very good question. Mannitol has been used for decades to try and reduce disequilibrium, cramping and intradialytic hypotension. Most of the studies are small and were not placebo controlled and were performed in prevalent patients. In 2019, a randomized controlled trial was done that did ...
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...