Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
How do you decide when to refer for an access angiogram in a patient on hemodialysis with a drop in Kt/V but no other signs of access dysfunction?
In a JASN study (Coyne et al., PMID 9259360), the 3 comment causes of low Kt/V were: 42%- from poor blood cleaning due to low blood flow or shortened HD time 25% - due to recirculation from access dysfunction or reversed needles 33% - no cause identified, but on subsequent monthly testing, it normal...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
What is your approach to treating concomitant hypernatremia and hyperglycemia in patients with encephalopathy?
The risk-benefit assessment begins by identifying the primary physiologic problem. In patients with concomitant hypernatremia and hyperglycemia, the dominant abnormality is usually a profound free water deficit from osmotic diuresis. My goal is to restore normal physiology by replacing that free wat...
How do you counsel patients on peritoneal dialysis regarding the safety of engaging in aerobic and resistance exercises, considering the risk of developing abdominal wall complications?
The effect of exercise on intra-abdominal pressure (IAP) while on PD was examined decades ago by Twardowski et al., PMID 3774076. They found that walking, jogging, or using an exercycle resulted in only modest increases in IAP, while jumping or straining (e.g. weight- lifting) resulted in more marke...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
I think there are a few problems or nuances involved in answering this broad question:First, other practitioners may use other IV cephalosporins, but we only use cefazolin, ceftriaxone, cefepime, and ceftazidime (as part of Avycaz).Second, the calculated CrCl often poorly correlates with the patient...
In hospitalized patients with ESKD who develop mechanical hemolysis from high-velocity dialysis, what is your approach to balancing lower ultrafiltration rates to mitigate hemolysis while also optimizing inpatient length of stay and volume management?
To compensate for the lower ultrafiltration rate, I would prolong the dialysis session time. For example, the standard 3-4 hour inpatient dialysis sessions can be extended to 5-6 hours. This lowers the hourly ultrafiltration rate while achieving the same total fluid loss per treatment. I would also ...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...