Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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.
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...
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...
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...