Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you determine the fill volume of icodextrin for a volume-overloaded ESKD on PD patient considering that the dwell may last throughout the day?
For patients with acute, symptomatic volume overload, hypertonic dextrose solutions are often used as these solutions act more quickly. Icodextrin is typically not used in an acute setting because it acts more slowly. However, for patients who are asymptomatic, icodextrin can be used in the long dwe...
Do you recommend placement of a backup AV fistula in an advanced CKD patient who is planning to do peritoneal dialysis?
This is a controversial point for which I don't believe there to be great data. An old study in the British literature- I can't get my hands on it right now- purportedly demonstrated that only 7% of such fistulae were ever used/ useable. With improved fistula technique and survival this number is un...
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
What do you use for treatment induction in pure class V lupus nephritis with nephrotic-range proteinuria when MMF is contraindicated?
I'll begin my response by commenting that other than an allergic reaction, which is very rare or pregnancy, there is really no absolute contraindication to MMF. On the other hand, there are patients who cannot tolerate MMF most often due to G.I. side effects in which case mycophenolic acid is an opt...
How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?
If the patient is asymptomatic and the catheter is functioning well, I recommend starting anticoagulation.If the patient develops symptoms, he or she should still be anticoagulated but the catheter removed. Anticoagulation options in ESRD patients include Coumadin, Eliquis (my preference is a dose o...
Do you eventually stop urate-lowering therapy in gout patients with CKD who start hemodialysis?
Hemodialysis is an extremely effective serum urate lowering therapy (ULT). As such, whether or not to keep patients on other ULT depends on average serum uric acid levels, how often a patient is having flares, etc. From what I have seen, although some patients will have increased flares in the first...
Would you recommend use of ESA for anemia of kidney disease in the setting of metastatic solid tumor malignancy?
It is not unreasonable in CKD patients with symptomatic anemia and a non-curable metastatic cancer to consider using an ESA. However, this requires an extensive discussion with the patient. ASCO/ASH guidelines recommend against the use of these agents in patients with curable malignancies, so if the...
In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?
I typically only use spot UPCRs because (1) they are easy to obtain and thus trend (2) they account for BSA indirectly because it accounts for Cr excretion. The best role of urine protein measurements is really just to trend if your therapy is effective or to screen for disease. When looking at urin...
How do you approach treatment of osteoporosis in patients with CKD who develop a fragility fracture while on denosumab?
The only option left at this point is a PTH compound. Please it or not, it still works every time in subjects with a secondary elevation of PTH. I would try either Forteo or Tymlos for a few months and see if the patient can tolerate it and if the calcium numbers remain stable. I am not sure about r...
How do you approach prophylaxis against glucocorticoid-induced osteoporosis in patients with end-stage renal disease on dialysis?
Treating patients with end-stage renal disease on glucocorticoids to prevent bone loss is a challenge. A patient with end-stage renal disease cannot be treated with bisphosphonates. However, denosumab the RANKL antibody has no restrictions regarding renal disease. So my suggestion is to treat a pati...