Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend initiating a potassium sparing diuretic in patients with recurrent nephrolithiasis who have hypercalciuria but do not tolerate thiazide diuretics?
No. The idea of using a thiazide diuretic as a preventive treatment for calcium-containing stones is its hypocalciuric effect. Potassium-sparing diuretics do not have this ability. Loop diuretics worsen hypercalciuria and, in general, are inappropriate for use in calcium stone formers. One could con...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
Do you recommend giving IV albumin with furosemide to augment diuresis in a patient with hypoalbuminemia and volume overload?
I'm a fan of IV albumin in patients with edema and hypoalbuminemia <3g/dL. It stabilizes intravascular volume and may blunt the rise in serum creatinine that can occur with diuresis. It may lead to a decrease in serum creatinine in some patients, especially those with liver disease and impending hep...
Are you offering GLP-1 agonists to patients with CKD and diabetes mellitus?
According to KDIGO 2022, GLP-1RA are second line DM Rx (see fig 3: Rossing et al., PMID 36272755); this class of medications still awaiting a CKD-dedicated RCT such as FLOW (Rossing et al., PMID 36651820). However, secondary outcomes of CVOT show kidney protective effects for some GLP-1RAs (non-exen...
Would you offer adjuvant immunotherapy in a patient with high risk RCC with new/worsening post-op renal dysfunction and CrCl<30?
My preference in situations like this is to stabilize the renal function first. I am comfortable treating the patient with adjuvant pembrolizumab with a CrCl <30 mL/min but it should be stabilized first. That will make it easier to diagnose potential irAEs as compared to starting adjuvant treatment ...
Do you rule out active urinary tract infections prior to performing a kidney biopsy?
The 2 infectious reasons to avoid a renal biopsy are- active kidney infection and active skin infection at the site of the biopsy (Luciano & Moeckel, PMID 30661724).Perinephric hematoma is common after a kidney biopsy and there is a report in the literature where this has gotten infected in the pres...
Would you consider reducing the dialysate sodium concentration to 135 meq/L as a strategy to decrease interdialytic weight gain in a hypervolemic ESKD patient?
Yes. It is worth a try. I don't expect miracles though. It may make a minor difference. The best option remains longer and more frequent dialysis if possible and agreeable with the patient which is often not the case.
How soon after an intervention is done for peritoneal catheter inflow or outflow obstruction is it advisable to repeat the Kt/V?
The timing of repeat Kt/V measurement after an intervention to revise a peritoneal dialysis (PD) catheter depends on the extent of the procedure. If the catheter cuff and exit site are not disturbed, then Kt/V can usually be repeated in 1-2 weeks. If the exit site is moved to a new location or a new...
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....