Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
Do you routinely prescribe acetazolamide for patients with cystinuria who do not have significant urinary alkalinization or are intolerant to citrate therapy?
I have not used acetazolamide in this situation, although it makes good physiological sense, as urinary alkalinization increases urine cystine solubility. Sodium bicarbonate would be a bad idea because natriuresis increases cystinuria. I have used potassium citrate historically, and it is generally ...
In which patients with non-proteinuric chronic kidney disease would you initiate a SGLT2i?
I agree with Dr. Wish. I do not use SGLT2i in non-proteinuric diseases for kidney protection indication. EMPA-Kidney study also did not show benefit for UACR <30 (HR 1.01, 0.66-1.55) among >1200 participants with UACR <30 in the trial. While the secondary analysis looking at mean annual change in eG...
How would you manage a patient with stable axial spondyloarthritis who develops newly active IgA nephropathy?
Increased serum IgA levels and IgA nephropathy are known to be an extra-articular feature although uncommon within the spectrum of spondyloarthropathies, just like uveitis, apical lung fibrosis, cardiac conduction defects, aortitis, etc., especially with AS (ankylosing spondylitis). If IgA nephropat...
Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?
No. Although hyperthyroidism is a reported cause of hypercalcemia and hypercalciuria, it must be very rare cause of nephrolithiasis. I suspect the patient would be obviously hyperthyroid on examination. Hyperparathyroidism is a much more common cause of kidney stones. In my practice, if the stone an...
What is your plasma oxalate target when treating patients with lumasiran for end stage kidney disease secondary to primary hyperoxaluria type 1?
We have a lot of experience with the PH1 population on dialysis here using the Mayo Clinic Laboratory Plasma oxalate assay. Ideally, we shoot for a pre-dialysis value of 30 or less. In our experience with this and other Hyperoxaluric patients, the risk of oxalosis would be low at those numbers and a...
What is your approach to recurrent uric acid stone formers who have a persistently acidic urine pH and are unable to tolerate potassium citrate?
I use sodium bicarbonate. I teach the patient how to titrate the dose using pH dipsticks to get the urine pH >6.0. Although sodium may increase urine calcium excretion, in uric acid stone formers, this is not an issue. Long experience with sodium bicarbonate tells us it does not raise blood pressure...
Do you avoid ESAs in patients with end stage kidney disease who also have heart failure due to increased risk of stroke?
If the question is whether I avoid ESAs in patients with ESKD who also have heart failure, the answer is no for several reasons. The warning in the ESA package insert regarding using ESAs with caution in patients with heart failure (HF) comes from the CHOIR study (Singh, et al., PMID 17108343) of no...
Do you give a short-acting antihypertensive before starting outpatient hemodialysis on an asymptomatic ESKD patient with a predialysis blood pressure of more than 200/100?
I rarely use short-acting antihypertensive agents. I usually give long-acting calcium channel blockers, b-blockers or ace inhibitors if the blood pressure is very high. Ultimately the best option would be to remove more and more fluid slowly over time if patient can tolerate it. However, I find flui...
What is your approach to management of recurrent nephrolithiasis in patients with mixed composition uric acid and calcium phosphate stones?
Likely the urine pH is more typically low in such patients, since the uric acid components will dissolve during periods of higher pH. Consequently, the appearance of uric acid crystals in the stone suggests that the urine pH is more typically low. Drinking more fluid to cause more dilute urine alway...