Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How often do you monitor plasma oxalate levels for patients with ESKD secondary to primary hyperoxaluria who are on hemodialysis and receiving lumasiran?
There is no absolute correct answer. Largely, it depends on how the patient is doing and how stable their oxalate status has been. Typically, we had like a predialysis plasma oxalate at a minimum once per month in a stable patient. I typically would do this on a Monday so that is the absolute highes...
What strategies have you used to help patients with advanced kidney disease who are asymptomatic understand the severity of their condition?
It is not unusual for patients with advanced kidney disease (stage 4, for example) to be asymptomatic or for the symptoms to be so insidious that the patient doesn't notice them or denies them. That's why it's very useful for such patients to be seen with a significant other or relative who can prov...
What is your blood pressure threshold to hold an ESA for patients with ESKD, anemia, and hypertension?
I will hold ESA for BP 170 or higher.
How long do you wait before reassessing a 24 hour urine calcium level in patients with recurrent nephrolithiasis, hypercalciuria, and osteoporosis who are initiated on bisphosphonate therapy?
Thank you for your excellent question. This is a relatively common concern, and yet I am aware of very little hard data. Opinions will differ; here is mine: In this scenario, it is my practice to have the patient visit with our Stone Clinic dietitian regarding dietary recommendations for calcium, so...
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...