Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
Do you use serum or urine biomarkers other than creatinine when evaluating patients with acute kidney injury?
I use the urinalysis (including microscopy) as well as the furosemide stress test but no other "novel" biomarkers have sufficient accuracy to guide clinical care at this time.
Are there instances when you do not perform urine microscopy and rely solely on laboratory performed urinalysis when evaluating a patient for acute kidney injury?
Direct visualization of urinary sediment under a proper microscope is a cornerstone of AKI evaluation from intrinsic renal disease. If I am relatively sure the cause of AKI is prerenal or post-renal and AKI improves promptly with intervention, then I may forego sediment evaluation. I am in the lab l...
When do you restart ACEi/ARB medications for patients whom these medications were previously discontinued due to acute kidney injury?
I generally wait until the patient’s kidney function has stablilized at a new baseline, the patient’s acute illness that led to AKI has resolved and the serum potassium is acceptable.
Do you use alkali therapy in those with stable chronic kidney disease and a normal serum bicarbonate level who have a low urine pH?
Generally, no. There is no reason to increase the pill burden with bicarbonate therapy in a patient with normal blood chemistry. I would only treat urine pH in a stone-forming patient with uric acid stones.
How much decrease in eGFR do you tolerate before discontinuing a SGLT2i started in patients with diabetic kidney disease?
SGLT2i are known to have an acute, reversible dip in eGFR in the first 2-4 weeks after initiation. This effect on glomerular hemodynamics (more pronounced in diabetics) usually decreases eGFR by less than 30% and has been associated with better long-term cardio-renal benefits in some studies. A dip ...
How much decrease in eGFR do you tolerate before discontinuing finerenone started in patients with diabetic kidney disease?
I use the same approach investigators did in the Fidelio DKD study: patient on max dose of ACEi/ARB. Add finerenone--> check GFR in 4 weeks. If more than 30% drop hold any NS-MRA up titration and recheck GFR in 1 week. If stable, continue same drug regimen, if GFR further decreases, hold finerenone,...
Do you obtain periodic kidney ultrasounds in patients with stable chronic kidney disease to evaluate for changes in kidney size that might reflect progression of kidney disease not detected with serum studies?
No. I believe the serum studies would be much more accurate in determining kidney function than the ultrasound. The only time I obtain periodic ultrasounds would be if someone has suspicious lesions and I want to follow up over time or with cysts.
When do you avoid or stop erythropoietin-stimulating agents in patients with anemia and end stage kidney disease?
For the most part, I don't. If the patient has uncontrolled hypertension, then I would air on the side of using less and possibly even not giving it. In patients with cancer, I always check with hem/onc to see if it is okay to give it. Most of the time, I find that they don't have a problem giving i...
When do you avoid or stop iron agents in patients with anemia and end stage kidney disease?
I don't give iron if patients have hemoglobin over 12. There is no reason to give iron if hemoglobin is over the desired range even if the patient seems iron deficient on labs. I also do not give iron if the serum ferritin is > 800-1000. I think at this point the risk of iron overload outweighs the ...