Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you prefer transtubular potassium gradient (TTKG) or urine potassium to urine creatinine ratio when evaluating patients with abnormal potassium levels?
Metrics for assessing dyskalemias have become controversial over the last few years. There is very little data, but a fair amount of theorizing, addressing this issue. Importantly, no metric for diagnosing the cause of a dyskalemia should be used without careful assessment of the overall clinical an...
What degree of hyperkalemia do you tolerate for those with proteinuric chronic kidney disease and persistently elevated serum potassium levels?
The K comes back 6.3 and you send them to the ER, and repeat K is 5.7, no EKG changes. That dance gets tiresome. How often do you think the opposite would occur? (K is 5.7 and you repeat it and it is 6.1?) K varies day to day and lab measurement to lab measurement.I am extreme, I do not expect other...
What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?
Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even th...
What is your approach to managing hypocalcemia following a parathyroidectomy in patients with end stage kidney disease?
The hungry bone syndrome can be tricky and insidious. I have seen patients go home after a pth-ectomy without evidence of it and then a few days later show up in the ED with symptoms of hypocalcemia. Hemodialysis may mask it (as well as treat it) by supplying a large IV calcium load. If you dialyze ...
What is your daily correction goal for those patients being treated for hypernatremia?
There is no correction per se. Although, older guidelines recommend a correction of no more than 8-10 mEq/dL in 24 hours. The theoretical risk of correcting hypernatremia too fast is the development of cerebral edema. However, a recent study (Chauhan et al., PMID 30948456) showed no evidence of cere...
What is your approach to the use of desmopressin prior to performing a kidney biopsy to potentially prevent procedural associated bleeding?
I do not routinely request a bleeding time or administer desmopressin prior to performing a percutaneous kidney biopsy. The bleeding time is very operator dependent and therefore could be prolonged even when platelet function is normal. I ask patients to hold aspirin one week before performing a kid...
Is there a platelet count threshold when you would avoid performing a kidney biopsy in patients with thrombocytopenia?
The kidney biopsy is considered a high-risk procedure. The society of Interventional Radiology recommends: INR less than 1.5 and platelet more than 50,000.We follow these recommendations!Patel et al., PMID 22513394
Are there instances when you perform a repeat kidney biopsy in patients whom tolerated the first procedure but are still without a definitive diagnosis?
Of course. In general, every time I re-biopsied a patient, I found the same diagnosis that second time around. Of course, if the sample is inadequate then I often re-biopsy. I always suggest to re-review the biopsy already taken before re-biopsying.
What is your mmHg threshold to cancel a kidney biopsy for patients with pre-procedural elevated blood pressures?
I am most comfortable doing a percutaneous kidney biopsy at a BP<140/90. Patients are often anxious prior to the biopsy and this can raise their BP. I usually administer an anxiolytic prior to the procedure. I also administer oral antihypertensives such as clonidine or short-acting nifedipine in the...
Do you require patients who undergo a kidney biopsy to be admitted to the hospital for observation?
We do but that is not the common practice. We do send some patients home if the biopsy is done early enough and we can watch them in IR but the majority stay overnight. When IR does the biopsy, they do not admit the patient.