Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
How long would you wait before performing a kidney biopsy in a patient with nephrotic range proteinuria, a negative PLA2R antibody, a negative anti-THSD7A antibody, and stable renal function who recently started treatment a week ago with a DOAC for a pulmonary embolism?
Since the renal function is stable, and holding the DOAC carries significant risk, I would wait at least 3 months, and if the kidney function is still stable then, possible 6 months before the kidney biopsy.
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
Do you obtain additional studies such as stool elastase or oxalate load testing in patients with hyperoxaluria for whom you are attempting to differentiate enteric from primary processes?
If I have serious question of the possibility of primary hyperoxaluria, I would order genetic testing to rule this disease in or out.
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...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
What specific strategies have you found most effective in your academic program for inspiring internal medicine residents to consider nephrology as a career?
Probably the best tool we have is having residents rotate with us. Nephrology is a mandatory rotation at RUSH Internal Medicine, and frankly, we are excellent teachers, so that sparks interest that may not have happened if they did not rotate. I cannot believe that all IM programs do not require nep...
What is your approach to managing neobladder acidosis?
Alkali supplementation is the mainstay of treatment of neobladder acidosis. Since prolonged urinary contact with the intestinal epithelium used for urinary reconstruction leads to increased ammonium reabsorption and chloride absorption in exchange for bicarbonate secretion, regular catheterization o...