Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
In what instances might you recommend twice daily 7.5% icodextrin to patients on peritoneal dialysis?
Adequacy in peritoneal dialysis takes into account both the Kt/V from peritoneal dialysis as well as the Kt/V from residual kidney function. As residual kidney function declines over time, adequacy is primarily achieved from peritoneal dialysis. This often requires intensification of the peritoneal ...
How do you manage severe intra-dialytic hypertension that is not responsive to dry weight challenge in an asymptomatic patient with ESKD?
If the patient is truly not hypertensive at the start of treatment but becomes hypertensive during treatment (need solid evidence of this), then the best option would be an ACE or an ARB. If the blood pressure is high throughout then would continue to challenge dry weight as long as patient is able ...
Do you recommend performing a kidney biopsy in patients with suspected ifosfamide nephrotoxicity?
AKI from ifosfamide occurs as a result of direct tubular toxicity of the drug as well as from pre-renal azotemia as a result of nausea/vomiting/anorexia/diarrhea. The urine sediment is usually inactive. The creatinine generally plateaus within 7-10 days. The presence of an active urine sediment, sys...
Do you recommend obtaining a vasculitis work up for all patients seen for chronic kidney disease who are without a kidney biopsy?
I don't. There is a false positivity rate with ANCA testing which can complicate management, especially if the patient has diseases such as inflammatory bowel disease or rheumatoid arthritis. I would only check ANCA levels if the patient has hematuria, worsening renal function, or some other issue t...
Do you recommend holding cinacalcet after kidney transplantation and monitoring PTH levels before restarting it?
Recommend to monitor calcium levels and resume cinacalcet if the patient has hypercalcemia. If the calcium level is normal, do not need to resume post-transplant. In addition, if the calcium level is 9 or below, would stop cinacalcet and monitor calcium levels.
How often do you monitor labs such as complete blood count, liver function panel, and urine protein in a patient with cystinuria receiving tiopronin?
I check patients newly started on tiopronin or after an increase in dosage about one month later. Assuming the lab results are normal, I do not continue to check them. I think late adverse reactions must be very rare. Stephen B Erickson, MD
How do you manage recurrent hemodialysis filter clotting in an in-center ESKD patient with heparin-induced thrombocytopenia?
I have actually not faced this situation recently. something that may be tried though: flush the lines more frequently with saline, giving patients dose of eliquis orally prior to treatment, other anticoagulant?
Do you recommend targeting a higher Kt/V in an ESKD patient on hemodialysis with pruritis and a Kt/V of 1.4?
I do not. I believe there is not good evidence to suggest more dialysis will help with ckd pruritis and in general slightly higher kt/v usually does not correlate well with actual clinical findings. A better study to be done would be to see if more frequent dialysis will help treat ckd pruritis.
Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?
Certainly the lower the PNa is, any increase in PNa will have a greater effect on serum osmolality, so yes the lower the PNa the more careful I am. I would suggest never to be complacent, but for instance if the PNa was 105 I would make sure not to increase it by more than 6 in 24 hours, but if it w...
How long do you continue a thiazide diuretic in a patient with nephrolithiasis and hypercalciuria who achieves normalization of urinary calcium excretion following therapy initiation?
This question needs to be viewed from many angles in considering the answer. At the first level, an effective therapy choice for stone formation should be continued as long as the patient remains a stone former, which is probably for the rest of their life. We should always remember that the desired...