Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you perform dialysis on a patient with altered mental status in the setting of an elevated blood urea nitrogen level attributed to a tube feeding diet?
Uremia is symptomatic azotemia, I don't see how you don't dialyze that patient. The idea behind tube feeds is nutrition, that you need amino acids to make protein, but if the BUN is rising, clearly you are catabolizing some of them, and I would check with the dietician to make sure the patient isn't...
Do you hold CRRT for a period of time before performing a diuretic challenge in a patient with whom you are assessing for the ability to wean off of continuous dialysis?
You may want to sit down for this answer, I think the diuretic challenge is overrated and if I’m not mistaken, it was really developed to see if a patient may need to start RRT for Aki, not come off it. I would hardly use it on a patient with aki on Crrt for a decision. It isn’t rocket science to de...
Would you consider adding an SGLT2 inhibitor to augment diuresis in patients with worsening renal function presenting with acute decompensated heart failure and AKI on CKD?
SGLT2 inhibitors can provide another avenue in providing the much-needed diuresis our decompensated patients have. AKI often accompanies this decompensation. SGLT2 inhibitors can be used safely at times with GFR> 25. I would consider adding it to my regimen of aggressive diuresis to provide aggressi...
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
What criteria do you use, if any, to recommend statin therapy for patients with polycystic kidney disease?
If the patient has an indication for a statin for cardiovascular risk factors, I will of course recommend statin as per AHA guidelines. For low-risk individuals (e.g. young PKD patients) with borderline lipids, we will discuss the theoretical pleiotropic effects of statins with respect to ADPKD. Dep...
Do you recommend obtaining 24 hour urine ammonium levels in patients with recurrent uric acid nephrolithiasis?
An astute question! As you imply, uric acid stones have very little to do with uric acid! Otherwise, we would see more sodium urate, potassium urate, and ammonium urate stones, which are very rare. Uric acid (hydrogen urate) stones are highly dependent on a lower-than-normal urine pH. The two main r...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
What is your approach to a living kidney donor evaluation for a patient with normal kidney function who wishes to donate to their monozygotic twin who has ESKD due to an autoimmune disorder?
This really depends on whether there is a genetic component to the autoimmune disorder and whether there is a family history of autoimmune diseases in other members. Depending on the nature of the disease I might get some screening serologies and if positive consider consultation with Rheumatology. ...
Is there a role for a kidney biopsy in patients diagnosed with Fabry disease through genetic testing?
Is there a role for kidney biopsy in patients diagnosed with Fabry disease through genetic testing is not straightforward. However, there is utility most of the time if you are asking: Should you start therapy? When should you start therapy? Could it be something other than Fabry? If the patient ...
Do you avoid losartan in patients with hypertension and uric acid nephrolithiasis due to the drugs uricosuric effects?
This is an important question. I continue to use losartan or other uricosuric drugs in uric acid stone formers. Control/prevention of uric acid stone formation is primarily related to raising urine pH to 6.5 (at least above 6), since uric acid solubility is so strongly dependent on pH. Any minor inc...