Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to monitoring for recovery in a patient with non-oliguric AKI requiring dialysis?
In my opinion, the best test to monitor the recovery of renal function in an AKI patient is a daily measurement of serum creatinine. Decreasing serum creatinine is the most reliable marker to indicate recovery of kidney function after AKI. The main confounder would be simultaneous loss of muscle mas...
How would you manage a patient with recurrent calcium phosphate nephrolithiasis who has hypercalciuria, hypocitraturia, and a urine pH greater than 6.3?
Good question! Calcium phosphate stone formers are the second most common type after calcium oxalate stone formers. The underlying problem is an elevated urine pH. Your differential diagnosis will include primary hyperparathyroidism, renal tubular acidosis, medullary sponge kidneys and the use of al...
Do you recommend a kidney biopsy in a patient with myelodysplastic syndrome diagnosed two years prior who develops new onset proteinuria?
The decision to perform a kidney biopsy on any patient should hinge around whether the diagnosis can be made non-invasively (very rare), whether the biopsy should not impose an undue risk to the patient, and if a change in treatment may result from the biopsy diagnosis.In MDS, a variety of lesions m...
Do you recommend using dextrose based solutions to induce osmotic diuresis for euvolemic patients with acute kidney injury in the setting of a hemolytic condition?
The incidence of hemolysis (especially after blood transfusion) has been so low that to my knowledge there have been no good studies about the treatment of AKI with osmotic diuretics in this setting. Older literature has always used Mannitol to induce osmotic diuresis, but whether that improved the ...
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...