Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you manage vitamin D dosing in patients with nephrolithiasis and hypercalciuria who require supplemental vitamin D for treating other medical conditions?
This is a common treatment for osteopenia/osteoporosis. For calcium stone formers, I watch for hypercalcemia and/or hypercalciuria. If present, I reduce the dose of calcium and/or vitamin-D until their urinary parameters normalize. Otherwise, I think they can take these medications safely in standar...
For patients with nephrolithiasis and hypercalciuria attributed to a parathyroid adenoma, how long after a partial parathyroidectomy do you assess for improvement in 24-hour urine calcium levels?
An interesting question! The physiology of parathyroid hormone is to reabsorb urinary calcium; that is why most patients with primary hyperparathyroidism are hypercalcemic! The better question is why are they hypercalciuric? I think the best answer has to do with the filtered load of calcium exceedi...
How long would you wait for outflow to improve before consulting surgery in a peritoneal dialysis patient with an outflow obstruction who is prescribed laxatives for catheter migration?
Any PD patient with outflow dysfunction that does not improve with laxatives should undergo abdominal x-ray to evaluate the position of the PD catheter. If the PD catheter is outside of its expected position within the mid-pelvis, there may be ongoing issues of catheter dysfunction if the catheter i...
What are some measures to prevent flares of loin pain-hematuria syndrome?
Loin pain hematuria syndrome is a difficult problem because there are multiple potential causes that require individual solutions. For example, nutcracker syndrome requires decompression of the left renal vein. Recurrent kidney stones require the expertise of a urologist skilled in ureteroscopic or ...
In patients with intrinsic acute kidney injury of unknown etiology and with pending kidney biopsy results, are there instances when you would recommend a trial of glucocorticoids?
I usually don't if I know I will have preliminary results of the biopsy within 24-36 hours. I do sometimes when it is not possible to do the biopsy in a timely manner. I don't think a 1-2 day delay would make a major difference in the amount of kidney damage.
Which medications do you recommend for lactating mothers with kidney disease and proteinuria that persists post-delivery?
I use ACE inhibitors, including enalapril and lisinopril, in the lactating mothers with proteinuria and hypertension. Captopril is also safe, but as it is dosed multiple times per day, I avoid this. There is no data on ARBs. If they are still recovering from an AKI or there is another issue, like hy...
What considerations do you take when evaluating a patient for kidney transplantation who has a history of kidney disease and an abdominal aortic aneurysm treated with past stenting?
If the external iliac vessels are spared then the patient does not have an absolute contraindication to transplantation. The risk factors associated with the AAA will need careful review, e.g., smoking, cholesterol, hypertension, CAD, and other vascular diseases, and mitigated if possible. Anecdotal...
For patients on CRRT with worsening hyperkalemia despite high replacement fluid rate using a 0 mEq/L potassium bath, do recommend using an additional CRRT machine with separate dialysis access for improved clearance?
I think this situation would be unusual. I would first try to optimize everything about the dose of the CRRT. If hyperkalemia persists despite the optimization for a number of hours (it will require a few hours of the change before one sees an effect), the options are: Switch to intermittent hemo w...
Are there any instances when you use vitamin B6 to prevent kidney stones in patients with recurrent calcium oxalate nephrolithiasis who do not have primary hyperoxaluria?
I occasionally try empirical vitamin B6 in patients with hyperoxaluria that does not respond to usual dietary oxalate restriction plus low fat and higher calcium. I have not done it systematically and have only a handful of cases where it may have helped. Thus, I would not recommend routinely adding...
What are your management strategies for patients with chronic kidney disease attributed to deferasirox use who require frequent blood products for a hematologic disorder?
It depends on the type and severity of the hematological disorder as well as the extent of CKD. Currently, two oral chelators; deferasirox and deferiprone, are available, in addition to deferoxamine, which can be administered SubQ or IV. These can be mixed and combined, and combination therapy may b...