Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend a ketogenic diet for patients with autosomal dominant polycystic kidney disease?
So far, what we know based on pilot studies is that the keto diet "doesn't not work" in PKD. I tell this to patients and some are motivated to pursue it, which should be done in a supervised way and focus on fat from salmon and avocado rather than super high saturated fat options where possible. Som...
Are there instances when you recommend performing a kidney biopsy in patients with presumed acute interstitial nephritis who are already on steroids and have improving renal function?
The decision to perform renal biopsy in a patient with presumed allergic interstitial nephritis on steroids, who is demonstrating improvement depends on the magnitude and rate of improvement. In a patient whose magnitude and rate of improvement, I suggest that the prior acute kidney injury baseline ...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...
Do you generally reduce DOAC dosing for extended anticoagulation in patients with first unprovoked VTE?
I frequently recommend low-intensity DOAC therapy in this setting, but only after careful consideration of the patient's risk factors for recurrent VTE and bleeding, and after determining the patient's preference about treatment options following a discussion of the pros and cons of each option.
Do you recommend using methionine to acidify the urine in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
I have not used it. Many of these patients have a partial renal tubular acidosis and will develop a metabolic acidemia if so treated. I suggest checking a urinary acidification test before prescribing it. Stephen B. Erickson, MD
What is your approach to managing patients with new laboratory evidence of hypopituitarism (e.g. very low plasma ACTH level and low morning serum cortisol) and a remote history of trans-sphenoidal surgery for NFPA?
It is sufficient to start corticosteroids with mineralocorticoids in such patients.
How frequently do you monitor anti-PLA2R antibody titers in patients with stable renal function/proteinuria and a past diagnosis of PLA2R-associated membranous nephropathy?
Serum anti-PLA2R antibody levels measured by ELISA are valuable in informing initial treatment decisions when used in combination with clinical and laboratory parameters. However, there are no clear guidelines on how frequently we should measure it. Insufficient data to guide the use of anti-PLA2R a...
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
Would you recommend starting a moderate-intensity statin in a patient under the age of 40 years old with HIV and a 10-year ASCVD risk estimate below 5%?
I am impressed by the benefit of statins in HIV patients but wonder if the benefit is affected by viral load (which may cause generalized inflammation and/or immune activation). I have not yet reached the point where I am ready to put low-risk, non-hypercholesteremic HIV patients on statins, but am ...
How do you determine duration of anticoagulation for an ovarian vein thrombosis following a provoking event?
This specific question has not been addressed in a clinical trial to my knowledge. If the patient is symptomatic, I would anticoagulate for 3 months in the absence of a contraindication, just as I would for most other provoked VTE events. One might consider a watch and wait approach without anticoag...