Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Where do you place romosozumab in your treatment sequence for osteoporosis management?
I agree. It is very effective as first-line therapy in patients at high risk for fracture. It can also be useful post bisphosphonate therapy. I have used it successfully multiple times to transition patients from long-term Prolia therapy without loss of bone mass.
When do you restart ACEi/ARB medications for patients whom these medications were previously discontinued due to acute kidney injury?
I generally wait until the patient’s kidney function has stablilized at a new baseline, the patient’s acute illness that led to AKI has resolved and the serum potassium is acceptable.
Do you use alkali therapy in those with stable chronic kidney disease and a normal serum bicarbonate level who have a low urine pH?
Generally, no. There is no reason to increase the pill burden with bicarbonate therapy in a patient with normal blood chemistry. I would only treat urine pH in a stone-forming patient with uric acid stones.
How much decrease in eGFR do you tolerate before discontinuing a SGLT2i started in patients with diabetic kidney disease?
SGLT2i are known to have an acute, reversible dip in eGFR in the first 2-4 weeks after initiation. This effect on glomerular hemodynamics (more pronounced in diabetics) usually decreases eGFR by less than 30% and has been associated with better long-term cardio-renal benefits in some studies. A dip ...
How much decrease in eGFR do you tolerate before discontinuing finerenone started in patients with diabetic kidney disease?
I use the same approach investigators did in the Fidelio DKD study: patient on max dose of ACEi/ARB. Add finerenone--> check GFR in 4 weeks. If more than 30% drop hold any NS-MRA up titration and recheck GFR in 1 week. If stable, continue same drug regimen, if GFR further decreases, hold finerenone,...
Do you obtain periodic kidney ultrasounds in patients with stable chronic kidney disease to evaluate for changes in kidney size that might reflect progression of kidney disease not detected with serum studies?
No. I believe the serum studies would be much more accurate in determining kidney function than the ultrasound. The only time I obtain periodic ultrasounds would be if someone has suspicious lesions and I want to follow up over time or with cysts.
Do you treat low 25-OH vitamin D levels in those with end stage kidney disease?
Low 25-OH vitamin D levels in those with end-stage kidney disease should absolutely be treated. The assumption that calcitriol administration satisfies all the vitamin D needs of the body is incorrect. While it is true regarding the endocrine effects of calcitriol (calcium and phosphate homeostasis)...
How do you approach COVID-19 vaccination in those who underwent kidney transplantation for native kidney glomerular disease?
The approach to all kidney transplant recipients regardless of the cause of end-stage kidney disease remains the same following the guidelines for immunocompromised patients. The benefits of vaccination and protection against COVID-related hospitalization and death outweigh vaccine-related incidents...
Do you routinely advise patients waiting for a kidney transplant to seek referrals at multiple institutions to decrease waiting time?
If your center is in a region (e.g., California and New York) with long wait time of up to 8-10 years, we routinely advise patients to seek referral at multiple centers with a shorter wait time out of the region if the patient does not have any potential donors.
For which patients do you prioritize ambulatory blood pressure monitoring over self-measured blood pressure?
Self-measured blood pressure can be useful for anyone who has been diagnosed with hypertension or is found to have office blood pressures (BPs) above normal (120/80 mm Hg).1 Correctly measured home BPs inform my decision on when to start antihypertensive medications or when to adjust antihypertensiv...