Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to thiazide diuretic use in those with uncontrolled hypertension and advanced chronic kidney disease?
The Chlorthalidone for Hypertension in Advanced Chronic Kidney Disease (CLICK) trial provides an answer to this question. Chlorthalidone is still effective at lowering BP when eGFR is 15-30 mL/min/1.73m^2. Personally, I find it helpful to continue chlorthalidone in advanced CKD to help with kaliures...
How do you estimate daily dietary sodium intake in your patients with hypertension?
The best and simplest method is to check 24-hour urine for sodium excretion. In the steady state, the 24-hour urine sodium will closely approximate the daily intake of sodium.
What degree of hyperkalemia do you tolerate for those with proteinuric chronic kidney disease and persistently elevated serum potassium levels?
The K comes back 6.3 and you send them to the ER, and repeat K is 5.7, no EKG changes. That dance gets tiresome. How often do you think the opposite would occur? (K is 5.7 and you repeat it and it is 6.1?) K varies day to day and lab measurement to lab measurement.I am extreme, I do not expect other...
Do you advise patients to limit physical exertion including lifting heavy objects following a kidney biopsy?
I don’t think there is data on this, who would do a trial, but for an uncomplicated biopsy I tell them to take it easy for 3 days, usually over the weekend, a reason I like to do them on a Friday. No sports no working out no heavy lifting. I also tell them not to just lay around because if they are ...
How frequently do you obtain 24 hour urine stone risk profiles in your patients with kidney stone disease who pass less than one stone per year?
When I do 24h urine collections in patients, I repeat the collection in order to see if the goal of therapy was achieved. Whether that was fluids, dietary changes, or medications, I usually want to see if we were successful. After that, I'm less interested in repeating the study especially if the st...
In which patients do you obtain genetic testing for further evaluation of kidney stone disease?
First stone as a pre-adolescent, stone complicated by kidney failure, history of growth retardation, family history of stones or nephrocalcinosis or unexplained kidney failure, hearing impairment, ocular crystals High stone burden on imaging or nephrocalcinosis Concomitant low molecular weight prot...
How do you advise your kidney stone patients about optimal daily fluid intake?
Measuring urine is better than counting liters of intake and shoot for 2-3 liters/day. If they aren’t getting up most nights to urinate they probably aren’t drinking enough water. When they get tired of drinking and urinating I tell them to remember the pain associated with their stone.
What dietary advice do you provide your patients with calcium oxalate nephrolithiasis?
High water intake (at least 2.5L of urine volume per day) Low sodium and low animal protein intake (high dietary sodium and high animal protein correlate with higher urine calcium) Normal dietary calcium balance around 1000mg per day (maintain bone health and ensure adequate dietary calcium to bin...
How do you advise patients with sickle cell disease on contraception?
According to both the "ASH Pocket Guidelines" and the National Heart Lung and Blood Guidelines for health maintenance in Women with sickle cell disease, progestin only and barrier methods of contraception are the preferred recommendations for contraception. Combined hormonal agents can be considered...
Would you consider thrombophilia testing in a pregnant patient with VTE?
I would not check antiphospholipid antibodies in a pregnant woman with thrombosis unless she had a history of autoimmune disease or other concerning findings. However, if it were checked, I would make sure that it is a true positive. DOACs often cause a false positive LAC. I have had patients with f...