Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you use serum or urine biomarkers other than creatinine when evaluating patients with acute kidney injury?
I use the urinalysis (including microscopy) as well as the furosemide stress test but no other "novel" biomarkers have sufficient accuracy to guide clinical care at this time.
Are there instances when you do not perform urine microscopy and rely solely on laboratory performed urinalysis when evaluating a patient for acute kidney injury?
Direct visualization of urinary sediment under a proper microscope is a cornerstone of AKI evaluation from intrinsic renal disease. If I am relatively sure the cause of AKI is prerenal or post-renal and AKI improves promptly with intervention, then I may forego sediment evaluation. I am in the lab l...
When do you avoid or stop erythropoietin-stimulating agents in patients with anemia and end stage kidney disease?
For the most part, I don't. If the patient has uncontrolled hypertension, then I would air on the side of using less and possibly even not giving it. In patients with cancer, I always check with hem/onc to see if it is okay to give it. Most of the time, I find that they don't have a problem giving i...
When do you avoid or stop iron agents in patients with anemia and end stage kidney disease?
I don't give iron if patients have hemoglobin over 12. There is no reason to give iron if hemoglobin is over the desired range even if the patient seems iron deficient on labs. I also do not give iron if the serum ferritin is > 800-1000. I think at this point the risk of iron overload outweighs the ...
Are there cases of glomerulonephritis where you do not perform a kidney biopsy in a patient deemed safe to undergo the procedure?
In adults, there are some circumstances where a biopsy may be deferred/ 1. Patients with nephrotic syndrome, normal kidney function and an elevated PLAR2 Antibody level (in the absence of other systemic diseases e.g. SLE, diabetes). A presumptive diagnosis of PLA2R ab-associated membranous nephropat...
When do you perform a kidney biopsy in a patient with AKI that is thought to be related to an immune checkpoint inhibitor?
I would wait for the response to corticosteroid therapy before the renal biopsy.
Are there preventative measures that you take in your cancer patients with chronic kidney disease who require periodic iodinated contrast CT studies for monitoring of their malignancy?
Recommendations include discussing the utility of other imagining modalities with the hematology or oncology team caring for the patient. In general, the risk for AKI from IV contrast increases with lower eGFRs. Cancer patients may have misleading "normal" or "good" Cr and eGFRs due to malnutrition ...
What changes to immunosuppressant medications do you adopt for kidney transplant patients who contract COVID-19?
It really depends on the severity of their symptoms. For patients with mild symptoms, we typically lower the MMF somewhat as well as treat with paxlovid as the first line. Due to the interactions with the CNIs etc., we adopt the following protocol for tacrolimus and paxlovid: Day 1- First Paxlovid ...
Do you prefer transtubular potassium gradient (TTKG) or urine potassium to urine creatinine ratio when evaluating patients with abnormal potassium levels?
Metrics for assessing dyskalemias have become controversial over the last few years. There is very little data, but a fair amount of theorizing, addressing this issue. Importantly, no metric for diagnosing the cause of a dyskalemia should be used without careful assessment of the overall clinical an...
What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?
Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even th...