Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend continuing peritoneal dialysis in an ESKD patient on peritoneal dialysis who is diagnosed with encapsulating peritoneal sclerosis since abdominal symptoms may worsen when peritoneal dialysis is stopped?
It is generally accepted that after a diagnosis of encapsulating peritoneal sclerosis (EPS), most patients are transitioned off peritoneal dialysis (PD) and switched to hemodialysis as patients with EPS often have chronic abdominal pain and will often have difficulty with dialysis adequacy and ultra...
How would you approach a patient with elevated CPK in the 500-1000 range with no weakness on exam or myositis on MRI but with positive HMGCoA ab?
No treatment but follow closely for weakness and muscle enzyme further elevation. If CK starts to go up and doubles and triples, or weakness start, then start treatment as soon as possible.
In a patient with a history of HIT, how would you reintroduce Heparin?
When patients with even remote histories of HIT are re-exposed to heparin, there is a very high risk of heparin-PF4 antibody seroconversion (Warkentin and Anderson, PMID 27114458). I have seen two patients who suffered a fatal relapse of HIT (e.g., case one in Kodityal et al., PMID 12890149). Bivali...
Would a surgical decompression be indicated in a patient with amyloidosis and severe median neuropathy at the wrist?
Yes, of course, if the median neuropathy is symptomatic. I am not aware of any literature suggesting lower rates of success with carpal tunnel release surgery in patients with various amyloidosis subtypes compared to non-amyloid CTS.
Do you recommend obtaining a spot urine or 24-hour urine magnesium measurement when evaluating patients with persistent hypomagnesemia of unknown etiology?
I try to avoid 24-hour collections for just about everything short of stone evaluations (Litholink). They are hard to do properly and bad information is worse than no information. I would use a FeMg and from UpToDate a FEMg > 3% in the setting of hypoMg and nl renal function usually indicates urinar...
In which patients awaiting a kidney transplant do you evaluate for primary hyperoxaluria given the high risk of allograft dysfunction following transplantation?
Primary hyperoxaluria is often diagnosed in adolescents and young and is typically diagnosed prior to being referred for transplant. One might consider work-up in a young to middle-aged adult with a significant history of kidney stones that are not explained by other conditions.
What is your approach to patients with membranous glomerulonephritis who have persistently elevated PLA2R titers but largely improved proteinuria and creatinine?
Depends on the evolution of the PLA2RAB titer. Please see the algorithm from De Vriese et al., PMID 27777266.
Would you recommend anti-platelet or anticoagulation in a patient with recurrent strokes, CADASIL, and Antiphospholipid Syndrome?
It depends on the circumstances (e.g. co-morbidities). Would use neither for CAA alone.
How accurate of an indicator is reticulocyte hemoglobin equivalent for iron deficiency?
I am not sure that question is answerable right now. I can tell you if I had an autoanalyzer with a RET-He, I would use it to determine who needs iron and who does not using a value of 30.7 as the cutoff for iron deficiency and 28.5 to determine the likelihood of responsiveness to iron [remember tha...
Can an acid loading test be used to assist with the diagnosis of RTAs other than an incomplete distal RTA?
This almost seems like a trick question. It is so odd but I have to think the answer is no. An acid load tests the kidneys' ability to respond to metabolic acidosis by increasing Nh4+ excretion. The only situation where that is impaired is distal rta. Normally you do not need to acid load because th...