Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you use diuretics for non-oliguric patients with volume overload in the setting of hepatorenal syndrome who have normal MAPs?
Absolutely. First, since most patients with HRS are oliguric and have low MAPs, I would look for alternative explanations for renal insufficiency. But, yes, if someone like this is volume overloaded, then I do use diuretics, often in conjunction with large volume paracentesis, to manage the volume o...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
Would you offer peritoneal dialysis to a patient with ESKD who also has a ventriculoperitoneal shunt?
I would not place a PD catheter in an adult ESRD patient who has a ventriculoperitoneal shunt (VPS). I would instead place a hemodialysis vascular access and encourage this patient to do home hemodialysis. However, if the patient had exhausted all vascular access sites and was catheter-dependent, I ...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
Are there instances when you offer dialysis to patients with high-risk hepatorenal syndrome who are not transplant candidates?
I never say never. The diagnosis of HRS is not 100% accurate. Particularly in a young person, but in others as well, if it seemed like there was an acute event, I might offer a time limited period of dialysis.
What is your preferred hemodialysis regimen for patients with acute lithium toxicity?
Assuming that renal function is normal or new normal, I would dialyze them in the most rapid way possible, high blood flow, a large dialyzer, and a longer time. Repeat lithium levels and repeat dialysis if levels remain elevated is crucial.
Do you prefer liquid calcium carbonate over other calcium carbonate formulations for patients with recurrent calcium oxalate nephrolithiasis who have persistent hyperoxaluria on 24 hour urine studies?
I would not differentiate between the use of a liquid or tablet form of calcium carbonate based on urine oxalate measurements. The only reason to choose between these two forms would be patient preference or some usual physical limitation with taking the tablet form. Much more commonly, I encounter ...
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
Can a dihydropyridine calcium channel blocker (CCB) like amlodipine be prescribed in addition to a non-dihydropyridine CCB such as diltiazem or verapamil for treating hypertension?
Yes, with extreme caution. Diltiazem and Verapamil are CYP450 inhibitors, which can interfere with the metabolism of many medications (commonly statins and calcineurin inhibitors), but also can increase levels of nifedipine and presumably other dihydropyridine CCBs, like amlodipine. Diltiazem or ver...