Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
In patients with hypertension and suspected primary aldosteronism who have undergone negative confirmatory testing, what follow-up and monitoring strategies would you recommend to ensure early detection of potential aldosteronism?
If the screening test is convincing (PRA suppressed and plasma Aldosterone >15) I would repeat confirmatory testing. If the first test was saline suppression I would do salt loading and a 24 h urine collection, and vice versa. These confirmatory tests are useful but do not have high sensitivity. If ...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What is your approach for stone prevention for patients with recurrent nephrolithiasis who are started on GLP-1 agonist therapy and subsequently consume less daily water intake?
There is no approach except clinical interaction to promote continued fluid intake. I have personal experience with this kind of problem and believe one can achieve a reasonable response - albeit it can require some increase in visits.
What factors would lead you to consider revascularization in a patient with bilateral renal artery stenosis between 50-70% who has persistently uncontrolled hypertension despite maximal medical therapy?
Several randomized controlled trials (RCTs) (STAR 2009, ASTRAL 2009, CORAL 2013) have shown that medical therapy has similar outcomes to revascularization (stenting) in patients with 50-70% renal artery stenosis (RAS). In these RCTs, serious complications of the interventional procedures occurred in...
How would you tailor immunosuppression in an elderly patient presenting with primary FSGS?
Would use less [or avoid] high dose glucocorticoids. Rituximab would be preferred approach. Other options include CNIs and MMF.
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
Will you use vadadustat in place of an ESA in treating anemia of chronic kidney disease?
Vadadustat is approved by the FDA only for patients who have been on dialysis for at least 3 months. It is not approved for patients with CKD not on dialysis. Its efficacy and safety are comparable to that of ESAs. I would consider using vadadustat in two patient populations: those on home dialysis ...
When do you recommend genetic testing prior to kidney transplantation for a patient with ESKD secondary to FSGS?
Agree with Dr. @Dr. First Last's assessment. If a transplant candidate has clear evidence of secondary causes of FSGS (weight-based, medications, infections, autoimmune) and biopsy showed only patchy podocyte effacement, then I do not think the genetic testing would add much. The post-transplant mon...