Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach for minimizing volume intake for patients on dialysis who are receiving total parenteral nutrition (TPN)?
I would use concentrated TPN formulations by using higher concentrations of dextrose and amino acids to deliver more calories and protein per mL. I would adjust the dialysis prescription to account for TPN-related fluid gains. For example, ultrafiltration targets on dialysis days can be increased to...
How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?
This is not exactly a rare problem! I have a number of comments: Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because: a) patients really don't under...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Would you add tolvaptan to manage difficult to treat SIADH in a patient who is already on high doses of sodium chloride tablets and urea but fails to reach adequate serum sodium levels?
First of all, I am NOT a fan of salt tablets for SIADH; it takes a bit over 7 one-gram salt tablets to equal the mmol supplied by a single 15-gram packet of urea. And that many (large) pills can be nauseating, much more so than urea. By far, I would prefer tolvaptan over urea, but tolvaptan is often...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...
What is the role of APOL1 genotyping in the evaluation of a living kidney donor?
Testing for APOL-1 in living donors is controversial and a topic of much discussion and debate. There are not standardized guidelines of who and when to test. Some centers incorporate testing into their protocols while others individualize the decision regarding testing. There are a couple aspects t...
How do you counsel patients about the likelihood of improvement in kidney disease after anti-cancer treatment is initiated in a patient with malignancy associated membranous nephropathy?
There are numerous case reports to support that if the patient has a paraneoplastic MN then the expectation is that the renal lesion will respond to cancer directed therapy.
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
How do you decide when to refer for an access angiogram in a patient on hemodialysis with a drop in Kt/V but no other signs of access dysfunction?
In a JASN study (Coyne et al., PMID 9259360), the 3 comment causes of low Kt/V were: 42%- from poor blood cleaning due to low blood flow or shortened HD time 25% - due to recirculation from access dysfunction or reversed needles 33% - no cause identified, but on subsequent monthly testing, it normal...