Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a role for vadadustat in addition to an ESA in ESKD patients who are hyporesponsive to ESA’s alone?
I am not aware of any published studies of HIF-PHIs such as vadadustat used in combination with ESAs in ESKD patients who are hyporesponsive to ESAs alone. The vadadustat label recommends pausing vadadustat treatment for patients receiving ESA rescue for Hb <9 during the transition phase from ESAs, ...
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?
I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is...
Are there any special considerations when treating patients with recurrent nephrolithiasis who also have medullary sponge kidney?
Sponge kidney patients present a very challenging therapeutic situation. Anatomically speaking, a sponge kidney is often a congenital, although occasionally acquired, dilation of the renal collecting ducts, which in turn causes the inability to acidify urine. Urine pH is typically unusually alkaline...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
Do you recommend patients with hypertensive kidney disease transition from wrist to upper-arm home blood pressure monitoring prior to making dose adjustments to their antihypertensive regimen?
Possibly, if I think the measurements are not accurate. Home BP monitoring is an important part of hypertension management. In my practice, I've noticed that positioning while taking the BP is more important than the specific device type. I advise patients to check their BP at home in a hard-backed ...
Do you plan to incorporate fish-oil supplementation into the care of hemodialysis patients to reduce cardiovascular events in light of the PISCES trial results?
I showed the paper to an Internal Medicine friend of mine who is more statistically savvy than me. He wrote this: "So I read the study, and I’m still at a loss to understand it. I’m pretty Bayesian, but this study breaks my priors. Prior studies were basically negative, not to mention that nothing e...
What is your approach for arranging outpatient antibiotics on discharge for a hospitalized patient with ESKD who receives in-center hemodialysis at a unit you do not round at?
Ideally, the best option would be to call both the dialysis unit and the outpatient nephrologist. Understandingly, this may be time-consuming. If I were to choose between the two, I would call the outpatient nephrologist since they may have a reason to change the plan to some degree; however, one ri...
Do you recommend avoiding morphine in patients with ESKD?
I would not recommend using other than for a few doses for acute severe pain but not for more prolonged use other than in the setting of terminal illness/hospice.