Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach recommending an AVF for a patient with advanced CKD who is concerned about the cosmetic appearance of the fistula?
My approach is usually 2-fold. First, I try to emphasize the medical benefits of an AVF over a catheter. Second, I point out that the catheter is also the most aesthetically appealing option to have. I then go over possible solutions of covering the AVF (sleeves, etc.). This could also be a good ...
Do you prefer maximizing fluid removal during dialysis or starting new antihypertensive medications for patients with ESKD on intermittent hemodialysis who are chronically hypertensive?
Fluids, fluids, and fluids are the most crucial first step. Challenging dry weight is the most important part in controlling blood pressure, and then adding more blood pressure medications is the next step. The only "exception" is high dose diuretics to reduce intradialytic weight gain. Additionall...
What is your approach to using intraperitoneal sodium thiosulfate for a patient with ESKD on peritoneal dialysis who develops calciphylaxis?
I believe if the patient has calciphylaxis, PD should not be continued, and more efficient IHD or HHD with the addition of sodium thiosulfate is better.
Do you have your patients with recurrent calcium phosphate nephrolithiasis and hypocitraturia avoid high citrate containing foods if they have alkaline urine?
A good question, and I don’t think we have hard evidence to answer it. Most kidney stones are a mixture of calcium oxalate and calcium phosphate, the oxalate content usually predominating. Pure oxalate stones should prompt a search for one of the hyperoxalurias. Pure phosphate stones (apatite/brushi...
What is your approach to managing patients with recurrent nephrolithiasis who consistently fail to adhere to recommended dietary changes including animal protein and sodium restriction and remain at elevated stone risk due to hypercalciuria despite thiazide diuretic use?
I typically repeat the prior recommendations and discuss potential barriers to better compliance with the patient in follow-up to try to encourage better compliance. I do point out that they might compensate for some dietary indiscretions in salt and protein by drinking extra fluid, since "dilution ...
Do you recommend SGLT2 inhibitors for patients with Fabry disease and proteinuria despite ACEi/ARB use?
Like most other nephrologists, I have had very little experience with Fabry's disease (1 patient for a couple of months over the last 26 years). If enzyme replacement is indicated and given, and an ACE-ARB is already instituted, I don't see a problem with starting SGLT-2 in addition.
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
What is your approach to waiting period for an ESKD patient getting a kidney transplant after just being treated for bacteremia?
In general, I would like a waiting period of at least 6-8 weeks. I would review the clinical course of the hospital admission to ensure that the patient has recovered well physically and that the source of bacteremia has been adequately addressed, e.g., any lines/abscesses. If this is a living donor...
How have you incorporated donor-derived cell-free DNA to help with the diagnosis of rejection or monitoring of the treatment response to rejection?
I typically use it in lieu of an allograft biopsy in patients on surveillance, particularly if there are reasons to avoid a biopsy (antiplatelet agents, bleeding risk, difficult anatomy). Serial cf-DNA levels that improve following treatment of rejection have been helpful as well to give us an idea ...