Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
How often do you check serum glucose and lipid levels after starting a thiazide diuretic for patients with recurrent calcium based nephrolithiasis?
I think checking serum glucose, electrolytes, and lipids about one month after starting a thiazide is reasonable. If levels are normal, I would revert to annual monitoring. Stephen B. Erickson, MD.
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
How do you advise patients with recurrent nephrolithiasis and polyuria who require more than one 24 hour collection jug and need to adequately mix the specimens prior to aliquoting for mail-off lab analysis?
My understanding of methods for dealing with large volume collections (more than 1 container) is that each container is sampled and tested separately, and the results are combined by the processing laboratory to provide the actual 24-hour totals. While one could envision methods for mixing the conte...
What is your approach to managing patients with recurrent nephrolithiasis and hypercalciuria who develop sun photosensitivity following thiazide diuretic initiation?
I am afraid my answer is too prebian. If I cannot use a thiazide and I need to lower urine calcium and protein in order to prevent stones, I resort to reducing dietary calcium to about 60 mEq/day. People who do not respond to a lower diet in sodium and protein with a fall in urine calcium often have...
How do you determine the optimal time to restart a diuretic in a patient with cirrhosis, ascites, and lower extremity edema who presented with acute kidney injury that resolved with IV albumin and holding diuretics?
Good question. It is tricky. Spironolactone can be resumed fairly quickly. With loop diuretics it is harder to resume them. If necessary, I would resume at lower dose and slowly uptitrate as needed with close monitoring. Ideally, it is better to do frequent paracentesis with albumin infusion than gi...
What is your approach for managing patients with recurrent nephrolithiasis who have elevated urinary cystine levels but calcium oxalate stone composition?
This is usually heterozygous cystinuria, and the urine cystine is in the range of 50 mg. Supersaturation with cystine is absent, and the cystine can be ignored. Rarely, urine cystine is high enough to produce stones, and I treat both stone risk factors. In all cases where urine cystine is above 100 ...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
How do you distinguish TMA caused by CNI toxicity versus antibody mediated rejection in a kidney transplant patient?
It really boils down to "the company you keep". If the biopsy shows evidence of antibody-mediated rejection with peritubular capillaritis, glomerulitis, or C4d positivity, I would lean towards AMR-associated TMA. Also need to always consider whether the primary cause of the ESKD. Was there an undiag...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...