Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you avoid potassium citrate initiation in a pregnant patient with hypocitraturia and recurrent calcium oxalate nephrolithiasis?
I agree with Dr. @Dr. First Last, there is no clear contraindication. However, it would not be my first step. Preferable would be to optimize dietary and fluid therapy first. Stephen B. Erickson, MD
Under what circumstances would you use tenapanor over more frequently prescribed phosphorus binders for managing hyperphosphatemia in CKD patients?
Our current experience has been using tenapanor only as an added medication to oral phosphorus binders when further reduction of serum phosphate is required. We have not used tenapanor as the primary medication to control hyperphosphatemia, but this may change in the future as we learn more about th...
Do you recommend avoiding SGLT2i use for patients with proteinuria from diabetic kidney disease if they have urinary retention requiring catheterization?
I would probably avoid SGLT-2 in such a patient because of the risk of infection. Likely, the risk is not worth the benefit.
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
Do you adjust the hemodialysis bicarbonate bath to match the elevated serum bicarbonate level in ESKD patients with hypercarbia due to COPD?
I do not typically for COPD itself, but I do consider it in circumstances where there is severe resp acidemia with no other options for stabilizing their pH. In a subset of patients on home ventilation/AVAPS, they have little reserve to handle even a little more CO2 retention. I will modulate the di...
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
What is your preferred management approach for scleroderma renal crisis in a patient with a history of anaphylaxis to ACE inhibitors?
The important thing is to lower the BP regardless of the how. ACE I were the first medication to show survival benefit in patients with scleroderma renal crisis so they have become the treatment mainstay. Time is kidney so the best treatment is to lower the BP with whatever BP lowering medication yo...
How do you approach selecting a dialysis modality for a patient with advanced CKD who is interested in home therapy but has a history of medication non-adherence and poor attendance at clinic appointments?
Good question. I would like to give them a chance at home dialysis before declaring that they are not candidates but I think it should be evaluated on a case by case basis.
Do you still use the urinary anion gap to estimate renal ammonium excretion in patients with a non-anion gap metabolic acidosis, given its limitations?
Yes, I do, but especially as a teaching tool to help understand the make-up of urine in different clinical scenarios. Of course, a urine NH4+ would make this all so much easier, but I believe that the UAG is usually still of value in the evaluation of a NAGMA. The Achilles heel of it, of course, is ...
Do you temporarily hold ESAs for your patients with kidney disease who have an upcoming surgical procedure with the goal of reducing the risk for DVTs?
I do not routinely recommend this. I think the risk is very small given modern use of ESAs and thromboprophylaxis.