Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
How do you approach vitamin D supplementation in patients with chronic kidney disease, given the findings that vitamin D2 supplementation may lead to decreased conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3?
In early 2000, there was a publication suggesting that ingesting vitamin D2 increases the destruction of vitamin D3 and therefore could increase the risk for vitamin D deficiency. Although I had never seen this happen in my clinic, we decided to conduct a study to evaluate what the effect of vitamin...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
Do you routinely discontinue SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease due to concern for volume depletion?
I would temporarily hold SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease if they are at risk of volume depletion (i.e. reduced oral intake, vomiting or diarrhea, high fevers with insensible fluid losses). Holding SGLT2 inhibitors in these acutely i...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
Do you routinely mention the risk for encapsulating peritoneal sclerosis as part of your consent process for dialysis initiation in a patient with advanced CKD who is considering the different dialysis options?
I do not do so. The incidence of EPS within the first 5 years of PD is extremely low. Just as I do not discuss with patients the possible occurrence of rare complications of HD (e.g., osteomyelitis), I do not discuss EPS either. The ISPD recommendation is to consider discussing the possibility of EP...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...