Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you manage serum sodium monitoring for an asymptomatic outpatient with newly diagnosed SIADH and a serum sodium level of 127 mEq/L, for whom you are initiating treatment with urea?
Based on the current available data, treatment of SIADH with urea is effective with a very low risk of overcorrection. In a meta-analysis of 23 studies involving 537 patients with SIADH, urea increased serum sodium concentration by a mean of 9.6 mmol/L, and the mean increase in serum sodium after 24...
How would you approach de-intensifying antihypertensives in frail older adults with SBP < 130 mmHg who have nephrotic range proteinuria, given the results of the RETREAT-FRAIL trial?
I would withdraw antihypertensive drugs that do not have any significant anti-proteinuric effect: dihydropyridine calcium channel blocker, beta blocker, alpha-1- blocker, hydralazine, and clonidine. Thiazide/loop diuretic may also be withdrawn if it is not needed for control of edema due to the neph...
Do you recommend outpatient dialysis initiation or inpatient admission for dialysis initiation in a CKD Stage 5 patient with stable electrolytes but experiencing nausea and vomiting related to uremia?
For a patient with CKD Stage 5 who has stable electrolytes but is experiencing nausea and vomiting from uremia, the patient can be managed with outpatient dialysis initiation. However, if the patient is at high risk for dialysis disequilibrium syndrome (DDS) due to markedly elevated BUN, I prefer in...
Do you have different 24 hour serum sodium correction targets for patients with severe, moderate, and mild hyponatremia?
It is known that overly rapid correction is significantly more likely to cause osmotic demyelination syndrome (ODS) in patients with more severe hyponatremia, particularly when initial serum sodium is ≤105 mmol/L. Since transcellular water movement is mediated by changes in osmolality across the cel...
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.
Would you recommend adjusting the hemodialysis schedule for a TTS dialysis patient who is scheduled for surgery on a Monday?
It depends on the patient. If the patient has no residual renal function, it’s prone to volume overload or hyperkalemia; such a patient would benefit from a dialysis session on Monday before surgery. If the patient is recently initiated on iHD, or has good volume control and electrolytes are fine, y...
Do you recommend patients with ESKD time their daily B complex multivitamin to after hemodialysis on hemodialysis days?
Yes. B vitamins do get removed some with dialysis but their removal is limited. Vitamin C on the other hand seems to be removed better. I don't see any harm of taking them after dialysis.
In patients with hypertension and suspected primary aldosteronism who have undergone negative confirmatory testing, what follow-up and monitoring strategies would you recommend to ensure early detection of potential aldosteronism?
If the screening test is convincing (PRA suppressed and plasma Aldosterone >15) I would repeat confirmatory testing. If the first test was saline suppression I would do salt loading and a 24 h urine collection, and vice versa. These confirmatory tests are useful but do not have high sensitivity. If ...
What is your approach for stone prevention for patients with recurrent nephrolithiasis who are started on GLP-1 agonist therapy and subsequently consume less daily water intake?
There is no approach except clinical interaction to promote continued fluid intake. I have personal experience with this kind of problem and believe one can achieve a reasonable response - albeit it can require some increase in visits.
What factors would lead you to consider revascularization in a patient with bilateral renal artery stenosis between 50-70% who has persistently uncontrolled hypertension despite maximal medical therapy?
Several randomized controlled trials (RCTs) (STAR 2009, ASTRAL 2009, CORAL 2013) have shown that medical therapy has similar outcomes to revascularization (stenting) in patients with 50-70% renal artery stenosis (RAS). In these RCTs, serious complications of the interventional procedures occurred in...