Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How would you approach the decision to biopsy a kidney transplant recipient who previously experienced a Page kidney following a kidney biopsy?
The decision to perform a renal biopsy should be made after thorough deliberation regarding the appropriate indications and the potential diagnostic information that the procedure may yield to inform patient management. Under suitable conditions, renal biopsy is considered a safe and well-tolerated ...
Would you avoid potassium citrate initiation in a pregnant patient with hypocitraturia and recurrent calcium oxalate nephrolithiasis?
Difficult question to answer. There is no clear contraindication; however, if her urine pH is OK, I would likely avoid it. I would make sure she is adequately hydrated and would recommend having fresh squeezed Lemons to help. However, if it appears necessary to use it, I would.
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.