Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What is your approach to managing patients with recurrent ammonium urate kidney stones?
Pure ammonium urate stones are very unusual, and, to my knowledge, there are no studies to guide us in their treatment. Much more common are magnesium ammonium urate stones, commonly known as "struvite". These are caused by urease-producing bacteria, usually Proteus or Klebsiella. I would first chec...
Do you dose ESAs via an intravenous or subcutaneous route for hospitalized patients with ESKD and anemia?
ESAs are dosed IV at our hospital. No good reason aside from patient comfort probably. I personally think giving ESAs to hospitalized patients is largely a waste due to their inflammation, infection, etc.
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
Do you advise your patients with CKD to consume a set amount of fluids daily in an attempt to prevent disease progression?
No. I advise them to limit fluid intake and drink only according to thirst. There 3 caveats to this.Patients with a history of kidney stones need to drink more water.Patients with hypernatremia need to drink more water. Whether drinking more water will prevent bladder cancer has been debated, but I ...
Would you offer peritoneal dialysis to a patient with ESKD who also has dementia but lives with family who can assist with dialysis treatments?
The key words in this question are "can assist". Change it to "WILL assist" and the answer is an unequivocal "yes". But I would not leave it optional.
What is your preferred blood flow rate for a patient with ESKD who has an AVF but is only undergoing an ultrafiltration session?
I see no reason to limit the blood flow. Clearly, if you are just UF, the blood will "thicken" as you remove protein and cell-free water component of the blood, and the higher the blood flow, the lower the filtration fraction (FF) and the less "thick" the blood will get. If your UF says 3 liters ove...
Do you recommend checking a serum phosphorus level in patients with recurrent nephrolithiasis?
For patients with pure calcium phosphate or mixed calcium phosphate/oxalate nephrolithiasis, l routinely check serum phosphorus as part of a panel that also contains serum calcium, PTH, creatinine, and 25-vitamin D, looking for primary hyperparathyroidism, a surgically curable cause of these stones....