Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What drives you to choose voclospsorin over tacrolimus given the substantially higher cost?
In a discussion of comparing voclosporin versus tacrolimus to treat LN, I would first like to address the issue of cost. As far as any individual patient, out-of-pocket expenses may be similar for these two calcineurin inhibitors since it is often covered by insurance. Additionally, Aurinia has a ve...
Do you ever combine voclosporin and belimumab in the treatment of lupus nephritis?
The combination of these two therapies has not yet been formally tested. Having said that, the combination has an appealing rationale. Immunologically, modulating T cells and B cells in LN seems likely to be efficacious. Beyond the immunology, there are other reasons that favor this combination. Voc...
Do you check carnitine levels for your patients on CRRT?
Our institution doesn’t routinely check Carnitine levels. A few years ago, we did use Carnitor supplements, but in the lack of any major clinical benefit, the practice has since been abandoned, besides many clinical nutrition formulas have carnitine.
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.
How do you advise an ESKD patient who wants to drink pickle juice to reduce intradialytic muscle cramps?
Salt is addicting! Acknowledge that changing habits is hard. Make a case that the reason for cramps is RATE at WHICH fluid is being removed. Ask the patient to recall the days when the goal of fluid removal was low. During those treatments, the risk and occurrence of cramps were less likely when com...
Would you start patiromer in a patient with CKD who has persistent hyperkalemia despite taking sodium zirconium cyclosilicate and adherence to a low potassium diet?
If the question is in addition to, I would first ensure adherence with SZC and diet (maybe measure 24-hour urine K) and maximize dose. Then, you might consider switching to patiromer rather than adding.
Would you recommend SGLT2 inhibitors for patients with sickle cell nephropathy and severely increased albuminuria despite the potential medication associated risk for vaso-occlusive crises?
No