Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to treating hypercalcemia secondary to immobilization?
My first approach is to have the patient become mobile if at all possible, even just increasing mobility in bed by doing leg and arm exercises, which can help, and getting up and walking is preferable if at all possible. Physical therapy is also helpful. I would make sure that the patient is well hy...
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Would you recommend starting finerenone for a patient with diabetic kidney disease who has marked improvement from severely increased albuminuria to moderately increased albuminuria following ARB and SGLT2i initiation?
Yes, if the potassium and blood pressure allow it. The real question is whether there is an added benefit from finerenone compared to spironolactone. My personal belief is no, except that finerenone is much less likely to cause hyperkalemia.
When would you pursue a kidney biopsy for patients with inflammatory bowel disease who have non-proteinuric progressive CKD of unknown etiology?
I have done kidney biopsies in patients in this setting. Helpful to know what is going on in the kidneys.
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...