Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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....
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Would you opt to start IV iron load, maintenance iron therapy, or no iron at all in a patient with ESKD on hemodialysis who has a stable hemoglobin level at around 12.0 g/dL but also has low iron stores as evidenced by a low transferrin saturation and ferritin?
I routinely give an IV iron load to such patients. Iron is required for metabolic functions other than hemoglobin production and, for example, studies in non-anemic iron-deficient patients with heart failure consistently demonstrate improved outcomes with IV iron administration. If the patient is no...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
What is your approach for ESKD patients on peritoneal dialysis who request to do their own exchanges during a hospitalization?
I am very fortunate in that the University of Colorado Hospital has PD nurses on call 24/7. When patients are hospitalized, they are all, even those who usually do CAPD at home, treated with APD performed by the on-call PD nurse. For liability reasons, all machines are set up by the PD nurses. I rea...
Would you avoid fistula placement in patients with ESKD secondary to scleroderma?
I do not have any direct experience with this, but I would be very reluctant to place a fistula in someone with scleroderma.
What is your preferred method for latent tuberculosis screening prior to outpatient hemodialysis initiation for a patient with new dialysis requirements?
Definitely Quantiferon testing. It can be done at the same time as the hepatitis B blood test. The patient does not have to come back and have it read a couple of days later.
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...
How do you time 24-hour urine collections when calculating creatinine clearance for patients receiving thrice-weekly hemodialysis?
Great question. I think no matter how one does it there is bound to be some inaccuracies but it would still be helpful. My routine is to do the urine collection starting the morning after dialysis and ending the morning of dialysis. Then to check serum creatinine before dialysis. Of course, the seru...