Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
At what initial sodium level do you recommend strict avoidance of overcorrection (e.g., no more than 6 mEq/L in 24 hours) in patients with hyponatremia?
Less than 120.
What factors do you consider when advising a patient with lupus nephritis on the safety of becoming pregnant?
I agree with Dr. @Dr. First Last's excellent suggestions (with just one exception!). I don't increase prednisone prophylactively for lupus pregnancy - I would only add or increase steroid if there is a flare. The risks of steroid in pregnancy impact both maternal and pregnancy outcomes, so we try to...
What are your criteria for starting tolvaptan in adult patients diagnosed with autosomal dominant polycystic kidney disease?
This question is probably a bit too broad to answer in detail here, but in broad strokes, depending on the age, imaging criteria (Mayo class / total kidney volume), and kidney function of the patient, as well as other clinical factors, you assess the patient's risk of rapid disease progression to ma...
Do you recommend patients temporarily hold cilostazol prior to and after a kidney biopsy?
Kidney biopsy is considered a high-risk bleeding procedure by SIR (Society of Interventional Radiology).Cilostazol is a PDE inhibitor leading to the inhibition of platelet aggregation. The Drug has a half-life of 10 hours. In the past, it was recommended to stop the drug at least 24 hours before a p...
Would you recommend immediately exchanging a peritoneal dialysis catheter, or waiting until the completion of antibiotics with transition to HD, if a PD patient presents with peritonitis and a nonfunctional PD catheter?
Optimally, peritonitis should be completely resolved before placing a new (and hence sterile) foreign body into the peritoneum. That said, all attempts to restore PD catheter function without invasive measures (non-surgical) should be attempted first. If the PD catheter can be restored with minimall...
How much proteinuria would warrant consideration of native kidney nephrectomies at the time of a kidney transplant?
We don't typically consider native nephrectomies unless the proteinuria is > 5-6 grams. We rarely end up doing native nephrectomies, though. The main problem, besides the complications associated with heavy proteinuria, is the inability to assess for recurrent disease post-transplant. This can be pa...
Do you recommend first consulting interventional radiology or vascular surgery if you lack access to interventional nephrology in a patient with ESKD who is suspected of having a clotted fistula and is unable to receive hemodialysis?
Yes. Not all institutions have access to Interventional Nephrology. Anyone with the required skill, expertise, and availability would need to be consulted urgently to manage the clotted AV access - especially if it is indeed a fistula (as opposed to a graft). The longer the fistula remains clotted, ...
Would you recommend avoiding intravesical (bladder) tobramycin administration in a patient with advanced chronic kidney disease?
Guess fear is absorption, build up, and toxicity. A single loading dose of an aminoglycoside is not to toxic level. Maintaining the level of risks ototoxicity, build up also nephrotoxicity. Would depend on absorption and residual GFR. Try a single loading dose, check levels after 12 or 24 hours to g...
Do you recommend prophylactically adding heparin to the dialysate in patients hospitalized for peritoneal dialysis associated peritonitis given higher incidence of fibrin-associated catheter issues?
For patients with peritonitis, IP heparin (500 units/L) can be helpful to prevent catheter occlusion when the drain fluid (effluent) is cloudy. Note that while most antibiotics are stable when admixed into peritoneal dialysate, after heparin is added, the length of stability may be shortened for cer...