Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I do but the issue is complex. Interpreted in context - life events, surgeries, meds etc - they tell me the range of behaviors for a patient in chemistry terms. But it takes a lot of time, and is not a good idea unless you are prepared to take that time.
What is your recommended sequence of therapies for achieving optimal proteinuria reduction in IgA nephropathy, especially in light of the recent approvals of sparsentan, delayed-release budesonide, and iptacopan?
I am actually quite persistent with conservative therapies first - I push an ARB or ACE inhibitor in an effort to get the proteinuria under 1 gram per day, or ideally 0.75 gram per day. I favor stronger ARBs such as olmesartan or azilsartan over weaker ones such as losartan or valsartan, and really ...
Would you start a mineralocorticoid receptor antagonist or aprocitentan first in a patient with resistant hypertension and advanced CKD?
My cut offs for prescribing a new mineralocorticoid receptor antagonist are eGFR < 30 (for spironolactone and eplerenone) and eGFR < 25 (for finerenone). I will, however, continue these meds down to an eGFR of 15 if they have been taking them without a history of hyperkalemia, which is often the cas...
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.
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 ...
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....