Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
I emphasize that the reference range intentionally excludes normal individuals who are a little different from the average person, and that the reference range is just a numerical exercise and general guidance, not something that was ordained by higher powers. I don't use the analogy for patients, b...
Do you recommend zinc for patients with advanced CKD who have dysgeusia?
I do not recommend routine zinc supplementation for advanced CKD patients with dysgeusia due to mixed evidence and the risk of copper deficiency due to zinc supplementation. Zinc can interfere with copper absorption and may potentially cause copper deficiency. However, a trial of zinc supplementatio...
Do you routinely check serum phosphorus levels after IV iron therapy?
I do not routinely monitor serum phosphorus levels after intravenous iron therapy if ferric carboxymaltose (FCM) is not being administered. At our institution, the top two formulary choices for outpatient use for iron repletion are iron sucrose and ferumoxytol, neither of which is associated with a ...
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
Would you recommend adding a mineralocorticoid receptor antagonist or endothelin receptor antagonist for a patient with bevacizumab-induced proteinuria who is already on an ACEi or ARB?
Unfortunately, we have no data to guide the choice of anti-proteinuric agents in this particular setting. We do have biological plausibility for antagonizing the endothelin pathway, as we know that vascular endothelial growth factor inhibition results in upregulation of endothelin-1, and the resulta...
How do you decide when to stop routine laboratory monitoring in a patient with CKD Stage 5 who has chosen conservative management?
I normally don't as patients often change their mind when they are sick. However, if the patient requests not to monitor labs then I would honor their wishes.
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...