Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to inpatient immunosuppression for a kidney transplant patient on home tacrolimus, prednisone, and mycophenolic acid who cannot tolerate anything by mouth?
When someone is NPO or cannot tolerate tacrolimus by mouth we give it sublingually. The sublingual dose is twice as potent as po so if someone is on 2 mg twice daily PO we would give 1 mg SL bid and monitor levels. Mycophenolate mofetil is available IV and is a 1:1 dose. Someone on 500 mg po bid MMF...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
How long do you recommend waiting before repeating a serum electrolyte panel after the conclusion of an intermittent hemodialysis session to ensure accurate results are obtained?
Depends on what our goal is. For an accurate potassium level, I would wait at least 4 hours, but likely 6 hours. For an accurate urea level, 1-2 hours would be fine. For phosphorus, again, I would wait longer. At times, I check labs right after dialysis to see if the temporary decrease in serum elec...
What precautions need to be taken to ensure the successful maturation and long-term functionality of an endovascular arteriovenous fistula?
A broad topic - I'll attempt to hit the main points. Considering many fistulas do not mature (forearm fistula > upper arm) - Successful maturation starts with vein preservation (avoiding PICC lines, IV lines, and marking the chosen limb with a bracelet); choosing an appropriate artery (non-calcified...
Would you consider not returning the blood from the dialysis circuit as a strategy for managing polycythemia in a patient with ESKD on hemodialysis who has a hemoglobin level greater than 16 g/dL?
It has been a while since I had a patient on hemodialysis with polycythemia, but I have “wasted” the blood circuit so the patient wouldn’t have to go for phlebotomy on a non-dialysis day. I believe that we didn’t return the blood once a week until his hematocrit was at goal, and then as needed there...
What is the recommended workup for PTH-independent hypercalcemia secondary to an elevated 1,25-dihydroxyvitamin D level?
I presume what is meant is that the PTH is suppressed, and therefore, with an elevated 1,25-dihydroxyvitamin D concentration, it is likely the primary cause? The 2 major causes for elevated 1,25-dihydroxyvitamin D when serum 25-hydroxyvitamin D is normal or sometimes low are due to either a granulom...
Would you recommend CRRT instead of intermittent hemodialysis to prevent lithium rebound in a patient with lithium toxicity after an initial intermittent hemodialysis session?
I think the best way to approach any "overdose" of a drug that is dialyzable and may have a rebound is to start with hemodialysis and run it until you have achieved your desired response (drug level, improvement in some other parameter) and follow that with CRRT to manage any rebound. This is well s...
Do you prefer a mycophenolate or tacrolimus based glucocorticoid-sparing regimen for patients with minimal change disease?
I prefer using CNIs over MMF as a steroid-sparing agent. It is important to note that the mechanism of action of CNIs in glomerular disease is likely not just from its immunomodulatory effects as CNIs can also cause stabilization of the podocyte cytoskeleton Peleg et al., PMID 32152065
Which salt substitutes do you recommend for your patients with recurrent nephrolithiasis who have hypercalciuria from excess sodium chloride intake?
In practice, as opposed to theory, I never use salt substitutes. I want patients to reduce use of sodium chloride as a life habit and work toward that end. I have no experience with salt substitutes, therefore.
Given the cardioprotective and renoprotective effects of SGLT2 inhibitors, should we consider administering to patients with well controlled type 1 diabetes despite the risk of DKA?
The key word in this question is "consider". GIven the lack of published clinical trials to assess efficacy (CV and CKD hard outcomes) versus safety (DKA) in this population, an answer at this time would be a qualified yes, with the qualifications being a well-motivated patient who adheres to self-g...