Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you consider adding an SGLT2i for a patient with proteinuric kidney disease who is already on maximal dose ACEi/ARB and has a UACR < 300 mg/g?
I not only would consider it, I've done it on many occasions. There's nothing magical about UACR <300 that eliminates the risk of CKD progression. The risk decreases but it's not an inflexion point. The lower the albuminuria, the lower the risk of progression, which has been well demonstrated in IgA...
Do you recommend treating asymptomatic Proteus urinary infections in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
Yes! Proteus species are typically rapid producers of urease, splitting urea to ammonium and raising urine pH, often into the high 7s and precipitating, magnesium, ammonium phosphate stones, otherwise known as struvite.Your patient’s Proteus infection apparently splits urea more slowly with less ele...
How do you approach “clearing” a patient with SLE and ESRD for renal transplant?
Prefer the term "optimizing" as opposed to "clearing" SLE patients for procedures such as renal transplants and issues here similar to identifying the preferred time to proceed with pregnancy, specifically in patients with a history of LN, with the goal in both scenarios of achieving desired outcome...
How do you manage hemodialysis for an ESKD patient presenting with severe hyponatremia and a serum sodium more than 10 mEq/L below the lowest available dialysate sodium concentration?
There are multiple ways of dealing with this situation. One option is not to dialyze if not urgent and let the sodium come up before starting dialysis. The most exact way of dealing with the situation is to do hemofiltration either continuously or intermittently with a concomitant D5W infusion adjus...
Do you recommend temporarily holding SGLT2 inhibitors in patients with CKD who are undergoing CT imaging with intravenous contrast?
Probably should hold the morning dose before giving contrast. The risk I would assume is very low, likely lower than giving lasix prior to the contrast which we normally do not hold.
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
Are there instances when you recommend kidney stone disorder gene testing in patients suspected of having cystinuria?
If the patient has a stone analysis showing pure cystine, I consider that proof positive of homozygous cystinuria and do not recommend genetic testing for the patient. However, I suggest that first degree relatives get genetic testing for cystinuria, and, if homozygous, I recommend preventive treatm...
Do you recommend malic acid supplementation for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
F. Malic acid, like citric acid, is metabolized as a protonated acid and used as a metabolite—it produces no alkali. Malate is metabolized as an acid and in doing so takes up a proton—just as citrate does—producing new bicarbonate, and so is an alkali.Rodgers et al., PMID 24059642 reports malic acid...
What is your approach to intensifying the hemodialysis prescription for patients found to have dialysis-related amyloidosis?
These are the patients in whom hemodiafiltration would be the most useful. If not available then using the most high flux dialyzer, longer dialysis times are other options to remove more b2 microglobulin.
Would you recommend against starting SGLT2 inhibitors in patients with a history of struvite nephrolithiasis who also have proteinuria and chronic kidney disease?
Yes! Although SGLT2 inhibitors are helpful in most patients with proteinuric chronic kidney disease, they can also exacerbate some coexistent conditions. Increasing glycosuria predisposes patients to UTIs. For patients with struvite stones, SGLT2s would likely exacerbate the infection and increase s...