Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
Is there a BMI cutoff for which you would refer a patient needing a native kidney biopsy to interventional radiology?
I refer all my patients who require a kidney biopsy irrespective of BMI to our in-hospital Interventional Nephrology service. They evaluate the depth of the kidney from the skin surface with ultrasound and decide whether they will be able to obtain adequate renal tissue for diagnosis. If the kidney ...
Does your treatment strategy differ when managing patients with recurrent calcium oxalate monohydrate versus calcium oxalate dihydrate stones?
I manage calcium oxalate monohydrate and calcium oxalate dihydrate stones the same way. Based on my laboratory studies of calcium oxalate crystallization, the differentiating feature between these two stone types is likely related to differing inhibitor properties of urinary proteins; forming the di...
Do you recommend stopping triamterene in patients with recurrent kidney stones who have stone composition results consistent with calcium based stone disease?
No. Decades ago, some triamterene containing kidney stones were reported. However, I have not seen one in many years. Typically, when I start a thiazide-type diuretic for the treatment of hypercalciuria, I do not add a potassium blocker since my patients have been instructed in a sodium-restricted d...
Do you have a preferential 24-hour urine lab test between urine urea nitrogen, urine protein catabolic rate, and urine sulfate when evaluating a recurrent calcium based stone former who has hypercalciuria presumed secondary to excess animal protein intake?
No. I refer most of my stone patients to the stone clinic dietitian who takes an accurate history of dietary nutrient intakes, including protein, and makes recommendations accordingly. Stephen B. Erickson, MD
What is your approach to dosing sodium thiosulfate for a patient with ESKD who is receiving CRRT?
It seems a bit oxymoronic, mutually exclusive, contradictory, - not sure if any of those are the right words. But if a patient needs CRRT, I dont think STS is something I am worrying about. It is not something that works right away, not even close. It can be missed for a while until patient is back ...
Are there instances when you recommend oral phosphate for patients with recurrent nephrolithiasis?
Yes. There have been two studies both done long ago looking at the effectiveness of oral phosphates in preventing kidney stones. The first using K Phos Neutral was done at Mayo and showed a decrease in the frequency of stone passage. The second, done in a California system, used K Phos Acid and show...
How long do you wait to repeat a 24 hour urine stone risk study after stopping topiramate in patient with recurrent calcium based kidney stones attributed to the medication?
Assuming normal or near normal GFR, topiramate should be effectively eliminated after approximately 5 days, and urine pH should have returned to its pretreatment level. If more data is desired, a 24-hour urine supersaturation could be collected then. Topiramate predisposes to kidney stones by inhib...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...