Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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 ...
Do you recommend initiating an ACE inhibitor or ARB in a patient with proteinuric CKD Stage 5?
ACE-I’s and ARB’s have been shown to be renal protective, and patients who have stopped these agents do worse than those who continue them. Potassium binders are an excellent option to lower K levels and enable patients to stay on these RAAS inhibitors. I would not take CKD patients off RAAS inhibit...
Would you recommend initiating a SGLT2i for proteinuria secondary to bevacizumab in a patient who has a sub-optimal response to an ACEi or ARB?
We don't have specific data for this scenario, but there is no reason to think that SGLT2i would not have a beneficial role though I agree with Dr. @Dr. First Last that risk/benefit needs to be weighed. At the same time, in this particular scenario, I'd carefully look at the time course of proteinur...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
A practical question! My answer is nuanced. If serial imaging, preferably CT, shows an increase in stone volume on their current treatment program (metabolic stone activity), yes. I think the benefit of controlling their stone formation outweighs the risks and inconvenience of a urinary catheter. I ...
Do you temporarily hold diuretics when measuring 24-hour urine calcium levels in the evaluation of primary hyperparathyroidism?
It is mandatory to stop diuretics at least 2 weeks before evaluating a patient for PHPT. One should have a fasting blood sample on the morning of the end of the collection for calcium phosphate and PTH to complement the urine collection. Thiazide-type diuretics raise serum calcium and lower urine ca...
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
Would you consider using acetazolamide to manage glomerular hyperfiltration in patients with type 1 diabetes, since SGLT2 inhibitors are contraindicated in this population?
Clever idea, but I think it is a bit much to assume that increased Na delivery from carbonic anhydrase blockade proximally would have the same renoprotective effect as an SGLT2i. So, no, I would not do this. However, I admire anyone thinking outside the box!
How often do you check serum glucose and lipid levels after starting a thiazide diuretic for patients with recurrent calcium based nephrolithiasis?
As I am mostly a consultant, the PCP usually times routine bloods. I would think once yearly is enough to monitor thiazides in relation to glucose. But potassium losses worsen insulin resistance, and as I monitor these and treat low potassium levels in blood aggressively, and as panels with potassiu...
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...