Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What adjustments do you make to a hemodialysis prescription for a patient with a recent stroke?
There are multiple considerations in the setting of a CVA in a patient requiring hemodialysis. One is addressing potentially high intracerebral pressure (ICP). A slow reduction in BUN to avoid osmotic-related brain cell swelling and an associated rise in ICP may be addressed in a variety of ways. Lo...
What are your management strategies for patients with end stage kidney disease on hemodialysis who develop hypercalcemia of immobility?
I have seen this situation from time to time. First, I would make sure the patient is not getting any calcium or vitamin D-containing products. Then would try to use a lower calcium bath. Unfortunately, many units are unable to lower the calcium bath below 2.0 mEq/L currently and a lot of time that ...
Do you favor Sotagliflozin over SGLT2i alone for cardiovascular risk reduction in patients with Type 2 diabetes and chronic kidney disease?
The use of Sotagliflozin rather than SGLT2i alone is reasonable based on the results of the SCORED trial (Aggarwal et al., PMID 39961315). Although this trial compared sotagliflozin to placebo, rather than to SGLT2i, it did show a reduction in both MI and stroke in patients who have type 2 diabetes ...
In which patients with MGUS do you recommend a kidney biopsy to evaluate for MGRS?
If a patient has unexplained renal disease, and this could be interstitial or glomerular, and an MGUS, I strongly consider it. I typically try to get heme to do a bone marrow biopsy first because their findings may obviate a renal biopsy if they find something (although sometimes they may find low-g...
Do you prioritize adding a GLP-1 receptor agonist over an SGLT-2 inhibitor in patients with CKD related to type 2 diabetes, uncontrolled proteinuria despite being on an ACEi, and obesity?
My habit to date has been to use an SGLT-2 inhibitor first. I refer patients to PCPs or others for GLP-1 treatment for obesity, even if they have CKD.
How does contralateral suppression of more than 50% with cosyntropin during adrenal venous sampling influence your decision to recommend adrenalectomy in patients with primary aldosteronism?
Most but not all studies support it as a secondary criterion, and ratios <1 and 0.5 compared to the periphery have been suggested. There have been rare cases where I have used it as the sole criterion where the contralateral adrenal vein could not be successfully catheterized (usually in conjunction...
What is your PTH target for patients with ESKD and brown tumor?
Great question. I would definitely shoot for a lower goal. May be 150-300. I am looking forward to see what our bone experts suggest.
What is your preferred initial imaging choice for a patient suspected of having renal artery stenosis who does not have any contraindications to imaging contrast media?
If the suspicion is for atherosclerotic-related renal artery stenosis (>55 years old, history of systemic atherosclerosis, tobacco use), then I start with a renal duplex ultrasound. Importantly, I do not get a renal duplex ultrasound on all patients with resistant hypertension. If the suspicion is f...
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Do you recommend avoiding combination vancomycin and piperacillin-tazobactam in patients with acute kidney injury?
Personally, I don't think the risk is that high and I won't necessarily recommend against it. If a patient develops worse renal function while on the drugs though, I would have a low threshold of switching to something different. I would also try to avoid vancomycin levels over 30.