Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to anticoagulation in a patient with AKI and cirrhosis who has frequent filter clotting on CRRT?
A meta-analysis (Qi et al., PMID 37186766) compared 348 patients from 9 studies receiving RCA to 127 patients from 5 studies receiving heparin anticoagulation. Among the RCA recipients, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis was 5.3%, 26.4%, and 1.8%, resp...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
How do you address patient concerns regarding the necessity of REMS monitoring when prescribing sparsentan?
I point out to patients that sparsentan itself did not have an increased incidence of liver function abnormalities in trials, and that this REMS monitoring is required out of an abundance of caution because of liver function abnormalities seen with other anti-endothelin drugs like bosentan. Of cours...
Do you use the same hemoglobin target as an ESKD patient for an outpatient with AKI-D who has been receiving dialysis for more than 30 days and is prescribed an ESA?
Yes. The real question is whether Hgb between 10-11 g/dL is better than Hgb between 12-14 g/dL for just ESRD patients or even the General population. My guess is the latter. Lower Hgb is likely to be associated with lower bp and less stroke/CV disease. The benefit that the general population will de...
How do you titrate midodrine in your patients with ESKD who suffer from intradialytic hypotension?
I start out with 10 mg an hour before coming to dialysis and go up at high at 20 mg depending on the response.
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...
Are there instances when you recommend initiation of dialysis in patients with advanced chronic kidney disease who are scheduled for a major surgery but do not currently have any indications for renal replacement therapy?
There is this very annoying (annoying because I don't want to believe it) literature regarding CV surgery patients with CKD stages 4-5, but not on RRT, doing better post-op if dialyzed pre-op. It rarely rears its ugly head. Maybe there is something there despite my denial, or better yet my skepticis...
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
Do you recommend holding ACE inhibitors, ARBs, and SGLT2 inhibitors for patients with chronic kidney disease and malignancy who are about to start high-dose intravenous methotrexate?
This is obviously an opinion-based question since there are no clinical data on this topic. If a patient has risk factors for AKI (underlying CKD, advanced age, low body mass) then it may be reasonable to hold RAAS blockers prior to treatment and resume following the completion of that cycle of high...
Do you recommend dosing potassium citrate three times or two times daily for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I recommend twice daily dosing to help with compliance. I monitor 24-hour urine citrate and increase the dose rather than frequency if adequate urine levels are not achieved. Stephen B. Erickson, MD