Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you recommend against a kidney biopsy in a patient with a single kidney who otherwise has indications for a biopsy, consents, and has no medical contraindications for the procedure?
I don't think so. These days the risks of having to do nephrectomy after kidney biopsy is very small and having a single kidney is a weak argument for not doing kidney biopsies. In my practice, a patient with a single kidney would get biopsied by interventional radiology to minimize the risk as much...
Do you prefer sodium bicarbonate or sodium citrate in your chronic kidney disease patients with metabolic acidosis?
I have always used sodium bicarbonate in this scenario. The easiest/cheapest way to prescribe it is to advise patients to use Arm & Hammer baking soda, which is essentially sodium bicarbonate. I gm of sodium bicarbonate provide 11.9 mEq of bicarbonate; therefore one half of a teaspoon (about 2.5 gm)...
Do you offer home administration of ESAs for your patients with anemia of chronic kidney disease?
Yes, it the patient's prescription drug plan allows it. Traditional Medicare does not allow home administration of ESAs since they are covered under part B rather than part D. However, many Medicare Advantage and commercial insurers do allow for home administration of ESAs, so I offer that option to...
How do you approach consults regarding clearance of patients with chronic kidney disease for surgery?
I never provide "clearance" for surgeries. I comment whether kidney disease is stable and whether there are any contraindications to surgery, medications, etc. based on the kidney disease.
Would you avoid SGLT2 inhibitors in patients with nephrostomy tubes?
I probably would unless a compelling reason to use. I worry about risk of infection and would imagine that depending on the reason for the nephrostomy tubes might limit the potential upside of using these agents. Maybe in future years as we gain more experience in non-study populations my answer wil...
Do you recommend increasing dietary potassium intake for blood pressure management in non-CKD patients with hypertension?
Yes! The AHA guidelines from 2017 list a heart-healthy diet like the DASH diet (which has natural sources of potassium from fruits and vegetables) as strong recommendation (class I) supported by the highest level of evidence (level A). It is even recommended to use potassium supplements if not contr...
Do you recommend repeat kidney stone composition testing for a patient with recurrent nephrolithiasis who passed an additional stone but previously already had stone composition testing performed?
Good question. Certainly, if there has been a gap in stone events prior to new development of stones, it is reasonable to confirm both the stone composition and the 24-hour urine chemistry, to see if conditions have changed in a meaningful way. It would be less important, if the patient had regular ...
Is the phosphorus-lowering benefit of patiromer compelling enough to switch a patient with chronic hyperkalemia and hyperphosphatemia from sodium zirconium cyclosilicate to patiromer?
I don't think so but I think Patiromer is a better agent anyway as it does not have sodium in it. Patients with CKD and especially dialysis patients are often volume overloaded. It definitely makes sense to use an agent that does not have sodium in it.
How long do you monitor proteinuria after starting an SGLT-2 inhibitor before considering adding another medication if proteinuria is not at goal?
I would typically wait 2-3 months. Most such patients should be on RAAS blockade which should be maximized if tolerated first.
How soon after an end stage kidney disease patient receives a MRI study with gadolinium contrast do you perform their next hemodialysis session?
Very contentious question. But as an author of the NKF and ARA position paper on this, I would follow our advice, no need to dialyze immediately after, but try to time the study with the next dialysis.Weinreb et al., PMID 33170103ASN Communities (for ASN members) had a VERY LONG post on this general...