Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
Do you recommend bedtime administration of antihypertensives in patients who exhibit nondipping on ambulatory blood pressure monitoring?
Most of the effective anti-hypertensive medications are long-acting, with therapeutic levels maintained for up to 72 hours between doses. From a pharmacokinetic perspective, dosing these meds (like amlodipine and chlorthalidone) at night would not make a difference. Data supporting nocturnal dosing ...
Would you add an additional alkali medication for patients with recurrent uric acid nephrolithiasis who are on high doses of potassium citrate and continue to have acidic urine?
Maybe. My first concern is poor compliance with potassium citrate. I would like to see the patients home pH records. I strongly encourage patients on alkali therapy to test urine pH periodically, and more frequently if a dose adjustment appears to be needed. I prefer potassium citrate to sodium bica...
For patients with kidney stone disease and chronic kidney disease, is there an eGFR threshold at which you no longer recommend pursing 24 hour urine stone risk studies?
While I agree with Dr. Erickson's comments in general, though, I have encountered patients that newly presented for stone disease at late stages of CKD and even on dialysis. The critical consideration is whether there is evidence of ongoing stone formation/growth. We must be aware that a stone passa...
How do you approach hematuria in a patient with diabetic nephropathy?
This is a difficult question to answer. If young, no risk factors for GU malignancy and only microscopic hematuria would generally not pursue but make patient aware of small risk and make sure PCP also knows. Helpful to know if red cells are dysmorphic and if there is also proteinuria. Gross hematur...
Would you recommend a SGLT2i for a non-diabetic patient with recurrent uric acid or calcium phosphate nephrolithiasis?
No. A major risk factor for uric acid stones is low urine pH. A major risk factor for calcium phosphate (as opposed to calcium oxalate) stones is high urine pH. I am not aware that SGLT2 inhibitors substantially change urine pH. Stephen B. Erickson, MD
For which patients with calciphylaxis would you recommend a parathyroidectomy?
In those with refractory hyperparathyroidism (typically PTH above 800-1000 pg/mL) despite medical therapies like cinacalcet.
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
Below what eGFR would you consider discontinuing lithium in a bipolar disorder patient with chronic kidney disease?
It seems nowadays we have other effective therapy besides lithium for the treatment of bipolar disorder. I tend to stop lithium as soon as I get a sense that there is a decline in kidney function as to avoid further damage. Of course, all of this depends on the specific situation and other possible ...
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...