Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you have a higher threshold regarding when to hold bevacizumab for proteinuria in patients who had known baseline proteinuria from diabetic nephropathy?
This is an interesting question. It’s not uncommon to have patients with cancer who have other underlying conditions that may lead to proteinuria. I don’t have a higher or lower threshold to recommend holding VEGF inhibitors, but in all patients who are on them who develop proteinuria, the degree of...
What is your approach to exit-site prophylaxis in patients receiving peritoneal dialysis who are unable to tolerate gentamicin or mupirocin due to allergic reactions?
There are a number of other antibacterial regimens that have been proposed, most of which are either ineffective or actually pose a higher risk of fungal infections (at least in diabetic patients). These include polysporin triple antibiotic ointment and medical-grade antibacterial honey. The only ag...
What are your management strategies for patients with recurrent uric acid nephrolithiasis and chronic kidney disease who have persistent hypocitraturia and acidic urine pH?
This is a good question. The primary goal is to correct the urine pH to at least 6 and preferably 6.5, regardless of renal function. Hypocitraturia is not a critical issue in uric acid stones disease, though it will likely respond to therapies listed below. Concurrent chronic kidney disease does not...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
What is the minimum eGFR at which we should avoid initiating SGLT2i therapy?
The minimum eGFR to avoid initiating SGLT2i is different depending on the medication. Canagliflozin or Invokana is less than 30 ml/min. Dapagliflozin or Farxiga is less than 25 ml/min. Empagliflozin or Jardiance is less than 20 ml/min. With recent study suggests you still can continue the therapy wi...
Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?
I understand the physiology upon which the cinacalcet suppression test is based. However, I have not used it in my practice. Once I see a discordant result between a parathyroid hormone level and its main determinants: serum calcium, phosphorus, and vitamin D (or 1, 25-vitamin-D), I use a sestamibi ...
Is there a role for calcitriol in dialysis patients regardless of PTH level?
I believe the general consensus among endocrinologists is that the origin of circulating calcitriol is from the kidney and this is considered the traditional endocrine pathway of vitamin D influencing bone and intestinal mineral absorption. However, many tissues have the ability to synthesize calcit...
What is your approach to managing osteoporosis in patients with end stage kidney disease?
I don't believe you can make a diagnosis of osteoporosis in patients with ESRD. They have to be treated based on the disorders associated with CKD-MBD and not solely based on the results of a bone density scan. In some patients with documented low turnover disease and mineralization defect, some may...
Would you recommend desmopressin for a patient with ESKD receiving thrice weekly hemodialysis who is hospitalized for a persistent gastrointestinal bleed not amenable to usual interventional treatment strategies?
Yes. I always give desmopressin in patients with uncontrolled bleeding and uremia to fix the bleeding time abnormality. In this situation, the benefits should out way the possible harms.
How do you manage nephrotic range proteinuria in a pregnant patient with a known history of diabetic nephropathy prior to pregnancy?
Interesting question. Part of this depends on what one thinks of the etiology of the nephrotic syndrome. With a history of diabetic nephropathy, the odds are this is a continuation/natural worsening of the underlying diabetes, and hence there is no specific therapy exists. Hence, a renal biopsy woul...