Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you routinely transition patients with recurrent calcium based kidney stones off of hydrochlorothiazide and onto chlorthalidone or indapamide for optimal control of hypercalciuria?
Yes, I do as they are longer acting thiazides and thus have better control over hypercalciuria. I generally start with Indapamide 1.25 mg daily and will titrate up if necessary. I prefer that as opposed to Chlorthalidone as to start with 12.5 mg Chlorthalidone, you need to cut it in half, which is n...
Would you feel comfortable adding benlysta to patient already taking both mycophenolate and tacrolimus (and hydroxychloroquine) who still has some evidence of active lupus nephritis?
ABSOLUTELY (if the mycophenolate + tacrolimus combination therapy had had positive benefits on decreasing proteinuria plus was well tolerated thus far)!1. Per the package insert label for indications, "BENLYSTA is indicated for patients aged ≥5 with active systemic lupus erythematosus (SLE) or activ...
Would you treat an ESKD patient with renal artery stenosis in an attempt to improve blood pressure control and preserve residual renal function?
When a patient is dialyzing, the dialysis prescription and lifestyle factors, like salt and water intake, dominate blood pressure control. In both CORAL and ASTRAL trials, blood pressure control and residual renal function was not improved by renal artery intervention. For both of those reasons, I w...
Would you consider restarting a SGLT2i at a reduced dose in a patient who you previously discontinued the medication because of an associated significant decline in eGFR?
Restarting an SGLT2i in a patient after a severe episode of AKI requires careful decision-making and patient agreement. If the AKI episode was deemed related to volume depletion (hemodynamically mediated AKI), I restart the SGLT2i at a lower dose. At the same time, I re-counsel the patent on fluid i...
Do you recommend immediate catheter removal or anticoagulating for a certain amount of time before removing the tunneled dialysis catheter of a patient with an incidentally found, asymptomatic thrombus at the end of the catheter that does not interfere with hemodialysis?
I agree with Dr. @Dr. First Last. Since this tunneled dialysis catheter (TDC) is functioning well, there is no urgency to remove it. Infact, removal runs the risk of dislodging the thrombus causing pulmonary embolism. I would provide systemic anticoagulation with a vitamin K antagonist (coumadin) us...
How do you approach COVID-19 vaccination in those with a prior history of glomerular disease?
It is well documented that patients with kidney disease are at increased risk for morbidity and mortality from SARS-CoV2 infection including increased rates of hospitalization, AKI and death. Those with preexisting glomerular disease (GD) have demonstrated impaired GFR recovery following AKI in the ...
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
What is your approach to managing hyperkalemia in pregnant patients with chronic kidney disease?
Have to look at entire renal panel Address - HCO3 if very low as hyperkalemia may be due to shifting Evaluate other med (i.e. heparin) and dietary intake Assess volume status Consider fluid bolus + dose of loop diuretic
What is your approach to managing patients with labile blood pressures secondary to baroreflex failure?
Managing BP in the setting of baroreflex failure or dysautonomia is challenging. It is sometimes helpful to educate patients on realistic expectations. Medications will not be able to replace the baroreflex function. Conservative measures like compression socks during the day, bathroom modifications...
Do you recommend a patient with recurrent nephrolithiasis who is performing a 24 hour urine collection add a urine preservative or keep the specimen refrigerated?
We always add a preservative that will not interfere with any of the analytes to be measured. Additionally, we recommend refrigeration of the specimen. Stephen B Erickson, MD