Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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...
What is your approach to differentiating diabetes insipidus from primary polydipsia in the outpatient setting?
I usually do overnight dehydration tests for 12 hours and if fasting AM urine osmolality is >600 DI is less likely. If urine osmolality is low with high serum sodium it indicates DI, whereas with primary polydipsia the serum sodium is low with low urine osmolality.
Are there any varying treatment considerations to make when managing patients with carbonate apatite versus hydroxyapatite kidney stones?
Both of these stone types require a relatively alkaline urine to crystallize. Not surprisingly, they are often found in combination within the same stone. My diagnostic and treatment considerations do not depend on which mineral composition predominates. Stephen B Erickson, MD
Do you make any changes to surveillance imaging frequency, 24 hour urine stone risk collection frequency, and stone preventative medication approaches for patients with recurrent nephrolithiasis who become pregnant?
Pregnancy is a lithogenic state. Stone passages peak in the second trimester. I avoid imaging that involves radiation. I monitor with ultrasound. I prefer to withdraw prescription medication and manage stone disease with diet and fluid therapy. Certainly, there are exceptions to this rule. Encouragi...
When would you administer the next maintenance dose of rituximab in a patient with ANCA glomerulonephritis who last received an infusion six months ago and has low immunoglobulin levels and an undetectable CD-19 cell count?
If an ANCA vasculitis patient is in remission and has no infections, I usually in clinical practice do not check Immunoglobulin levels or CD19/20 levels either. They should only be done in patients with recurrent sinus infections or Pneumonia. If the patient with recurrent infections has low Immunog...