Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a maximum dose of potassium citrate you would use for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I don’t think there is a maximum dose of potassium citrate. Hyperkalemia can occur, especially if GFR is impaired, and monitoring for that is important. In my experience, diarrhea is the most common dose limiting effect. Taste fatigue is common; fortunately there are multiple preparations available ...
What is your approach to managing patients with recurrent calcium oxalate nephrolithiasis since childhood who are found to be gene carriers for mutations in genes associated with primary hyperoxaluria?
Thank you for this question. In general, there is no good evidence that patients with a carrier of 1 of the 3 primary hyperoxaluria genes (AGXT, GR/HPR or HOGA1) has any phenotype consistent with primary hyperoxaluria, or that these genes are enriched in the general stone forming population. That be...
What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?
Yes, captopril is dialyzable with about ~35% of the drug being removed during intermittent hemodialysis. It is not recommended to be used if an AN69 hemofilter is used for iHD, as it is associated with anaphylaxis with that particular filter. There does not appear to be any contraindications to usi...
How often do you check urine osmolality and urine electrolytes when treating hospitalized patients with hyponatremia?
Correction of hypovolemia with isotonic saline may result in overly rapid correction of hypovolemic hyponatremia once the stimulus for ADH secretion is removed, resulting in the excretion of a very dilute urine. Therefore, urinary electrolytes and osmolality should be closely monitored every 3-4 hou...
Do you use any urinary staining techniques when performing urine microscopy for patients with acute kidney injury?
No. Not at this time. At one point, about 10 years ago, we did have Wright stain to stain for eosinophilluria but it seemed too labor-intensive and not that helpful, so we stopped using it.
Have you considered priming CRRT machines with renal replacement solutions during the current crystalloid solution shortage?
Yes. We are doing it. I don't see any problems from this practice.
Do you use a phosphate binder to manage inpatient hyperphosphatemia in patients with AKI who have no history of CKD?
I agree there is uncertainty about optimal serum phosphate concentrations in patients, and essentially no data in AKI. However, increases in Phos do result in an increased risk of metastatic calcification, and increases FGF23 and PTH, even in AKI and these changes clearly have increased risks, thus,...
How do you approach palliative conversations about what patients can expect when deciding to stop maintenance dialysis?
I typically include this discussion with my patients as part of the discussion of what options are available to address irreversible progressive CKD (eGFR<25). I find it best to present all options for ESKD management in a balanced format and I open the clinic visits to all family and friends to sup...
How do you manage patients with end stage kidney disease and recurrent ascites who do not have any evidence of cardiac or liver disease?
This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...
What are your next steps for managing biopsy-proven interstitial nephritis from checkpoint inhibitors in patients who do not have a response to prednisone?
As indicated by Dr. @Dr. First Last, based on their publication, if there is biopsy-proven evidence for AIN with no evidence of concurrent GN or vasculitis, then a trial of infliximab is reasonable. Our experience at our institution is that the creatinine increases if the prednisone is tapered too q...