Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What recommendations do you offer for patients who have a peritoneal dialysis catheter and who wish to swim?
Exercise is an important part of health maintenance for all individuals, including those with ESKD requiring peritoneal dialysis (PD). Swimming is an excellent form of exercise for PD patients because it is not associated with increased intra-abdominal pressure, and is a low-impact aerobic activity ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
What are your management strategies for patients with biopsy proven IgA nephropathy with rapidly progressive glomerulonephritis?
In adults, I believe these patients should be treated similarly to other patients with RPGN. I would start out with high dose steroids, then move to possibly rituximab versus possibly cyclophosphamide shortly afterwards if no response to steroids alone.
What is your daily correction goal for those patients being treated for hyponatremia?
This is easily a short answer or 10,000 words. I choose the former. I try to limit it to 6 mmol/l/day, will tolerate 7. But a lot depends on where you start. A starting PNa of 100 is a lot different than a PNa of 120 as the relative osmotic shift will be greater at lower PNa.
In which clinical scenarios do you use prolonged intermittent renal replacement therapy (PIRRT)?
I have not been using PIRRT. We talked about it at the height of COVID when we thought we were going to run out of CVVH solutions. However it never needed to be instituted. Other than that scenario, I think we can tweak the settings of the CVVH machine enough to provide aggressive renal replacement ...
How would you approach a patient with end stage kidney disease on peritoneal dialysis who has an adequate Kt/V but persistent azotemia?
This question could serve as the springboard for a very lengthy discussion/ debate regarding PD "adequacy"- a term that ought to be outlawed! That said, I will try to be brief. First off, it must be recognized that Kt/V (by default meaning that for urea) is a very poor measure of the quality of dial...
Do you recommend avoiding ESAs in pregnant patients with anemia of chronic kidney disease who also have preeclampsia?
Yes
Do you stop activated vitamin D (ie paricalcitol) in your dialysis patients who have hyperphosphatemia despite low phosphate diet and phosphorus binder adherence?
I usually don't unless their phosphorus is very high (>8) or if they are on very high doses of Vitamin D analogues, in which case, I trial a lower dose. In general, I don't think Vitamin D analogues contribute that much to higher phosphorus levels. Of course, if the phosphorus and PTH are both high ...
What are your strategies for safely prescribing peritoneal dialysis for patients who have pets at home?
Pets are an important part of many people's lives, giving comfort, joy, relaxation, companionship, and even providing opportunities for exercise - therefore we should not exclude patients from home dialysis simply due to the presence of pets in the home. Some key strategies to help reduce PD complic...
Do you recommend prophylactic post-operative use of an intravenous calcium infusion for patients with ESKD who undergo subtotal parathyroidectomy for secondary hyperparathyroidism?
Ionized calcium concentration should be monitored closely post-operatively for hungry bone syndrome. Intravenous calcium infusion is indicated if there is a rapid and progressive decrease in the serum ionized calcium level.