Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you recommend normal saline for pre- and post-LHC hydration in patients with CKD stage III to IV with reduced LV systolic function, and if so, what is a reasonable amount of volume?
The POSEIDON trial, or Prevention of Contrast Renal Injury with Different Hydration Strategies, was a randomized controlled trial that found a personalized hydration strategy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. The tria...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
Do you routinely obtain serum anti-THSD7A and anti-NELL1 tests in your patients with nephrotic syndrome suspected secondary to membraneous nephropathy?
I usually follow up on serum anti-THSD7A titers in patients with kidney biopsy-proven THSD7A (+) Membranous Nephropathy. The Serum NELL-1 titer is not yet commercially available and is available only in the research setting that needs further validation.
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...
Do you recommend daily topical exit site antibiotic use for patients with a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
No. When PD catheters are being accessed only once weekly for flushes, we keep the exit site under a sterile dressing with a chlorhexidine-gluconate-impregnated disc surrounding the exit site. The catheter is accessed only by the PD nurse at the time of flushing, and we do not have the patient perfo...
Do you assess for podocyte detachment in addition to effacement when considering the degree of glomerular injury and potential treatment options following a native kidney biopsy in a patient with proteinuria?
Yes. This is very important in non-minimal change lesions including FSGS, membranous nephropathy, Immunoglobulin A Nephropathy, and the spectrum of Lupus related kidney manifestations.
Do you transition patients with recurrent nephrolithiasis and hypercalciuria off of hydrochlorothiazide in favor of an alternative thiazide diuretic?
No. Assuming the patient tolerates HCTZ well, and it is effective in lowering hypercalciuria, I continue it. Most of the thiazide research has been done using this agent. Stephen B. Erickson, MD
What is your approach to managing acidic urine in patients with recurrent uric acid nephrolithiasis who have normal urinary citrate levels?
After appropriate dietary advice from our Stone Clinic dietitian, I preferentially prescribe sodium bicarbonate tablets, teaching the patient how to adjust the dose using pH strip testing to reach the desired urinary pH. pH testing should be done frequently, as urine pH is in part dietary dependent ...
Do you routinely use markers or tests other than serum creatinine when estimating GFR to determine if patients with liver failure, not on dialysis, meet criteria for a simultaneous liver-kidney transplant?
This is a good question as eGFR cutoffs of 25ml/min (AKI) and 30ml/min (CKD) are used as criteria for SLK eligibility and yet the accuracy of the creatinine-based equations is known to be sub-optimal in patients with liver cirrhosis. UNOS does not specify the type of equation that should be used.In ...
Do you recommend using vitamin D analogs for patients with CKD and a high PTH but a normal 25-hydroxy vitamin D level?
The answer is that it depends on how high the PTH level is. KDIGO guidelines originally recommended targeting PTH between 65 and 130 for patients with non-dialysis CKD by using nutritional vitamin D if the 25-OH vitamin D level is low and using active vitamin D if the 25-OH vitamin D level is normal...