Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Are there instances when you use erythropoietin stimulating agents in patients with acute kidney injury requiring dialysis?
I cannot think of a reason to. ESA resistance is common in sick patients and I think you are wasting the drug. Please see reference: Aoun et al., PMID 35279078'Erythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia."
Do you alternate CT stone scans and renal ultrasounds for stone monitoring in your patients with recurrent nephrolithiasis with the goal of limiting radiation exposure?
No. Although I share your concern about radiation and expense, the purpose of monitoring kidney stone patients is to detect small differences in stone burden from year to year. Ultrasound is less accurate than CT for this purpose. Avoiding contrast views decreases CT radiation exposure and is my mon...
How do you dose gabapentin in patients with renal failure?
There are many algorithms available online about the renal dosing of gabapentin. However, it should be emphasized that the recommendations are not based on large patient studies; therefore, the efficacy of the reduced doses for neuropathic pain is not certain (Raouf et al., PMID 28184168).
What is your approach to managing hypokalemia in patients with Bartter syndrome who are on high doses of potassium chloride but cannot tolerate amiloride or ACEi/ARBs due to low blood pressures?
Since prostaglandin level is typically high in patients with Bartter syndrome, NSAIDS can be tried to treat hypokalemia in these patients who cannot tolerate amiloride or ACEi/ARB due to low blood pressure. However, close monitoring of renal function is required if NSAIDS were to be given in these p...
Do you use acetazolamide to aid diuresis in patients with acute on chronic respiratory acidosis with significantly elevated serum bicarbonate levels?
Yes, acetazolamide can be used in aiding diuresis in patients with chronic respiratory acidosis where the metabolic compensation results in an alkalemic pH which then sets up a vicious cycle of increasing CO2 as a compensation for the metabolic alkalosis. Use of acetazolamide results in a metabolic ...
What additional studies would you obtain for a patient with end stage kidney disease on hemodialysis who has persistent hypercalcemia and low PTH?
No studies or measures until I got the patient off Vit D, sensipar, and possibly Ca-based binders, and watched for a couple of months to see if PTH came up and hypercalcemia resolved. This is typical adynamic bone disease until proven otherwise.
How early do you involve palliative care in the management of a CKD Stage 5 patient who does not wish to pursue renal replacement therapy?
I tend to refer as soon as they are clear that they do not want to pursue renal replacement therapy for a couple of reasons: (1) By CKD 5, even if they do not have uremic symptoms, it is nice to establish longitudinal care with palliative care so that there is a strong relationship with trust when p...
Do you use potassium phosphate for patients with recurrent nephrolithiasis to acidify the urine and prevent certain types of stones?
Short answer: No. That study was done about 40 years ago, I think by the Kaiser group, and was negative. That said, they used a suboptimal dose of 250 mg bid and measured success by stone passages rather than stone growth. However, studies using neutral phosphates (K Phos Neutral) were done by my me...
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
Do you use terlipressin for patients with hepatorenal syndrome who also have elevated blood pressures?
There are those who would question HRS as a diagnosis if the patient had an elevated BP. Regardless, I believe its effect is related to BP so I would not use it in this situation.