Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
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.
Do you recommend uric acid lowering therapies for asymptomatic hyperuricemia in chronic kidney disease?
There is conflicting literature about what to do with elevated uric acid levels in CKD patients. In my practice, I do usually treat high uric acid level over 10 even if asymptomatic. I definitely give allopurinol earlier if elevated uric acid levels and history of kidney stones, even if they are not...
How would you approach the management of a new SLE patient presenting with lupus podocytopathy with FSGS and severe proteinuria (Pr/Cr 18) without immune complex deposition?
Hopefully one of the nephrologists will chime in on this one. However, this reminds me very much of a similar SLE patient I started to take care of about 6 years ago (BX = podocytopathy and FSGS; had marked proteinuria and renal dysfunction). I treated her with high-dose steroids, hydroxychloroquine...
Do you prefer starting a SGLT2i before steroids in patients with IgA nephropathy and proteinuria > 1.0 gram/day who are unable to tolerate ACEi/ARB due to hypotension?
I do try to start almost all of my IgAN patients on ACE-I/ARB and SGLT2i to help decrease proteinuria. The decision to start steroids or any other immunosuppressive treatment does not always have to wait for 6 months of conservative treatment and if still with residual proteinuria, then consider imm...
What is your approach to patients with advanced chronic kidney disease who are taking aluminum containing medications?
If taking infrequently would not be all that concerned although there are other options available. Would instruct them to avoid citrate-containing medications such as Bicitra due to their enhancing Al absorption from the GI tract.