Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
Do you prefer performing a kidney biopsy on the left or right kidney if both kidneys appear similar on pre-biopsy imaging?
At my institution, we have been biopsying almost exclusively the left kidney per the radiologist's preference. My teaching has been that we should prefer to biopsy the right kidney as if the spleen is enlarged then stabbing that with a needle is more risky than stabbing the liver. These days, with m...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...
Do you have patients with recurrent calcium oxalate kidney stones stop taking supplements containing vitamin C if their 24 hour urine oxalate excretion is normal?
No. I am not aware of data that suggests Vitamin C would aggravate kidney stone formation in this situation. Stephen B. Erickson, MD
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
What is your approach to ESA use in patients with ESKD and active malignancy on treatment?
Patients can receive ESA’s and keep hgb goal at 10. Would discuss this with an oncologist and get clearance and after a hematological workup is also attained.
Do you add a separate dose of losartan for patients with heart disease and proteinuric kidney disease who are on maximal doses of sacubitril/valsartan but continue to experience proteinuria?
There is data in studies of proteinuric kidney disease to suggest that combining an ACEi and an ARB confers a little additional benefit in proteinuria management but confers a significant risk of hyperkalemia. I would presume the same risk/benefit ratio when using 2ARBs and I would not opt for that ...
Would you recommend genetic testing to determine if there is a potential underlying primary process in a patient with congenital solitary kidney who is presumed to have secondary FSGS?
I do recommend genetic testing more frequently especially at our institution in which the cost to the patient is minimal to none. I would imagine very rarely one finds a positive genetic test result but one never knows what we find until we do the testing.