Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you give a short-acting antihypertensive before starting outpatient hemodialysis on an asymptomatic ESKD patient with a predialysis blood pressure of more than 200/100?
I rarely use short-acting antihypertensive agents. I usually give long-acting calcium channel blockers, b-blockers or ace inhibitors if the blood pressure is very high. Ultimately the best option would be to remove more and more fluid slowly over time if patient can tolerate it. However, I find flui...
What is your approach to management of recurrent nephrolithiasis in patients with mixed composition uric acid and calcium phosphate stones?
Likely the urine pH is more typically low in such patients, since the uric acid components will dissolve during periods of higher pH. Consequently, the appearance of uric acid crystals in the stone suggests that the urine pH is more typically low. Drinking more fluid to cause more dilute urine alway...
Are there patients with recurrent nephrolithiasis for who you recommend magnesium supplementation to reduce stone risk?
While magnesium supplementation may be justified on theoretical grounds, I have never used magnesium supplements as a treatment exclusively for kidney stones. I have only ever seen or used magnesium supplementation in stone patients that had concurrent hypomagnesemia.
What is the current recommendation for using thiazide diuretics in patients with calcium oxalate stone disease, given the negative results of the NOSTONE trial?
This trial will have no effect on my practice. Seven of 10 previous studies of thiazides for stones were positive, as was a meta-analysis. My preference is for the longer-acting drugs indapamide and chlorthalidone; I haven't used HCTZ which is probably a twice-a-day drug, for some years. Note that t...
Do you recommend taking any unique approaches to managing patients with persistent hypertension following bilateral renal artery stenting?
Yes, I will be more aggressive with lipid management, sometimes using PCSK9-INH in addition to a statin, if the cause of the renal artery stenosis was atherosclerotic-related. Also, I typically get yearly ultrasounds to evaluate the patency of the renal artery stents. From a management perspective, ...
What are your next steps when managing patients with suspected Gitelman syndrome for whom genetic testing reveals variants of uncertain significance or novel mutations not well characterized?
If the patient had a clinical syndrome that fit the Gitelman phenotype I would totally treating as such.
When would you recommend adding peritoneal dialysis to a patient with oxalosis who is already receiving hemodialysis?
Tang et al., PMID 24776840I have never done this. The amount of oxalate cleared by peritoneal dialysis is a very small fraction of the amount cleared by hemodialysis. In general, among patients with oxalosis, the oxalate is well cleared from the blood on hemodialysis, but oxalate has a very large vo...
Would you recommend AV fistula placement in a CKD Stage 5 patient who is over the age of 80?
An elderly patient who is functionally independent (i.e., not frail) without comorbidity (suggesting good survival) & good vein mapping may proceed with AVF creation if he/ she decides they want dialysis. This has to be done at least 9 months prior to HD. Predicting when HD will be needed is itself ...
How has the introduction of lumasiran affected the need for combined liver and kidney transplantation in patients with ESKD related to primary hyperoxaluria type 1?
A kidney transplant alone with lumasiran pre and post-transplant to maintain lowered serum oxalate levels and prevent the recurrence of oxalate stones is potentially a viable option for simultaneous liver-kidney transplantation.To date, there is only one small case series published of this approach ...
Do you stop tolvaptan below a certain eGFR in a patient with autosomal dominant polycystic kidney disease?
In general, the practical guidelines support continuing tolvaptan until dialysis or transplant (Chebib and Torres, PMID 33705818). There are situations where I will discontinue sooner, either due to apparent lack of benefit, due to precipitous, unexpectedly rapid decline or accelerated decline, or, ...