Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What changes to immunosuppressant medications do you adopt for kidney transplant patients who contract COVID-19?
It really depends on the severity of their symptoms. For patients with mild symptoms, we typically lower the MMF somewhat as well as treat with paxlovid as the first line. Due to the interactions with the CNIs etc., we adopt the following protocol for tacrolimus and paxlovid: Day 1- First Paxlovid ...
How do you approach COVID-19 vaccination in those who underwent kidney transplantation for native kidney glomerular disease?
The approach to all kidney transplant recipients regardless of the cause of end-stage kidney disease remains the same following the guidelines for immunocompromised patients. The benefits of vaccination and protection against COVID-related hospitalization and death outweigh vaccine-related incidents...
Do you routinely advise patients waiting for a kidney transplant to seek referrals at multiple institutions to decrease waiting time?
If your center is in a region (e.g., California and New York) with long wait time of up to 8-10 years, we routinely advise patients to seek referral at multiple centers with a shorter wait time out of the region if the patient does not have any potential donors.
For which patients do you prioritize ambulatory blood pressure monitoring over self-measured blood pressure?
Self-measured blood pressure can be useful for anyone who has been diagnosed with hypertension or is found to have office blood pressures (BPs) above normal (120/80 mm Hg).1 Correctly measured home BPs inform my decision on when to start antihypertensive medications or when to adjust antihypertensiv...
What is your approach to thiazide diuretic use in those with uncontrolled hypertension and advanced chronic kidney disease?
The Chlorthalidone for Hypertension in Advanced Chronic Kidney Disease (CLICK) trial provides an answer to this question. Chlorthalidone is still effective at lowering BP when eGFR is 15-30 mL/min/1.73m^2. Personally, I find it helpful to continue chlorthalidone in advanced CKD to help with kaliures...
How do you estimate daily dietary sodium intake in your patients with hypertension?
The best and simplest method is to check 24-hour urine for sodium excretion. In the steady state, the 24-hour urine sodium will closely approximate the daily intake of sodium.
Do you prefer transtubular potassium gradient (TTKG) or urine potassium to urine creatinine ratio when evaluating patients with abnormal potassium levels?
Metrics for assessing dyskalemias have become controversial over the last few years. There is very little data, but a fair amount of theorizing, addressing this issue. Importantly, no metric for diagnosing the cause of a dyskalemia should be used without careful assessment of the overall clinical an...
What degree of hyperkalemia do you tolerate for those with proteinuric chronic kidney disease and persistently elevated serum potassium levels?
The K comes back 6.3 and you send them to the ER, and repeat K is 5.7, no EKG changes. That dance gets tiresome. How often do you think the opposite would occur? (K is 5.7 and you repeat it and it is 6.1?) K varies day to day and lab measurement to lab measurement.I am extreme, I do not expect other...
What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?
Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even th...
What is your approach to managing hypocalcemia following a parathyroidectomy in patients with end stage kidney disease?
The hungry bone syndrome can be tricky and insidious. I have seen patients go home after a pth-ectomy without evidence of it and then a few days later show up in the ED with symptoms of hypocalcemia. Hemodialysis may mask it (as well as treat it) by supplying a large IV calcium load. If you dialyze ...