Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
Do you take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...
Do you routinely mention the risk for encapsulating peritoneal sclerosis as part of your consent process for dialysis initiation in a patient with advanced CKD who is considering the different dialysis options?
I do not do so. The incidence of EPS within the first 5 years of PD is extremely low. Just as I do not discuss with patients the possible occurrence of rare complications of HD (e.g., osteomyelitis), I do not discuss EPS either. The ISPD recommendation is to consider discussing the possibility of EP...
Do you plan to incorporate fish-oil supplementation into the care of hemodialysis patients to reduce cardiovascular events in light of the PISCES trial results?
I showed the paper to an Internal Medicine friend of mine who is more statistically savvy than me. He wrote this: "So I read the study, and I’m still at a loss to understand it. I’m pretty Bayesian, but this study breaks my priors. Prior studies were basically negative, not to mention that nothing e...
Would you recommend a diuretic renogram prior to planned unilateral nephrectomy for renal cell carcinoma in a patient with normal kidney sizes bilaterally?
This is more a urological question than a nephrological one. If renal function and kidney sizes are normal, then I am not sure I would, unless there is an option of doing a partial nephrectomy. Not sure how that would change management.
Do you recommend zinc for patients with advanced CKD who have dysgeusia?
I do not recommend routine zinc supplementation for advanced CKD patients with dysgeusia due to mixed evidence and the risk of copper deficiency due to zinc supplementation. Zinc can interfere with copper absorption and may potentially cause copper deficiency. However, a trial of zinc supplementatio...
Do you routinely discontinue SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease due to concern for volume depletion?
I would temporarily hold SGLT2 inhibitors during febrile illness or acute infection in patients with diabetic kidney disease if they are at risk of volume depletion (i.e. reduced oral intake, vomiting or diarrhea, high fevers with insensible fluid losses). Holding SGLT2 inhibitors in these acutely i...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
Do you recommend 24 hour urine stone risk studies for patients with no history of nephrolithiasis who are undergoing evaluation as potential kidney donors?
We ask all donors if they have had a history of kidney stones. All donors also get a CT angiogram of the abdomen. Patients with a stone history will need a 24-hour urine stone risk profile. If a donor has an incidental single stone, we may still allow donation, but we would ask for a 24 stone profil...
Has your management of post-transplant FSGS changed with the advent of new FSGS directed therapies?
The pathogenesis of FSGS and specifically recurrent FSGS post-transplant has remained an unmet need in nephrology. Multiple purported " circulating permeability factors " have been identified over the years, each of them providing a piece of the picture, but none that comprehensively and definitivel...