Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How would you approach de-intensifying antihypertensives in frail older adults with SBP < 130 mmHg who have nephrotic range proteinuria, given the results of the RETREAT-FRAIL trial?
I would withdraw antihypertensive drugs that do not have any significant anti-proteinuric effect: dihydropyridine calcium channel blocker, beta blocker, alpha-1- blocker, hydralazine, and clonidine. Thiazide/loop diuretic may also be withdrawn if it is not needed for control of edema due to the neph...
Do you recommend outpatient dialysis initiation or inpatient admission for dialysis initiation in a CKD Stage 5 patient with stable electrolytes but experiencing nausea and vomiting related to uremia?
For a patient with CKD Stage 5 who has stable electrolytes but is experiencing nausea and vomiting from uremia, the patient can be managed with outpatient dialysis initiation. However, if the patient is at high risk for dialysis disequilibrium syndrome (DDS) due to markedly elevated BUN, I prefer in...
Do you have different 24 hour serum sodium correction targets for patients with severe, moderate, and mild hyponatremia?
It is known that overly rapid correction is significantly more likely to cause osmotic demyelination syndrome (ODS) in patients with more severe hyponatremia, particularly when initial serum sodium is ≤105 mmol/L. Since transcellular water movement is mediated by changes in osmolality across the cel...
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.
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...
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
Would you recommend adjusting the hemodialysis schedule for a TTS dialysis patient who is scheduled for surgery on a Monday?
It depends on the patient. If the patient has no residual renal function, it’s prone to volume overload or hyperkalemia; such a patient would benefit from a dialysis session on Monday before surgery. If the patient is recently initiated on iHD, or has good volume control and electrolytes are fine, y...
Do you recommend patients with ESKD time their daily B complex multivitamin to after hemodialysis on hemodialysis days?
Yes. B vitamins do get removed some with dialysis but their removal is limited. Vitamin C on the other hand seems to be removed better. I don't see any harm of taking them after dialysis.
In patients with hypertension and suspected primary aldosteronism who have undergone negative confirmatory testing, what follow-up and monitoring strategies would you recommend to ensure early detection of potential aldosteronism?
If the screening test is convincing (PRA suppressed and plasma Aldosterone >15) I would repeat confirmatory testing. If the first test was saline suppression I would do salt loading and a 24 h urine collection, and vice versa. These confirmatory tests are useful but do not have high sensitivity. If ...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...