Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Is there a time frame in which you would no longer consider a prior vein mapping study reliable and thus recommend repeating the test in a patient with advanced chronic kidney disease who requires evaluation for fistula placement?
As a standard, typically 6 months is the longest I’d consider utilizing a vein mapping; however, the caveat here is to repeat after any hospitalization or known line placements/extensive blood draws. Vein mapping is very low risk and relatively easy to repeat vs the risk of a failure to mature fistu...
What is your approach to differentiating Randall plaques from actual small non-obstructing stones when reviewing imaging testing for your patients with recurrent nephrolithiasis?
In truth, I almost never can tell with present CT imaging. Once we have a URS with images, it is easier in a given case. Even more misleading is plugging, which can be dense looking on CT and essentially in tissues and not amenable to removal, now requiring surgery. Specialized, very high-resolution...
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...
How do you decide which patients with asymptomatic hyperkalemia and CKD warrant inpatient admission versus expedited outpatient management?
I would imagine that there is no EKG available as the patient is outpatient. I prefer not to admit patients as much as possible. I would not admit patients with potassium levels less than 6. For those between 6 and 6.5, I would try to treat medically and recheck potassium the next day. If potassium ...
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...
Are you comfortable using low molecular weight heparin as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis?
Low molecular weight heparin may be used as an alternative to unfractionated heparin for ESKD patients on nocturnal home hemodialysis. However, its use requires close monitoring and careful management. Unlike unfractionated heparin, which is fully reversible with protamine, LMWH is only partially re...
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...