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HM 14 Special Report: Nephrology Update

Presenter: Derek M. Fine, MD

Dr. Fine’s presentation covered several areas of nephrology that are of special interest for hospitalists in the day-to-day management of our patients.

Drug toxicities and renal clearance. We need to know the GFR of our patients. This will, for example, keep us from ordering an MRI with gadolinium in patients with impaired renal function and prevent the debilitating complication of nephrogenic systemic fibrosis.

There are multiple medications that are frequently dosed inappropriately in CKD. Examples that stick out are: nitrofurantoin (contraindicated); gabapentin, which can cause confusion, decreased level of consciousness, and unsteady gait; and cefepime, which can cause non-convulsive status epilepticus, if not adjusted for GFR.

Ultrafiltration in CHF. The use of ultrafiltration in decompensated CHF is limited. There is no benefit over diuretic therapy in general, except for subgroups of patients, who have inadequate volume control with diuretics or who do not tolerate diuretics because of significant electrolyte abnormalities or alkalosis. A pearl for sodium restriction and IV fluids IV NS at 84 ml/hr for 24 hours provides 7000 mg of sodium for our heart-failure patients.

Dialysis access issues. Avoid PICC lines in patients with advanced CKD and ESRD in order to preserve access sites for dialysis. Don’t discharge a patient with a bleeding AV fistula as they could bleed to death. A clotted AV access requires consultation with vascular surgery or interventional radiology, although it can be de-clotted for up to 2 weeks.

Renal artery stenosis. Angioplasty has not shown any benefit over medical therapy in the management of renal artery stenosis.

Key Takeaways:

  • Know your patients’ GFR
  • Pay attention to dose adjustments in patients with CKD. It seems obvious, but dosing errors are very common.
  • Preserve dialysis access sites and don’t place PICC lines in patients who will need dialysis soon.
  • Each liter of normal saline delivers 3542 mg of sodium to our CHF patients.

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, MN, and a member of Team Hospitalist.

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