Tag Archives: Nephrology

Clinical Pearls: PD-related peritonitis

One of the most common complications of peritoneal dialysis is peritonitis. Things to remember:

  • Diagnosis: Peritoneal fluid with >100 nucleated cells (usually >50% PMNs)
  • Pathophysiology: Skin-related (usually gram positive) vs. Secondary (enteric, usually gram-negative and polymicrobial)
  • Empiric treatment: Should cover gram positive and negative organisms. A frequently used combination is a first-generation cephalosporin (i.e. cefazolin) plus an anti-pseudomonal cephalosporin (i.e. cefepime). If the patient or population has a high frequency of methicillin-resistant organisms, vancomycin is a reasonable choice for gram-positive coverage.
  • Drug delivery: Intra-peritoneal (IP) preferred to intravenous (IV) route due to increased local concentration with IP. Vancomycin, aminoglycosides and cephalosporins can be mixed with dialysate solution and achieve therapeutic blood levels (must monitor closely)
  • Indications for catheter removal:

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Information based on ISPD 2005 guidelines for PD-related peritonitis

Electrolyte & Acid–Base Disturbances in Patients with Diabetes Mellitus

Our own master of electrolytes and kidney specialist, Dr. Biff Palmer, recently published an excellent review article in New England Journal of Medicine titled “Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus.” These frequently encountered clinical scenarios pose problems both in the inpatient and outpatient settings and it is important for physicians of all specialties to become familiar with common presentations and approach to workup and management.

Continue reading Electrolyte & Acid–Base Disturbances in Patients with Diabetes Mellitus

Milk-Alkali Syndrome 101

Below are some key points in diagnosing and managing milk-alkali-syndrome:

Triad of hypercalcemia, metabolic alkalosis, and acute kidney injury associated with the ingestion of large amounts of calcium and absorbable alkali.

  • Excessive amounts of calcium carbonate is considered 4-5 g daily
  • Originally described in association with the use of milk and sodium bicarbonate for the treatment of peptic ulcer disease
  • There may be a resurgence of this disorder due to increased calcium therapy for presenting/treating osteoporosis, more OTC calcium carbonate preparations, and use of calcium carbonate in patients with CKD to minimize secondary hyperparathyroidism
  • Among patients hospitalized with hypercalcemia, milk-alkali syndrome is the 3rd most common cause behind hyperparathyroidism and cancer
  • Pathogenesis remains uncertain as studies have shown that some patients given high amounts of alkali and calcium don’t develop milk-alkali syndrome
  • Although renal impairment is associated, it’s not a prerequisite to develop milk-alkali syndrome
  • Individual variations in the buffering capacity of bone may play role in the susceptibility to development of hypercalcemia
  • Patients at higher risk include
    • Older individuals
    • Those at risk for volume depletion (including patients on thiazide diuretics)
    • Medications that reduce GFR (ie ARB’s, ACE-I, NSAIDS)
  • Diagnosis is based upon the history of ingestion of calcium-rich medications and the exclusion of other causes of hypercalcemia
  • Treatment:
    • Stop offending agent
    • Treat with IV saline and furosemide
    • Hypocalcemia can occur transiently with rapid rise of PTH to supranormal levels which is unique to milk-alaki syndrome

(Medarov. Mayo Clin Proc. 2009 Mar; 84(3): 261–267.)

Causes of asymptomatic microscopic hematuria

Excellent board-review lecture today by Dr. Sambandam! He is a little clinical pearl, the causes of asymptomatic microscopic hematuria:

  • Benign essential Hematuria (37%)
  • Benign Prostatic Hyperplasia (24%)
  • Urethral Infection (21%)
  • Urinary Tract Infection (7%)
  • Nephrolithiasis (4%)
  • Urethral calculus (2%)
  • Bladder tumor (2%)
  • Renal Cyst (1.5%)
  • Renal tumor (0.5%)

Internal Medicine Journal Watch – April 2015

STRAIGHT FROM THE HOUSESTAFF – the April 2015 UT Southwestern Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from alcoholic hepatitis to which medications to use for stroke prevention in afib. Make sure to take the EKG challenge at the end! You will have to view this post on our website to access the PDF.  There is a quick run down of the topics below:


  • Corticosteroids in severe alcoholic hepatitis after recent upper GI bleed. Dr. Jan Petrasek reviewing Rudler et al., J Hepatol. 2015 Apr;62(4):816-21. 10.1016/j.jhep.2014.11.003. Epub 2014 Nov 11.
  • Serum ammonia level for the evaluation of hepatic encephalopathy. Dr. Jan Petrasek reviewing Ge et al., JAMA. 2014 Aug 13;312(6):643-4.


  • Extended report: Prediction of cardiovascular risk in rheumatoid arthritis: performance of original and adapted SCORE algorithms. Dr. Brian Skaug reviewing Arts, et al. Ann Rheum Dis. 2015 Feb 17. pii: annrheumdis-2014-206879. doi: 10.1136/annrheumdis-2014-206879

Pulmonary/Critical Care

  • Trial of Early, Goal-Directed Resuscitation for Septic Shock [The Protocolised Management in Sepsis (ProMISe) Trial]. Dr. James Galloway reviewing Mouncey PR et al. N Engl J Med. 2015;372(14):1301-11.
  • A Randomized Trial of Icatibant in ACE-Inhibitor-Induced Angioedema. Dr. James Galloway reviewing Bas M, et al. N Engl J Med. 2015;372(5):418-25.


  • High-Sensitivity Troponin T and N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) and Risk of Incident Heart Failure in Patients with CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study. Dr. Natalia Rocha reviewing Bansal N, et al. JASN 2015; 26:946-956
  • Preoperative renin–angiotensin system inhibitors use linked to reduced acute kidney injury: a systematic review and meta-analysis. Dr. Natalia Rocha reviewing Cheungpasitporn W, et al. Nephrol. Dial. Transplant. 2015; doi: 10.1093/ndt/gfv023


  • Which drug should we use for stroke prevention in atrial fibrillation? Dr. Douglas Darden reviewing Lau, Yee C.; Lip, Gregory Y.H. Current Opinion in Cardiology. 2014 July 29 (4): 293-300.
  • EKG CHALLENGE: Contributed by Dr. Jeanney Lew

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All of the work above comes from the IMJW Editorial Board: Jan Petrasek, Brian Skaug, Ben Galloway, Natalia Rocha, Doug Darden, and Jeanney Lew!

Medical Management of Kidney Stones

General Principles

  • Fluid intake that will achieve a urine volume of at least 2.5 liters daily
  • Pain control:
    • NSAIDS:
      • Any, but toradol has been given special interest. In one emergency department study, the narcotic-like analgesic effects of this agent were superior to the effects of meperidine
      • Contraindication to the use of extracorporeal shock wave lithotripsy, because of the increased risk of perinephric bleeding
      • Must balance with the presence of acute kidney injury
    • Narcotics: Codeine, morphine, hydromorphone, and meperidine are effective in suppressing pain
    • Medical Expulsive Therapy
      • Alpha blockers: tamsulosin: faster stone passage, fewer hospitalizations, fewer procedures
      • CCB: nifedipine – not as good as alpha-blockers

Stone-Specific Management

  • Calcium stones and low urinary citrate:
    • Potassium citrate to raise urine pH
    • Increase intake of fruits and vegetables and limit non-dairy animal protein
    • Thiazide diuretics to patients with high or relatively high urine calcium and recurrent calcium stones
  • Cystine stones:
    • Limit sodium and protein intake.
    • Potassium citrate to raise urine pH
  • Struvite stones: acetohydroxamic acid (AHA) to patients with residual or recurrent struvite stones only after surgical options have been exhausted
  • Calcium oxalate stones:
    • Limit intake of oxalate-rich foods and maintain normal calcium consumption
    • Give allopurinol to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium
    • Oral calcium carbonate in doses up to 4 g/d is used for patients with enteric hyperoxaluria to bind oxalate within the gastrointestinal tract
  • Uric acid stones or calcium stones and relatively high urinary uric acid:
    • Limit intake of non-dairy animal protein
    • Potassium citrate to raise urine pH
    • Allopurinol is not first line therapy

Internal Medicine Journal Watch – February 2015

STRAIGHT FROM THE HOUSESTAFF – the February 2015 Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from Metformin in CKD to pre-exposure prophylaxis for HIV. There is even an EKG challenge at the end, if you are up for it! You will have to view this post on our website to access the PDF.  There is a quick run down of the topics below:


  • American Diabetes Association’s Standards of Medical Care in Diabetes – 2015.
    • Dr. Jeremy Warshauer reviewing Grant RW, et al. Diabetes Care 2015 Jan;38 Supplement 1
  • Metformin in Patients With Type 2 Diabetes and Kidney Disease: A Systematic Review
    • Dr. Nicolas Barros reviewing Inzucchi, SE, et al. JAMA 2014; 312(24):2668-2675


  • Preliminary analysis of the Very Early Diagnosis of Systemic Sclerosis (VEDOSS) EUSTAR multicentre study: evidence for puffy fingers as a pivotal sign for suspicion of systemic sclerosis
    • Dr. Brian Skaug reviewing Minier T, et al. Ann Rheum Dis 2014;73: 2087–2093

Healthcare Policy

  • Using drugs to discriminate – adverse selection in the insurance marketplace
    • Dr. Ashish Gupta reviewing Jacobs DB and Sommers BD. N Engl J Med. 2015 Jan 29;372(5):399-402

General Internal Medicine

  • Disorders of Plasma Sodium — Causes, Consequences, and Correction
    • Dr. Nicolas Barros reviewing Sterns, R, et al. NEJM 2015; 372:55-65
  • Acid–Base Problems in Diabetic Ketoacidosis
    • Dr. Nicolas Barros reviewing Kamel K, et al. NEJM 2015 ; 372:546-554

Platelet Transfusion

  • A Clinical Practice Guideline From the AABB
    • Dr. Nicolas Barros reviewing Kaufman RN, et al. Ann Intern Med. 2015 Feb 3;162(3):205-13


  • Association of Albumin-Creatinine Ratio and Cystatin C With Change in Ankle-Brachial Index: The Multi-Ethnic Study of Atherosclerosis (MESA)
    • Dr. Ben Jenny reviewing Garimella P, et al. Am J Kidney Dis. 2015;65(1):33-40

Infectious Disease

  • Tenofovir-Based Preexposure Prophylaxis for HIV Infection Among African Women
    • Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Marrazzo J, et al. 2015; 372:509-518
  • Infectious Diseases Diagnosis and Treatment of C. difficile in Adults: Systematic Review
    • Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Bagdasarian N, et al. JAMA 2015; 313(4):398-408


  • An interferon-free antiviral regimen for HCV after liver transplantation
    • Dr. Jan Petrasek reviewing Kwo et al., NEJM. 2014; Dec 18;371(25):2375-82
  • Decreasing Mortality Among Patients Hospitalized with Cirrhosis in the United States From 2002 through 2010
    • Dr. Jan Petrasek reviewing Schmidt et al., Gastroenterology. 2015 Jan 23.


  • Twelve or 30 Months of Dual Antiplatelet Therapy after Drug-Eluting Stents (DAPT trial)
    • Dr. Ben Jenny reviewing Mauri L, et al. N Engl J Med. 2014 Dec 4;371(23):2155-66.

EKG Challenge

  • Dr. Ben Jenny
  • Untitled
All of the work above comes from the IMJW Editorial Board (with Dr. Brad Cuttrell): Jan Petrasek, Purav Mody, Nicolas Barros, Ragisha Gopalakrishnan, Jeremy Warshauer, Shetal Patel,  Ben Jenny (not Jennings), Vishwanatha Lanka, Brian Skaug, Ashish Gupta, and Roma Mehta!

“The Sweat Solution”

ESPN recently released a short documentary as part of their “30 for 30” shorts called “The Sweat Solution” about the creation of Gatorade. This athletic drink that is universally recognized is credited to Dr. Robert Cade who completed medical school at UT Southwestern and his residency in internal medicine at Parkland Memorial Hospital. He trained closely under the tutelage of Dr. Donald Seldin in nephrology. Dr. Cade then joined the IM faculty at University of Florida and worked on developing an oral solution to give their collegiate athletes that competitive edge. This led to the creation of Gatorade and the rest is history. Dr. Cade passed away in 2007 and is recognized as a brilliant physician scientist who made a significant impact.

Check out this fascinating video below!

The Sweat Solution

Check out this article from UT Southwestern about honoring Dr. Cade’s work in 2004:



Friday, December 19th

Housestaff vs Faculty

Starting at noon in D 1.520

The faculty took the win last year in a close battle,
but the housestaff are ready to take back the crown!

(hint: read the blog)

Holiday Bowl and Xmas Sweater

Polycystic Kidney Disease


  • Autosomal dominant polycystic kidney disease is an inherited systemic disorder with major renal abnormalities
  • It affects 300,000 to 600,000 Americans of both sexes and without racial predilection
  • Each child of an affected parent has 50% chance of inheriting the gene (PKD1 and PKD2) and penetrance is complete, 5% of cases are due to spontaneous mutation
  • Liver cysts develop in more than 80% of patients, usually larger in women
  • HTN occurs in childhood and affects nearly all patients with renal insufficiency
  • Gross and microscopic hematuria are present in 60% of cases
  • Renal cyst infections and pyleo are common problems for these patients
  • Renal failure requiring RRT occurs in 50%, usually 4th to 6th decade of life
  • Brain aneurysms occur in 8% and a family history increases this risk – screening however is only recommended for those with family hx of aneurysm or stroke or known cyts with new onset or severe HA or other CNS sx
  • There are currently no treatments that have been shown in RCT to slow the formation of the cysts or disease progression
  • Treatment is focused on BP control (<130/80), avoiding contact sports, monitoring for progression of renal insufficiency and managing any complications