I am a nephrologist at Zuckerberg San Francisco General Hospital and University of California, San Francisco. I am interested in electrolyte and acid base disorders.
The relationship between sodium, blood pressure and extracellular volume could not be more pronou... more The relationship between sodium, blood pressure and extracellular volume could not be more pronounced or complex than in a dialysis patient. We review the patients' sources of sodium exposure in the form of dietary salt intake, medication administration, and the dialysis treatment itself. In addition, the roles dialysis modalities, hemodialysis types, and dialysis fluid sodium concentration have on blood pressure, intradialytic symptoms, and interdialytic weight gain affect patient outcomes are discussed. We review whether sodium restriction (reduced salt intake), alteration in dialysis fluid sodium concentration and the different dialysis types have any impact on blood pressure, intradialytic symptoms, and interdialytic weight gain.
Background: There are few data on whether higher severe acute respiratory syndrome coronavirus 2 ... more Background: There are few data on whether higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody titers correlate with subsequent infection in the general population, much less in the dialysis patients. Methods: Fifty-four hemodialysis patients who had antibody titer measured against SARS-CoV-2 after vaccination were retrospectively looked at after 6 months. Rates of subsequent coronavirus disease 2019 (COVID-19) infection were correlated with initial antibody titers. Results: The mean antibody titer in the patients who subsequently developed SARS-CoV-2 infection was 437 relative fluorescent units (RFU) as compared with mean antibody titer of 1,436 RFU in patients who did not developed infection. Conclusion: It seems higher antibody titers are in general protective against subsequent infection; however, some patients developed subsequent infection despite having high antibody titers.
Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the me... more Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the mechanisms, diagnosis, clinical consequences, and conditions associated with pseudohyponatremia, and future developments for its elimination. The two methods involved assess the serum sodium concentration ([Na]S) using sodium ion-specific electrodes: (a) a direct ion-specific electrode (ISE), and (b) an indirect ISE. A direct ISE does not require dilution of a sample prior to its measurement, whereas an indirect ISE needs pre-measurement sample dilution. [Na]S measurements using an indirect ISE are influenced by abnormal concentrations of serum proteins or lipids. Pseudohyponatremia occurs when the [Na]S is measured with an indirect ISE and the serum solid content concentrations are elevated, resulting in reciprocal depressions in serum water and [Na]S values. Pseudonormonatremia or pseudohypernatremia are encountered in hypoproteinemic patients who have a decreased plasma solids content. ...
OBJECTIVE Finerenone significantly improved cardiorenal outcomes in patients with chronic kidney ... more OBJECTIVE Finerenone significantly improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease trial. We explored whether baseline HbA1c level and insulin treatment influenced outcomes. RESEARCH DESIGN AND METHODS Patients with T2D, urine albumin-to-creatinine ratio (UACR) of 30–5,000 mg/g, estimated glomerular filtration rate (eGFR) of 25 to <75 mL/min/1.73 m2, and treated with optimized renin–angiotensin system blockade were randomly assigned to receive finerenone or placebo. Efficacy outcomes included kidney (kidney failure, sustained decrease ≥40% in eGFR from baseline, or renal death) and cardiovascular (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) composite endpoints. Patients were analyzed by baseline insulin use and by baseline HbA1c <7.5% (58 mmol/mol) or ≥7.5%. RESULTS...
Herbal medicine, a form of complementary and alternative medicine (CAM), is used throughout the w... more Herbal medicine, a form of complementary and alternative medicine (CAM), is used throughout the world, in both developing and developed countries. The ingredients in herbal medicines are not standardized by any regulatory agency. Variability exists in the ingredients as well as in their concentrations. Plant products may become contaminated with bacteria and fungi during storage. Therefore, harm can occur to the kidney, liver, and blood components after ingestion. We encourage scientific studies to identify the active ingredients in herbs and to standardize their concentrations in all herbal preparations. Rigorous studies need to be performed in order to understand the effect of herbal ingredients on different organ systems as well as these substances' interaction with other medications.
There is fair amount of data that potassium administration will raise serum sodium concentration;... more There is fair amount of data that potassium administration will raise serum sodium concentration; however whether the above concept extends to other electrolytes is less well understood. Although real-world data are lacking on this concept, here we will discuss the reasons why one may logically conclude that magnesium administration in dextrose-containing solution does not in fact lower serum sodium concentration appreciably. Furthermore we will try to determine by how much one should expect the administration of magnesium intravenously will change the serum sodium concentration. World J Nephrol Urol. 2020;9(2):33-34 doi: https://doi.org/10.14740/wjnu409
There is fair amount of data that potassium administration will raise serum sodium concentration;... more There is fair amount of data that potassium administration will raise serum sodium concentration; however whether the above concept extends to other electrolytes is less well understood. Although real-world data are lacking on this concept, here we will discuss the reasons why one may logically conclude that magnesium administration in dextrose-containing solution does not in fact lower serum sodium concentration appreciably. Furthermore we will try to determine by how much one should expect the administration of magnesium intravenously will change the serum sodium concentration. World J Nephrol Urol. 2020;9(2):33-34 doi: https://doi.org/10.14740/wjnu409
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
BACKGROUND Hemodialysis corrects metabolic acidosis by transferring bicarbonate or bicarbonate eq... more BACKGROUND Hemodialysis corrects metabolic acidosis by transferring bicarbonate or bicarbonate equivalents across the dialysis membrane from the dialysis fluid to the plasma. With the conventional three-stream bicarbonate-based dialysis fluid delivery system, a change in the bicarbonate concentration results in changes in the other electrolytes. In practice, the dialysis machine draws either a little less or more from the bicarbonate concentrate and a little more or less from the acid concentrate, respectively in a three-stream delivery system. The result not only changes the bicarbonate concentration of the final dialysis fluid but also causes a minor change in the other ingredients. METHODS We propose a four-stream bicarbonate-based dialysis fluid delivery system consisting of an acid concentrate, base concentrate, product water, and a new sodium chloride concentrate. RESULTS By adjusting the flow rate ratio between the sodium chloride and sodium bicarbonate concentrates, one can achieve the desired bicarbonate concentration in the dialysis fluid without changing the concentration of sodium or ingredients in the acid concentrate. The chloride concentration mirrors the change in bicarbonate but in the opposite direction. CONCLUSION A four-stream, bicarbonate-based dialysis fluid delivery system allows the bicarbonate concentration to be changed without changing the other constituents of the final dialysis fluid.
The relationship between sodium, blood pressure and extracellular volume could not be more pronou... more The relationship between sodium, blood pressure and extracellular volume could not be more pronounced or complex than in a dialysis patient. We review the patients' sources of sodium exposure in the form of dietary salt intake, medication administration, and the dialysis treatment itself. In addition, the roles dialysis modalities, hemodialysis types, and dialysis fluid sodium concentration have on blood pressure, intradialytic symptoms, and interdialytic weight gain affect patient outcomes are discussed. We review whether sodium restriction (reduced salt intake), alteration in dialysis fluid sodium concentration and the different dialysis types have any impact on blood pressure, intradialytic symptoms, and interdialytic weight gain.
Background: There are few data on whether higher severe acute respiratory syndrome coronavirus 2 ... more Background: There are few data on whether higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody titers correlate with subsequent infection in the general population, much less in the dialysis patients. Methods: Fifty-four hemodialysis patients who had antibody titer measured against SARS-CoV-2 after vaccination were retrospectively looked at after 6 months. Rates of subsequent coronavirus disease 2019 (COVID-19) infection were correlated with initial antibody titers. Results: The mean antibody titer in the patients who subsequently developed SARS-CoV-2 infection was 437 relative fluorescent units (RFU) as compared with mean antibody titer of 1,436 RFU in patients who did not developed infection. Conclusion: It seems higher antibody titers are in general protective against subsequent infection; however, some patients developed subsequent infection despite having high antibody titers.
Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the me... more Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the mechanisms, diagnosis, clinical consequences, and conditions associated with pseudohyponatremia, and future developments for its elimination. The two methods involved assess the serum sodium concentration ([Na]S) using sodium ion-specific electrodes: (a) a direct ion-specific electrode (ISE), and (b) an indirect ISE. A direct ISE does not require dilution of a sample prior to its measurement, whereas an indirect ISE needs pre-measurement sample dilution. [Na]S measurements using an indirect ISE are influenced by abnormal concentrations of serum proteins or lipids. Pseudohyponatremia occurs when the [Na]S is measured with an indirect ISE and the serum solid content concentrations are elevated, resulting in reciprocal depressions in serum water and [Na]S values. Pseudonormonatremia or pseudohypernatremia are encountered in hypoproteinemic patients who have a decreased plasma solids content. ...
OBJECTIVE Finerenone significantly improved cardiorenal outcomes in patients with chronic kidney ... more OBJECTIVE Finerenone significantly improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease trial. We explored whether baseline HbA1c level and insulin treatment influenced outcomes. RESEARCH DESIGN AND METHODS Patients with T2D, urine albumin-to-creatinine ratio (UACR) of 30–5,000 mg/g, estimated glomerular filtration rate (eGFR) of 25 to <75 mL/min/1.73 m2, and treated with optimized renin–angiotensin system blockade were randomly assigned to receive finerenone or placebo. Efficacy outcomes included kidney (kidney failure, sustained decrease ≥40% in eGFR from baseline, or renal death) and cardiovascular (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) composite endpoints. Patients were analyzed by baseline insulin use and by baseline HbA1c <7.5% (58 mmol/mol) or ≥7.5%. RESULTS...
Herbal medicine, a form of complementary and alternative medicine (CAM), is used throughout the w... more Herbal medicine, a form of complementary and alternative medicine (CAM), is used throughout the world, in both developing and developed countries. The ingredients in herbal medicines are not standardized by any regulatory agency. Variability exists in the ingredients as well as in their concentrations. Plant products may become contaminated with bacteria and fungi during storage. Therefore, harm can occur to the kidney, liver, and blood components after ingestion. We encourage scientific studies to identify the active ingredients in herbs and to standardize their concentrations in all herbal preparations. Rigorous studies need to be performed in order to understand the effect of herbal ingredients on different organ systems as well as these substances' interaction with other medications.
There is fair amount of data that potassium administration will raise serum sodium concentration;... more There is fair amount of data that potassium administration will raise serum sodium concentration; however whether the above concept extends to other electrolytes is less well understood. Although real-world data are lacking on this concept, here we will discuss the reasons why one may logically conclude that magnesium administration in dextrose-containing solution does not in fact lower serum sodium concentration appreciably. Furthermore we will try to determine by how much one should expect the administration of magnesium intravenously will change the serum sodium concentration. World J Nephrol Urol. 2020;9(2):33-34 doi: https://doi.org/10.14740/wjnu409
There is fair amount of data that potassium administration will raise serum sodium concentration;... more There is fair amount of data that potassium administration will raise serum sodium concentration; however whether the above concept extends to other electrolytes is less well understood. Although real-world data are lacking on this concept, here we will discuss the reasons why one may logically conclude that magnesium administration in dextrose-containing solution does not in fact lower serum sodium concentration appreciably. Furthermore we will try to determine by how much one should expect the administration of magnesium intravenously will change the serum sodium concentration. World J Nephrol Urol. 2020;9(2):33-34 doi: https://doi.org/10.14740/wjnu409
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
Current Opinion in Nephrology & Hypertension, 2021
Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney ... more Purpose of review The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era. Recent findings One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus. Summary The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.
BACKGROUND Hemodialysis corrects metabolic acidosis by transferring bicarbonate or bicarbonate eq... more BACKGROUND Hemodialysis corrects metabolic acidosis by transferring bicarbonate or bicarbonate equivalents across the dialysis membrane from the dialysis fluid to the plasma. With the conventional three-stream bicarbonate-based dialysis fluid delivery system, a change in the bicarbonate concentration results in changes in the other electrolytes. In practice, the dialysis machine draws either a little less or more from the bicarbonate concentrate and a little more or less from the acid concentrate, respectively in a three-stream delivery system. The result not only changes the bicarbonate concentration of the final dialysis fluid but also causes a minor change in the other ingredients. METHODS We propose a four-stream bicarbonate-based dialysis fluid delivery system consisting of an acid concentrate, base concentrate, product water, and a new sodium chloride concentrate. RESULTS By adjusting the flow rate ratio between the sodium chloride and sodium bicarbonate concentrates, one can achieve the desired bicarbonate concentration in the dialysis fluid without changing the concentration of sodium or ingredients in the acid concentrate. The chloride concentration mirrors the change in bicarbonate but in the opposite direction. CONCLUSION A four-stream, bicarbonate-based dialysis fluid delivery system allows the bicarbonate concentration to be changed without changing the other constituents of the final dialysis fluid.
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