Hospitalists should adopt the “earlier is better” mantra for cases of electrolyte problems, such as hypokalemia, hyperkalemia, and significant hyponatremia, or low salt levels, he notes.
“We don’t mind being curb-sided,” Dr. Shapiro says. If the specialist gets a simple heads-up about a patient on the fourth floor—even if it doesn’t require immediate action—he can then pop in and check on the status of that patient when he’s there on his rounds, he says.
Dr. Shaikewitz admits that some kidney specialists prefer not to be called in very early; therefore, it’s important for hospitalists to develop relationships and understand individual preferences. But in his case, an early referral is favorable.
“When in doubt, refer a little bit on the early side,” he says. “It’s actually kind of a fun teamwork with the hospitalists, trying to manage the patient and doing everything as a group.”
—Ruben Velez, MD, president, Renal Physicians Association, president, Dallas Nephrology Associates
7) Always call a nephrologist when a kidney transplant patient is admitted.
Robert Kossmann, MD, president-elect of the RPA, and other experts agree that it’s a good idea to at least call and inform a nephrologist that a transplant patient has been admitted. The call can go something like, “I have this patient coming in to the hospital, their kidney transplant function is fine, but they’re here with X, Y, or Z,” he says. “Is there something that we should be paying particular attention to or do you need to come see that patient?”
Dr. Kossmann says hospitalists don’t need to automatically consult a nephrologist every time, but “it’s probably a good idea to call and talk to the nephrologist every time.”
Dr. Velez says he’s seen a lot of unnecessary mistakes around transplant patients.
“There’s a lot of drug interactions with immunosuppressive drugs that these patients take that could have been prevented or avoided,” he says. “Even on patients that have fantastic renal function up to transplant … these patients can turn sour on a dime.”
8) Don’t forget the power of a simple urinalysis.
You can get a lot of diagnostic information from the urinalysis—“from a simple dipstick,” Dr. Szczech says. She points out the value of the specific gravity reading.
“A specific gravity of 1.010 in the setting of a rising creatinine [level] probably means you’ve got injury to the tubule,” she says.
The power of this simple tool can sometimes be overlooked, she says, as clinicians seek to understand how to use the newer biomarkers.
“In nephrology, we can make things quite complicated,” she adds. “We can’t forget about the low-tech stuff that we just take for granted.”
9) Simply looking at serum creatinine level is not enough.
It’s extremely important to calculate the glomerular filtration rate (GFR), says Katherine Tuttle, MD, clinical professor of medicine in the University of Washington’s division of nephrology. Some hospital labs will do this, but hospitalists need to “make sure they review the GFR values, not just the serum creatinine,” she says.
And those readings have important ripple effects.
“Everything from need for adjustment of drugs for low GFR to drug interactions to caution about, for example, using iodinated contrasts because of risk of acute kidney injury, increased risk of infection, increased risk of cardiovascular complications,” she says. “So it’s a very important part of the clinical assessment.”