One of the challenging cases in nephrology is managing a patient with severe hyponatremia, where each decision seems precarious. Overcorrecting sodium levels increases the risk of osmotic demyelination, while undercorrection leaves patients susceptible to complications. Nephrologists thread the needle carefully, focusing on avoiding overcorrection, typically aiming for a 24-hour correction rate below 6 to 8 mEq/L, or even lower at 4-6 mEq/L in patients with alcoholism, liver disease, or...

One of the more challenging consultations in nephrology is evaluating a pregnant patient beyond 20 weeks’ gestation who presents with worsening proteinuria, high blood pressure, and increasing serum creatinine. In these situations, I am faced with deciding whether the findings show preeclampsia or the unmasking or progression of underlying chronic kidney disease (CKD). Preeclampsia often follows a more aggressive course and, in severe cases, may necessitate early delivery. In contrast, CKD is...

I have often seen patients with chronic kidney disease who have an abnormal serum protein electrophoresis (SPEP) or free light chain (FLC) ratio and are referred to hematology before a nephrology evaluation. Many undergo an extensive hematologic workup, including a bone marrow biopsy, before their kidney disease is assessed. If the biopsy is negative for multiple myeloma or other hematologic malignancy, the abnormal monoclonal studies are attributed to monoclonal gammopathy of undetermined...