Nephrology Board Review

Christopher McFadden, MD May 20, 2008

Outline
• • • • • Highlights of MKSAP Testable Points Multi-center Trials Questions throughout Questions please

Hypertension
• Prevalence
– 20% adults – 60% > 65

• Natural history • SBP correlates better than DBP

Chobanian: Hypertension, Volume 42(6).December 2003.1206-1252

53% on meds.HTN • Nephropathy now a risk factor • 70% aware of diagnosis. <130/80 w/ DM or CKD . and 27% controlled (NHANES) • Initial eval: Duration. risk factor stratification. and signs of TOD Goal: <140/90.

1206-1252 . Volume 42(6).7 Chobanian: Hypertension.December 2003.

December 2003.Initial Management per JNC 7 Chobanian: Hypertension.1206-1252 . Volume 42(6).

December 2003. Volume 42(6).1206-1252 .Chobanian: Hypertension.

ARBs beneficial in DM II • LIFE. CCB not • SHEP.ACE renoprotective w/ proteinuria in AA patients.Major Trials • ALLHAT.ARB > Beta-blocker w/ LVH .isolated SBP > 160 in elderly pts – Limited evidence for stage I HTN • RENALL/ IDNT.HTN.thiazides = amlodopine/ ACE • AASK.

• Question 1 .

abdominal bruit (particularly diastolic).Secondary Causes Features Age < 30 & > 55 Abrupt onset/ resistant TOD Hypokalemia. family hx of renal disease. PCKD. ACE assoc ARF RVD vs RAS 70% critical Doppler: 90% sens Renal Scan: 85% MRA: preferred: 90% ostial Mgmt: Some BP improvememntrarely corrects Renal outcomes limited Better response in FMD patients .HTN.

• In addition to counseling regarding lifestyle modifications. Her usual home blood pressure measurement is between 110/76 mm Hg and 120/80 mm Hg. She does not smoke cigarettes. • On physical examination. Results of laboratory studies. which of the following is the most appropriate management for this patient? – – – – A Begin hydrochlorothiazide B Begin enalapril C Perform ambulatory blood pressure monitoring D Continue home blood pressure measurement . Her mother has hypertension. including the creatinine level.• A 45-year-old woman is referred for evaluation for a blood pressure measurement of 150/94 mm Hg. Her husband is a nurse and regularly measures her blood pressure at home. are normal. her average blood pressure is 148/98 mm Hg.

arm at heart level • Palpate for loss of arterial impulse • Cuff bladder 80% arm circumference – Cuff too small  elevates BP • Inflate cuff 20 mm above level of BP loss • Reduce BP 2 mm/sec • Up to 30% people have white coat HTN .HTN Measurement • Resting comfortably.

Kidney Function Assessment • Creat clearance overestimates GFR • Creat lowered in malnourished diseases • MDRD estimates GFR accurately up to 60-90 ml/min .

large proportion Tamm.Proteinuira • > 150 mg/ 24 hours • Normally: albumin 30%.Horsfall proteins • Exercise induced • Orthostatic .

benzene exposure Sometimes repetitive evaluations . smoking.Hematuria • >3 erythrocytes/ hpf on centrifuged urine • W/U: urine cytology or cysto and upper tract imaging Risk factors: >40. analgesic use.

Nitrofurantoin. Quinine. Porphyrins • Foods: Beets. Fava Beans. Sulfonamides.Pigmenturia • Endogenous: Bilirubin. Myoglobin. Rhubarb • Drugs: Rifampin. and others . Hemogloblin.

tubular injury and death .inflammation or infection • Granular casts.Casts • Formed by Tamm-Horsfall mucoprotein secreted by distal tubules • RBC casts.glomerular disease • WBC casts.

Granular & RBC casts .

Glomerulus .

.

.

Nephrotic Syndrome Proteinuria > 3.5 g Hyperlipidemia Edema Hypercoagulability Sec hyperpara Low thyroxine (nl TSH) .

• Question 3 .

• Questin 16 .

Nephrotic Diseases • Primary Minimal Change FSGS Membranous Membranoproliferative • Secondary FSGS Membranous MPGN Amyloid • Treatment ? Immuno + supportive tx • Treatment Supportive: ACE/ HMG/ HTN control .

Membranous & Amyloid .

• Case 8 .

Acute GN • Hematuria.often RBC casts • HTN • Possible reduced GFR .

Glomerulonephritis (cont) • IgA.synpharyngitic hematuria Secondary dz associated w/ liver dz Treatment controversial. 30% reach ESRD – Henoch-Schonlein purpura: IgA deposits • Post-strep: 2-3 weeks after infection Treatment conservative .

Cytoxan/ Pred 5 (Membranous).supportive 3 (FPGN) and 4 (DPGN).GN (cont) • SLE.Treatmtent Stage 1(nl) and 2 (mesangial).controversial 6 Scarred .

SLE Nephritis .

RPGN • ANCA associated (pauci-immune) Wegener’s Microscopic Polyangitis/ Churg Strauss • Anti GBM Goodpastures. Post infection. Cryo. HSP . Idiopathic • Immune Complex SLE.

• Question 6 .

exam w/ basilar rales • UA 30 RBC.3 mg/ dL. Hgb 9. cough.8 g/ dL • Serologic wu: anti GBM positive • Renal biopsy: crescents and linear GBM staining . 2 + protein • Creat 2. and dark urine for 2 weeks • PMH negative • BP elevated. hemoptysis.GN Case (# 7) • 28 yo w/ arthralgias.

RPGN .

• Question 7 .

crystals. immunologic including sarcoid/ sjogrens • Triad of eosinophilia. fever.injury by infection. ischemia. rash limited to PCN AIN • Medications – – – – – Analgesics Aristocholic Acid Lithium Amphotericin B Cisplatinum . medications.Tubulointersitial Disease • Inactive Sediment • Cause.

• Question 15 .

Acute Interstitial Nephritis .

cast nephropathy. amyloid Lamda chains: amyloid Kappa chains: LCDD Dipstick NOT adequate Analgesic Nephropathy • Long duration/ combo • Lobulated • Transitional cell CA of GU tract .Myeloma Kidney • Light chains in urine toxic insult (LCDD).

Case 8
• • • • • 65 yo w/ cc fatigue & back pain New onset nocturia, polyuria Vitals normal, thoracic back pain Ca 12.8 mg/ dL, Creat 2.6 mg/dL UA: trace protein, no cells

Genetic Renal Disorders
PCKD AD >> AR AD 1:1000 Cerebral aneurysms Hepatic cysts; Valvular dz Men- Renal failure Het women- hematuria Hematuria; not renal failure Tubular d/o (CL B- worse, hypercalciuria transport; nl bp, low G- subtler, lower serum K magnesium Alphagalactosidase Glyoxalate aminotransferase Progressive systemic dz Liver disease

Alports Benign Familial Hematuria Barter’s/ Gitelman’s Fabry’s Disease Hyperoxaluria

X linked AR AR

Collagen defect

X-linked AR

PCKD
• Abx penetrating the cysts
TMP/SXT Chloramphenicol Ciprofloxacin

• Question 14 .

6 x (plasma gluc.5 (HCO3) + 8 +/.Formulas Body= 60% water.8 + gluc/ 18 Unmeasured anion if calcul vs meaured > 10 . 1/3 extracellular Expected dec Na= 1.Fluid/ Electrolytes. 2/3 intracellular.100)/100 AG= Na – (Cl + HCO3) Delta/ Delta= [AG change/ hco3 change] w/ nl 1-2 Winter’s Formula= 1.2 = pCO2 Plasma osmol= 2x Na + BUN/ 2.

12 meq/ L in 24 hours • Hypernatremia. hypokalemia. fluoxetine. cortisol levels Drugs causing SIADH: cyclophosphamide.Fluid/ Electrolytes. carbamazepine. check TSH.acquired NDI from lithiun.Pearls • Hyponatremia. hypercalcemia . and other cns agents Max correction rate. foscarnet. hctz. vincristine. haldol. chlorpropamide.treat vol status If euvolemic.

urine K (20 meq/24 hrs) to differentiate high loss (met alkalosis or RTA) vs GI loss/ shift/ poor intake • Hypophosphatemia. aminoglycosides.redistribution common w/ refeeding.Fluid/ Electrolytes.Pearls • Hypokalemia. .renal tubular loss due to cisplatinum. acute resp alk • Hypomagnesemia. ampho B. insulin to control hyperglycemia.

urine contacting GI tract  Cl absorption and K/ HCO3 excretion • Ethylene glycol associated w/ Ca oxalate crystals • Formic acid (methanol) assoc w/ blindnesss • RTA Proximal (2).high K. high urine pH • Met acidosis and resp alkalosis Eval for sepsis or saliclylate intoxication . high urine pH Distal (4).low K.variable urine pH Distal (1).Fluid/ Electrolytes.Pearls • Met acidosis.

(U Na/ P Na)/ (U Cr/ P Cr) * 100 Less than 1% in oliguric pre-renal patients .Acute Renal Failure • ACE-I.efferent vasodilation • NSAIDs.afferent vasoconstriction • FENA.

Renal Replacement Therapy • CVVHD not proven to be more effective than intermittent HD • Increased ultrafiltration w/ CVVH better outcomes • Daily dialysis better outcomes in single center study • “Renal dose” dopamine not effective .

Contrast Nephropathy • Creat peaks 4-5 days after exposure • Acetyl-cysteine has varying results • Limiting risk. and vol expansion pre-procedure .decreased contrast volume. use of isotonic contrast.

elderly.ARF. risk w/ vol depletion.Other causes • Aminoglycosides: 1-2 weeks. Dipstick incosistent • Cancer: r/o obstruction! Uric acid crystallization (allopurinol/ bicarb) Radiation (> 23 Grays) . HMG. & CSA use • Cisplatinum: may have NDI. lower troughs! • Amph B: 2 grams cumulative dose. often recovers • MTX: ATN and tubular obstruction • Mitomycin C: consider HUS • HIV: Indinavir crystals  obstruction • HRS: low FENa • Rhabdo: rapid Cr increase (trauma. cocaine.CoAs).

Cr 1.2 • Urine Na 6. osmol 670 mosm/ kg H20 • Previous creat 0.6 .1. CO2 20. edema • Na 122.ARF Case (# 15) • 61 yo w/ ascites and edema • Longstanding etoh abuse • BP 96/70. P 112 w/ distened abdomen. K 3. Cl 102.

Indinavir Crystals .

10% GN .CV Risk Reduction Complications Prepare for RRT RRT Cause of ESRD: 40% DM. 27% HTN.

• Question 9 .

• Question 12 .

5 (women) or >2.0 (men) • HTN AASK.control w/ ACE better • • • • DM control Protein Restriction Anemia management: goal Hgb 11-12 ROD: Phosphorus restriction/ Binders/ Vitamin D analogues (monitor Ca and Phos) .Internist Managment • Refer Cr > 1.CKD.

9 mg/dL (79.58 μmol/L). and atenolol. Laboratory studies reveal a normal hemoglobin level.• A 54-year-old woman is evaluated for a creatinine level of 1. and hypertension well controlled with lisinopril. 18 months ago. hydrochlorothiazide. this value was 0. She has a 5-year history of type 2 diabetes mellitus.95 μmol/L). • Which of the following diagnostic studies is most appropriate for this patient? – – – – – A 24-Hour urine collection for proteinuria B Kidney ultrasonography C Measurement of urine microalbumin D Serum protein electrophoresis E Measurement of hemoglobin A1c . She also uses glipizide and simvastatin.3 mg/dL (114. hyperlipidemia.

• Question 11 .

• Question 19 .

ESRD worse response w/ PTA.ESRD • • • • • Poor survival 20-40 % at 5 years (DM vs non) PD vs HD Main cause of death: CVD & Infection Historically. stent effect unclear .

• Question 5 .

gum hypertrophy • Tacrolimus: HTN. nephrotoxicity.Transplant • Better Survival LRRT 5ys: 90% CRT 5ys: 81% DM 5ys: 50% • CSA: HTN. nephrotoxicity hirsutism. DM • MMF: diarrhea and leukopenia • Aza: reduce dose of allopurinol! .

Question 2 • A 60-year-old woman with a history of type 1 diabetes mellitus and stage 4 chronic kidney disease comes for a routine follow-up examination. • Which of the following is the best option for this patient? • • • • • A 0-Antigen-mismatched deceased donor kidney transplantation B Peritoneal dialysis C Hemodialysis D Living donor kidney transplantation after a course of dialysis E Preemptive living donor kidney transplantation . She asks about modalities of renal replacement therapy.

t • Question 18 .

radiolucent – Tx. alkalinize. thiazides – NO calcium restriction (increases oxalate) • Struvite stones: chronically infected.Nephrolothiasis • Most patients: hypercalciuria – Tx: low salt. low protein.volume. d-penicillamine or alpha mercaptoppropionyl glycine (more soluble cysteine disulfide compound) .alkalinize urine and allopurinol • Cystine: metabolic (AR) defect – Tx. staghorn • Uric acid.

Nephrolothiasis Images .

Nephrolothiasis Images .

Nephrolothiasis • Work-up • Initial: chemistry. and imaging Hydration!!! 50% recurrence at 10 years • Recurrent stones: metabolic/ 24 hr urines Diarrhea  think IBD with ca oxalate stones . UA. stone analysis (if available).

consider hydatiform mole Tx HTN when DBP 100-110 or symptomatic Meds: 1st line. Hydralazine . “transient HTN of pregnancy” • Preeclampsia If before 20 weeks.Methyldopa.present before pregnancy or dx before 20 weeks • Gestational HTN.dx after 20 weeks.Renal Disease in Pregnancy • Tx asymptomatic bacteriuria • Chronic HTN.

difficult to determine signficance .4 • Mild hydro common.Renal Disease in Pregnancy • Higher risk w/ proteinuria and Creat > 1.

Emphysematous Pyelonephritis • Similar to pyelo • Majority pts have DM • Gas in renal/ perirenal tissues • Drainage mildmoderate cases. nephrectomy if severe • CT if pyelo pts not getting better! .

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0 . no orthostasis No volume overload Creat 1.HTN Case (# 3) • • • • • • 76 yo for fu. tobacco use BP 178/68. No medications No etoh. several elevated BP recently PMH negative.

• Evaluation BP change recently? Ideal 1st line agent: JNC 6: CCB or diuretics JNC 7: Stage 2: combination Auto regulation .HTN Case cont.

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