Cases (Day 1)

Question 1

What is your first step?
- pamidronate 30mg IV over 6 hrs
- IV NS bolus + 150cc/hr
- furosemide 40mg IV
- Denosumab
- Calcitonin

What is the mostly cause of hyperCa?
- primary HPTH
- secondary HPTH
- malignancy
- Vit D intoxication

Answer 1

1. fluids
2. Malignancy

• seen in SCC head, neck, lung (MCC), esophagus
• breast
• RCC
• lymphoma/myeloma

Question 2

How is calcium reabsorbed?
What is the effect of loop diuretics?

Answer 2

Question 3

What is the drug of choice/Level I evidence supported medication for hyperCa of malignancy?

Answer 3

Bisphosphonates - high affinity for hydroxyapatite, inhibit resorption/bone turnover
- more potent: zoledronate, pamidronate, ibandronate - higher rate of Ca normalization and lower rate of relapse

Question 4

What is a useful adjunct with bisphosphonates in rapidly reducing calcium?

Answer 4

Calcitonin - inhibits osteoclasts
- rapid, short half-life
- tachyphylaxis around 48hrs
4-8IU/kg IM/SQ q6 hrs

Question 5

Which hyperCa therapy doesn’t require dose adjustment for low GFR?

Answer 5

Denosumab - RANKL-Ab, inhibits rank-l mediated resorption
*can cause hypoCa if Vit D not replete

Question 6

Review of tx of HyperCa of malignancy

Question 7

What’s the dx?
- Light chain nephropathy (MM)
- acute uric acid nephropathy (TLS)
- acute nephrocalcinosis (Ca/phos dep)
- Acute granulomatous interstitial nephritis from NSAIDS
- acute infiltrating nephritis from lymphoma

Answer 7

fractured glassy casts

Question 8

Pathology review

Question 9

Prior to chemo, which should be administered?
- HD
- Urine alkalization
- glucose/insulin
- IV Calcium
- IV Fluid challenge

Answer 9

Question 10

Flip for treatment of TLS

Answer 10

Question 11

Which of the following labs explain his lab abnormalities?
- aldo
- cortisol
- ACTH
- TSH
- glucagon

Answer 11

Question 12

Pathophysiology of HTN, HypoK, Met. Alkalosis in Small Cell lung CA (flip)

Answer 12

Question 13

Kidney US with 18cm size bilaterally.

What is the most likely cause of AKI?
- obstructive uropathy
- AIN
- lymphomatous infiltration
- MN 2ndary to neoplasm
- renal vein thrombosis

Answer 13

Renal lymphoma
- enlarged on US/CT
- RP can cause obstruction or masses in kidney

Question 14

What is the most likely cause of this condition?
- cisplatin induced renal salt wasting
- SIADH
- Bleomycin induced renal salt wasting
- Paclitaxel autonomic neuropathy

Answer 14

Cisplatin
- dose-related nephrotoxicity (primarily tubular) and ototoxicity

Question 15

How can you prevent/treat Cisplatin-AKI/tubulopathy?

Answer 15

IV NS or 3% for forced diuresis
Amifostine (glutathione analog)
change to carbo/oxaplatin (don’t use OCT-2)
Na-thiosulfate

Question 16

What is the likely cause of her electrolytes disorder?
- Paclitaxel toxicity
- 2ndary hyperaldo
- stimulation of FGF23 by tumor
- Ifosfamide toxicity
- obstructive uropathy

Answer 16

Ifosfamide
vs. cyclophosphamide - hemorrhagic cystitis
- toxic metabolite of ifos is chloroacetaldehyde = causes problem in PCT

causes fanconi/neph DI, AKI/ATN

Tx: dose reduction/supportive care

Question 17

What is the cause of kidney disease?
- naproxen
- breast cancer
- pamidronate
- gemcitabine
- paclitaxel

Answer 17

Pamidronate - seen in long term, high doses
- AKI with nephrotic syndrome, collapsing FSGS and chronic tubulointerstitial disease

Zolendronate - after several doses, AKI/ATN
- CI if eGFR <30

Question 18

What is the most likely cause of hypoMg?
- irinotecan
- oxaliplatin
- cetuximab
- pantoprazole
- leucovorin

Answer 18

Cetuximab
- PPI cause GI Mg wasting, not renal
- EGFR inhibitor to treat epithelial cell malignancies (colorectal, head and neck, breast, lung)

Panitumumab also (cousin)

Question 19

What is the likely lesion seen in this patient?
- TMA
- FSGS
- crystalline-induced tubular injury
- AIN
- ATI/ATN

Answer 19

Immune checkpoint AIN
- CTLA-4 blockers and PD-L1 Ab

Question 20

Other pathologies associated with immune checkpoint inhibitors

Answer 20

<4% from ICPI induced AKI
usually AIN, can be GN/vasculitis
- no labs helpful, needs biopsy
- can be steroid responsive
- re-challenge reasonable with close monitoring (23% recurrence)

Question 21

Other pathologies associated with immune checkpoint inhibitors

Answer 21

<4% from ICPI induced AKI
usually AIN, can be GN/vasculitis
- no labs helpful, needs biopsy
- can be steroid responsive
- re-challenge reasonable with close monitoring (23% recurrence)

Question 22

UA: SG-1.018, pH 6, protein 1+, blood 3+, gluc neg, LE trace
Hb 10, WBC 8.7 w/ 3% eos

Answer 22

What is present on urine micro?
- dysmorphic RBC
- budding yeast
- renal tubular epithelial cells
- isomorphine RBCs
- WBC

What is the most likely diagnosis?
- IgA
- AIN
- bladder cancer
- ATN
- acute pyelonephritis

see next question in order

Question 23

Answer 23

Question 24

Lytes: ok, alb 3.2
BUN 75, Cr 4.9
WBC 18/5, eos. 5%
UA: SG 1.010, pH 5.5, prot 2+, gluc 1+, blood neg, LE, neg

Answer 24

What is the cell on urine micro?

Based on type of cell, what is the diagnosis?
- TMA
- ATI/ATN
- AIN
- HCV GN
- Uroepithelial cancer

see next question in order

Question 25

Answer 25

Question 26

single nucleus

Question 27

Answer 27

What on the urine micro? What's the diagnosis? - pre-renal AKI from SGLT2 - ATI/ATN - AIN - UTI - progressive DKD *see next question in order*

Question 28

Answer 28

Question 29

Answer 29

Whats seen on microscopy? What is the Dx? *see next question in order*

Question 30

Answer 30

Question 31

Answer 31

What's the cell on micrscopy? What is the diagnosis? - renal limited anti-GBM - ATI/ATN - AIN - IgA vasculitis - candida pyelonephritis *see next question in order*

Question 32

Answer 32

Question 33

name the cast

Answer 33

hyaline cast

Question 34

name the cast

Answer 34

waxy cast

Question 35

name the cast

Answer 35

renal epithelial cast

Question 36

name the cast

Answer 36

granual cast

Question 37

name the cast

Answer 37

RBC cast

Question 38

Answer 38

What crystals are present? - sulfonamide - Ca phos - Ca Ox - Uric acid - Hippurate *see next question for answer*

Question 39

Answer 39

Question 40

Question 41

Question 42

Answer 42

Question 43

Question 44

seen in what clinical scenario?

Answer 44

urease producing UTI struvite stones

Question 45

Question 46

Answer 46

genetic disorder - tx allopurinol to block XDH

Question 47

Associated with which organ dysfunction/failure?

Answer 47

cirrhosis/acute liver failure

Question 48

What drug are you concerned about in this patient? - acyclovir - ciprofloxacin - amoxicillin - sulfamethoxazole - atazanavir

Answer 48

sulfa crystals

Question 49

name these crystals

Answer 49

acyclovir, very thin - usually seen in bolus, not really with PO ciprofloxacin - more starburst pattern, develop in 1. excessive dose in CKD for GFR or 2. in alkaline urine precipitation

Question 50

name the crystals

Answer 50

Amox - thicker than acyclovir sulfa

Question 51

Answer 51

indinavir - HIV treatment, thicker rod in starburts, could form stones, now replaced atazanavir - more used, lesser degree of crystallization/stones

Question 52

Associated with treatment of lymphoma/malignancies

Answer 52

MTX - prevent with urinary alkalization

Question 53

Question 54

Right kidney with two branches - large with stenosis with darkening in upper 2/3 hypoperfused/darker - severe RAS

Question 55

MR w/ stenosis, still see blood flow past lesions, so tight but not completely occluded - kidney on that side smaller and shrunken, ischemic

Question 56

Tight stenosis with post-obst dilatation on angiogram

Question 57

Stenosis noted in the setting of AAA stent related stenosis, improved with renal stent placed

Question 58

RAS pearls

Question 59

Answer 59

Fibromuscular dysplasia

Question 60

FMD Pearls

Question 61

Name the lesion

Answer 61

Adrenal adenoma

Question 62

Question 63

Answer 63

PAN

Question 64

Answer 64

Page Kidney

Question 65

Answer 65

Renal Infarction

Question 66

What kind of stones can be seen on XR?

Answer 66

can see calcium may not see uric acid/cystine

Question 67

Answer 67

Staghorn Calculi - associated with chronic UTI/struvite forming

Question 68

Answer 68

acoustic shadowing

Question 69

Question 70

Answer 70

Question 71

RCC

Answer 71

Question 72

Angiomyolipoma - can differentiate by HF units - doesn't need to be resected unless causing pain - treat if >4cm, mTOR - associated with TSC

Question 73

Type of scan best for detecting infected cysts?

Answer 73

CT-PET

Question 74

What is the most likely diagnosis?

Answer 74

Medullary Sponge kidney

Question 75

Name the diagnosis

Answer 75

Nephrocalcinosis

Question 76

Answer 76

Question 77

What is seen on left? (Right is normal)

Answer 77

Papillary Necrosis

Question 78

Question 79

Labs: Na 131, K 6.5, HCO3 13, BUN 98, Cr 9, Hb 9, phos 7, alb 3 CXR w/ inc interstital edema/CHF UA 1+ prot, 1+ blood, 1+ LE sediment: 10-15 RBC, 5-10 WBC, 5-10 RTE, 1-2. gran cast, amorphous crystals

Answer 79

*see next question for answer/image*

Question 80

Answer 80

Question 81

Answer 81

Idiopathic RP Fibrosis - fibrotic tissue around aorta w/in RP with associated hydronephrosis

Question 82