JH IM Board Review - SOS III Flashcards
CKD classification (KDIGO 2012) is based on (3):
- Cause ==> Presence of systemic disease and its location in the kidney.
- GFR category.
- Albuminuria.
Etiology of CKD:
- DM (40%).
- HTN (25%).
- Glomerulonephritis (10%).
- Genetic (PKD, etc, 3%).
- Urologic (approx. 2%).
Calcific uremic arteriolopathy (calciphylaxis):
Skin and fat necrosis with calcification and thrombosis of small arterioles — MC in ESRD.
Calciphylaxis usually occurs in the setting of:
- High Ca x Ph.
- Violaceous, indurated skin lesions that may ulcerate.
- Predilection for the lower extremities and trunk.
ACEIs/ARBs delay CKD progression — What is their effect on Cr?
Rise is 20% or less — Continue therapy as there is long-term benefit in preservation of GFR.
Atenolol in CKD — Problem?
It is excreted via the kidney, therefore, use with caution or consider switching to a nonrenally cleared beta-blocker (eg metoprolol).
Tx of atherosclerotic RAS:
- ACEI/ARB + Statin + Aspirin (1st line).
- Stop smoking.
- Angioplasty + endovascular stenting — NOT superior to medical management except in selected cases.
Goal of HbA1C in CKD:
7% — Lower A1c is NOT a/w slower CKD progression and INCREASES RISK OF HYPOGLYCEMIA.
Statin therapy and N-acetylcysteine may reduce the risk of … nephropathy.
CONTRAST nephropathy.
Vaccines for CKD:
- Annual flu vaccination.
- HBV series.
- Pneumococcal ==> PCV13 (conjugate) followed by PPSV23 (polysaccharide) at least 8 weeks later.
Repeat PPSV23 in 5y.
***If previous PPSV23 vaccination ==> Administer PCV13 1y or more after last PPSV23 dose.
CIs to renal transplantation:
- Metastatic or untreated cancer.
- Recent malignancy (time varies according to cancer type).
- Active infection.
- Severe psychiatric disease.
- Active/unstable CAD or CHF.
- NON renal organ failure (liver, lung).
- Persistent substance abuse.
- Unresolved psychosocial problems.
…-…% of >50y have microscopic hematuria.
2-18%.
Hematuria is more than … per hpf.
3 RBC/hpf.
Urine dipstick testing is highly sensitive for microscopic hematuria but it is NOT specific.
Heme (+) testing in the absence of RBCs suggests:
(4)
- Myoglobinuria.
- Intravascular hemolysis.
- Povidone-iodine administration.
- Presence of oxidizing agents.
Exercise-induced hematuria typically resolves with …-… of rest.
1-3 days.
Papillary necrosis may be precipitated by:
Ischemic damage to renal papillae
- SCD/trait.
- DM.
- Heavy use of phenacetin or acetaminophen.
- NSAIDs.
- UT obstruction.
- TB.
3 MCC of isolated hematuria w/o significant proteinuria (<500).
- IgA nephropathy.
- Thin basement membrane disease.
- Alport syndrome.
Approx. …% of men and …% of women will have a symptomatic stone by age 70.
16%
8%.
Latent autoimmune diabetes of adulthood (LADA):
DM I that can present in adulthood.
Tx of necrobiosis lipoidica:
1st line ==> Topical and intralesional steroids.
For ulcers ==> Cyclosporine — hyperbaric O2 — Infliximab.
Diagnostic criteria for prediabetes:
3
- Impaired glucose tolerance — 2h plasma glucose 140-199 mg/dL during OGTT.
- Impaired fasting glucose — Fasting plasma glucose 100-125.
- Increased risk for DM II — HbA1c 5.7-6.4%.
Insulin is the preferable 1st line therapy in certain clinical situations:
(4)
- Pregnancy ==> Only insulin is approved for use in pregnancy.
- Polyuria — polydipsia ==> Indicates severe hyperglycemia that should be rapidly reversed with insulin therapy.
- Ketosis ==> Indicates insulinopenia.
- LADA.
IMPORTANT CI of liraglutide?
CANNOT BE USED IN TS W/ PERSONAL OR FHx OF MEDULLARY THYROID CANCER
OR
MEN II.
Factors that may increase urinary albumin excretion over baseline values include:
- Exercise within 24h.
- Fever.
- Infection.
- CHF.
- Marked hyperglycemia.
- Marked HTN.
- Pyuria.
- Hematuria.
The lower limit of normal for TSH may be LOWER THAN established in African Americans …
Leading to possible MISDIAGNOSIS of SUBCLINICAL HYPOTHYROIDISM in healthy individuals.
What is apathetic thyrotoxicosis?
Classic signs of thyrotoxicosis may be absent in the older individuals, except for:
- Weight loss.
- Mental status changes.
- A-fib.
What is the laboratory importance of T3/T4 ratio:
If it is increased ==> GRAVES.
In contrast, in thyroiditis, the serum T3/T4 ratio is normal.
TSH-antibodies may be useful for …? (3)
- Confirm Graves.
- Stratify risk of neonatal thyrotox when measured at 22wk.
- Prognostication in Graves EYE disease.
Methimazole vs PTU?
Methimazole is the drug of choice!
PTU, rarely, can cause …
Fulminant hepatic failure.
Pregnancy — MMI — PTU?
PTU in 1st trimester.
MMI in 2nd/3rd.
Iodine Tx for Graves — Antithyroid drugs must be stopped …-… days before Iodine administration.
3-7 days.
TSH is decreased in pts taking … or …
Dopamine or HIGH-dose glucocorticoids.
CIs to iodine tx:
Absolute ==> Pregnancy and recent breastfeeding.
Relative ==> Moderate to severe eye disease — may be worsen (may give pre-tx with glucocorticoids).
As said before, Iodine may do what to Graves ophthalmopathy?
EXACERBATION — Especially in smokers.
Conditions a/w an acute or subacute non thyroidal illness:
- Non thyroidal surgery.
- Infection.
- Stroke.
- PE.
- Parturition.
- DKA.
Amiodarone-induced Thyrotoxicosis — How many types?
2 types.
Amiodarone-induced thyrotoxicosis type 1 VS AIT type 2:
Preexisting thyroid disease ==> Yes — No.
Duration of amiodarone therapy ==> Months — Years.
Iodine uptake ==> Low — Very low.
TFTs ==> Same.
Thyroid Doppler ==> Increased parenchymal blood flow — Normal, decreased parenchymal blood flow.
Tx ==> Antithyroid drugs/Surgery — Prednisone/Surgery.
Slightly elevated serum TSH levels in the elderly (75-80) have been a/w …
SURVIVAL BENEFIT.
Keep in mind that a normal total Ca may actually be high if … is low.
ALBUMIN IS LOW.
Formula for correcting total calcium when albumin is LOW:
Corrected Ca = Total serum Ca + (0.8 x [4 — albumin]).
Renal manifestations of hypercalcemia:
- Polyuria and polydipsia ==> Interference w/ ADH + Inhibition of Na resorption.
- Azotemia ==> Dehydration + Afferent vasoconstriction (!).
Li causes hypercalcemia via what mechanism?
Changes “set point” for PTH.
CHRONIC manifestation of hypercalcemia in the EYES:
BAND KERATOPATHY ==> Deposition of Ca-Ph in sun-exposed cornea.
Role of bisphosphonates in hypercalcemia:
Pamidronate + Zoledronate = choice.
==> Potent and effective ==> Ca begins to decline in 2 days and hits nadir at 7 days.
AEs of bisphosphonates:
- Mild increase in temp.
- Myalgias.
- Transient increase in Cr.
Glucocorticoids for hypercalcemia:
Most useful in tx of vitD-mediated hypercal.
**also useful in certain malignancies involving cytokine release (!) — Some myelomas.
Glucocorticoids are the MC 2o cause for osteoporosis — Small or large doses for osteoporosis to occur?
SMALL — 5mg prednisone/day for 3 or more months.
In men w/ osteoporosis, consider checking …
TESTOSTERONE LEVEL — Hypogonadism is a fairly common cause.
X-ray is helpful for detecting early osteoporosis?
NO — Osteopenia is NOT evident until approx. 30% of bone is lost.
What are the indications for BMD measurement with DXA scan:
- All women >65y + All men >70y.
- <65 and <70 w/ one or more clinical risk factors ==> LBW — previous fracture — high risk meds — Comorbidities a/w bone loss.
Osteonecrosis of the jaw w/ bisphosphonates is a risk in which pts?
Cancer pts.
Long-term, uninterrupted (5y or longer) use of bisphosphonates a/w the very rare complication of …
Atypical fractures of the femoral shaft(subtrochanteric or diaphyseal).
Teriparatide is used for a max of 2y. Why is that?
It has been found to cause OSTEOSARCOMA IN RATS.
NOT in humans (yet).
Denosumab side effect to remember:
RANKL plays a role in immune function — 1% increased risk of infections.
*not opportunistic infections.
Tx for Paget is indicated in (4):
- All sx pts.
- Asx pts w/ involvement of the skull — axial skeleton — weight-bearing long bones (high risk of progression to deformity).
- Asx pts w/ ALP 3x greater than the upper limit of normal.
- Pts undergoing surgery on sites of active disease — Tx will reduce the hypervascularity of the bone.
What to give in Paget?
- Analgesics for pain.
- Bisphosphonates for severe disease — 1st line (higher doses than osteoporosis).
- Calcitonin is approved but rarely used (short-lived effect) — SIGNIFICANT BONE PAIN RELIEF.
Paget can be monitored w/ …(2):
- ALP.
2. C-telopeptide (!).
Ddx of pathologic SECONDARY amenorrhea consists of 4 main disease states:
- Hyperprolactinemia.
- Anovulatory states (MC PCOS).
- Androgen excess (androgen-secreting tumors).
- Hypothalamic amenorrhea.
Hirsutism and virilization:
Hirsutism = terminal hairs in male body sites (face, chest, back, lower abdo, inner thighs).
Virilization = MORE SEVERE ANDROGEN EXCESS — Deep voice, clitoromegaly, frontal balding, enhanced musculature, hirsutism.
Hirsutism MCC:
Idiopathic familial (physiologic).
Hirsutism MC OVARIAN cause:
PCOS.
Hirsutism MC adrenal cause:
CAH.
MCC of 1o hypogonadism in men:
Klinefelter.
Testosterone therapy — What must be kept in mind?
- Monitor possible erythrocytosis.
- Prostate exam + PSA in >40y.
- Caution with CVS risks.
PDE-5 inhibitors should be taken … before intercourse.
Their duration is …
1h before.
4h duration.
Tadalafil has a faster onset of action and longer duration (…)
36h!
Warn pts about potential side effects of PDE-5 inhibitors:
3
- Color vision changes.
- Headaches.
- SUDDEN BLINDNEES from NON ischemic anterior optic neuropathy (case reports).
45% of pituitary masses are hormone-secreting tumors — 45% are NON-secreting tumors.
10% include …
- Craniopharyngiomas.
- Rathke cysts.
- Meningiomas.
- Metastatic tumors.
- Lymphoma.
- Granulomatous diseases.
- The increasingly recognized AUTOIMMUNE LYMPHOCYTIC HYPOPHYSITIS — (either 1o or 2o to cancer immunotherapy — particularly IPILIMUMAB.
Incidentalomas <1cm grow in less than …% of cases.
10%.
Incidentalomas >1cm grow in about …% of cases.
35%.
Pituitary tumors may exist as part of genetic syndromes — Carney complex:
AD complex:
- Cardiac myxomas.
- Spotty pigmentation of the skin.
- Various hyperendocrine states (!) — often including GH secretion.
Pituitary tumors may exist as part of genetic syndromes — Familial isolated pituitary adenomas (FIPA):
(Sometimes called isolated familial acromegaly syndrome)
- AIP inactivating mutations.
- AD but low penetrance (20%).
- Tumors mostly GH-secreting + large + aggressive + typically early in life.
Lymphocytic hypophysitis occurs in about …% of pts taking ipilimumab.
10%
If prolactin is >…, prolactinoma is very likely.
> 200 ng/mL.
A sellar mass in the presence of elevated serum prolactin, is NOT a definitive proof of prolactinoma.
What may be happening?
A large, NON-secreting adenoma may cause elevated PRL levels by COMPRESSING THE PITUITARY STALK.
==> Inhibiting hypothalamic dopaminergic regulation of PRL.
***Suspect this if macroadenoma is seen and PRL is <100 ng/mL.
If PRL is elevated but the pt has no sx — The presence of MACRO-PROLACTINEMIA must be suspected.
What is happening now?
PRL molecules bind to circulating immunoglobulins — causing MARKED increased in PRL half-life (though biologically INACTIVE).
How can we identify macroprolactinemia:
By repeating serum PRL measurement AFTER precipitating immunoglobulins with POLYETHYLENE GLYCOL.
Macroprolactinemia Tx?
None.
In difficult cases of differentiation of pituitary vs ectopic ACTH, what can we do?
Bilateral inferior petrosal sinus sampling after administration of corticotropin-releasing factor.
Drug that inhibits ACTH secretion:
Pasireotide.
With pituitary tumors/mass effect the order of the loss of hormones is:
GH ==> FSH/LH ==> TSH ==> ACTH.
Is there a case when this may not be followed?
Yes — with other causes of hypopituitarism.
Radiation or lymphocytic hypophysitis (!).
Most cases of pituitary apoplexy happen in pts w/ …
Previously undiagnosed pituitary tumors (2/3 of cases).
What is the most dangerous consequence of pituitary apoplexy?
Acute lack of ACTH ==> Adrenal insufficiency.
What is the clinical presentation of GH deficiency in ADULTS?
- Decrease sense of well-being.
- Decreased muscle mass.
- Increased fat.
- Osteopenia.
- Abnormal lipid profile (increased total and LDL cholesterol).
Tx of central hypothyroidism — if we don’t follow the TSH, what do we do?
Repletion with T4 — Tx is ADJUSTED TO SYMPTOMS + Measure serum free T4 levels.
What should be kept firmly in mind when treating pts with central hypothyroidism?
Never replace thyroid hormone before assessing ADRENAL FUNCTION.
==> DANGER ==> Pharmacologically-induced euthyroidism.
***thyroid hormones accelerate cortisol catabolism.
Kallmann syndrome may lead to what eye problems?
Red-green color blindness.
2 electrolyte disturbances that may lead to NEPHROGENIC DI:
HYPOkalemia
HYPERcalcemia
Most adrenal incidentalomas (67-94%) are secretory or non secretory?
NON secretory.
What determines the management of incidentaloma?
MASS SIZE — If >4cm ==> REMOVE.
***Biopsy CANNOT differentiate between benign and malignant.
When FNA is appropriate management for an incidentaloma?
If metastases to the adrenals is suspected and pheochromocytoma has been r/o.
Lack of hypokalemia does or does not exclude aldo excess?
Does not — may be unveiled by the use of diuretics.
K should be normalized BEFORE evaluating for hyperaldo, because …
Hypokalemia suppresses aldo secretion.
Initial screening for hyperaldo?
With serum aldo-plasma renin ratio.
If <20 ==> HYPERALDO IS RULED OUT.
If aldo/renin ratio is >20, the next step is to …
Demonstrate nonsuppressible levels of aldo in presence of Na load.
Give 2L NS over 4h.
If aldo is not suppressed to <8ng/dL ==> HYPERALDO IS PRESENT.
In pts >40y, what is recommended in order to determine the SOURCE of excessive aldo?
(given higher prevalence of bil hyperplasia and adrenal incidentalomas)
ADRENAL VEIN SAMPLING.
MCC of hyperaldo is bil hyperplasia or adenoma?
Bil hyperplasia.
Adrenal androgen excess — Men are typically …
Asx.
Adrenal androgen excess — Women present with:
- Hirsutism.
- Virilization.
- Oligomenorrhea — amenorrhea — infertility.
- Acne.
Rare mutation that may cause pheochromocytoma:
Succinyl dehydrogenase gene mutations — Familial paraganglioma syndromes — FPGL.
Hyponatremia is seen less commonly with 2o adrenal insufficiency — If that is the case, then think of …
Central hypothyroidism.
Gold-standard test of adrenal function is …
INSULIN-INDUCED HYPOGLYCEMIA or INSULIN TOLERANCE TEST.
Insulin tolerance test is CI in:
- CAD.
- Seizures.
- > 60y.
MC used test for adrenal function assessment is …
ACTH stimulation test.
Give ACTH ==> Measure cortisol before and 60min following injection.
Other causes of hyporenimic hypoaldosteronism besides DM?
- ACEIs.
- NSAIDs.
- Cyclosporine.
- Heparin (!).
- AIDS (!).
