Nephro : Glomerular Disease / AKI / CKD Flashcards
1
Q
ANCA disease : nephrotic or nephritic ?
A
Nephritic disease
2
Q
ANCA vasculitis, when should you choose rituximab over cyclophosphamide ?
A
- Premenopausal women, men interested in preserving fertility
- Frail older adults
- Relapsed disease
- If no evidence of RPGN
IF RPGN / Cr > 354 : CYCLOP
3
Q
ANCA vasculitis, when should you consider PLEX ?
A
- Anti GBM (double positive / overlap)
- if ANCA + GN vital organ / life threatening, Cr > 500
- Pt at high risk of progression to ESRD (and accept a potential higher risk of infection)
4
Q
AntiGBM disease : nephrotic or nephritic ?
A
Nephritic / RPGN
5
Q
Do you need biopsy in case of IgA nephropathy ?
A
Rarely need biopsy
Diagnosis is clinical
6
Q
Does sodium bicarb decrease decline in GFR ?
A
Yes !
7
Q
For which nephropathy should you screen for malignancies ?
A
Membranous
Age-based screen + pretest probability
8
Q
FSGS nephropathy : nephrotic or nephritic ?
A
Nephrotic
9
Q
HBV renal disease : associated with which nephropathy ?
A
Membranous, MPGN, polyarteritis nodosa (PAN)
** 1-5% of patients with HBV develop PAN
Clinically pre renal AKI
10
Q
HCV renal disease : how are the labs ?
A
MPGN +/- cryo
Classically low C4 (but not always) and high RF
11
Q
HCV renal disease : MPGN +/- cryoglobulinemia : what is the clinical presentation ?
A
nephritic/proliferative picture, palpable purpura, arthralgias, weakness, peripheral neuropathies
12
Q
Henoch-Schönlein purpura : what is the presentation ?
A
SYSTEMIC IgA vasculitis with arthritis, purpura, GI symptoms
13
Q
Hepato renal syndrome : hematuria or proteinuria ?
A
Neither or minimal
Tubular function is preserved
14
Q
High K foods to watch out for ?
A
Fruits : oranges, tropical fruits
Avocado, tomato, potatoes
beans, green leafy vegetables
nuts/seeds/milks
15
Q
High PO4 foods to watch out for ?
A
Dairy : cheese, milk
Protein : shellfish, liver, deli meats
16
Q
How are the electrolytes in rhabdomyolysis ?
A
HyperK and hyperPO4
HypoCa
Uricemia
Metabolic acidosis
17
Q
How can you start metformin to a CKD patient ?
A
OK if GFR > 30
eGFR 30-44 : initiate at 1/2 dose and titrate upwards to half of max recommended dose
18
Q
How do you deal with hyperkaliemia for CKD-Db patients on ACE / ARB ?
A
Accept up to 20% rise of creatinine within 4 weeks
Consider K binder before altering RASi dose + dietary change
19
Q
How do you diagnose hepatorenal syndrome ?
A
Discontinue diuretics / antihypertensives and give albumine 1g/kg and you will not see an improvement
20
Q
How do you diagnose post streptococcal / infectious GN ? What labs?
A
LOW C3 and N C4
+ ASOT 70%
+ anti DNase B 90%
21
Q
How do you treat hypocalcemia in CKD ?
A
Calcium carbonate and calcitriol (1,25 vit D)
Can’t use vitamin D if hyperphosphatemic
22
Q
How do you treat IgA nephropathy ?
Name 3 points.
A
- ACEi or ARB if proteinuria > 0.5g/d, titrate to proteinuria < 500mg-1g/d
- Adequate BP control (SBP < 120)
- Consider steroids x 6 months if high risk of progressive CKD (refractory proteinuria >0.75-1g despite tx with RAASi x 90d)
23
Q
How do you treat nephrotic syndrome ?
A
- Edema : Na restriction + loop diuretics
- DLP : statins, diet
- Proteinuria : ACEi, BP control (SGLT2 NOT studied)
- Thombosis : consider full dose anticoag w warfarin if certain criterias
Definitive management with immunosuppresion in most 1e cases
24
Q
How does post streptococcal / infectious GN present ?
A
Varies from:
- Microscopic hematuria
- Proliferative GN : red/brown urine, proteinuria, edema, HTN, AKI
25
How is calcemia in rhabdomyolysis ?
Hypocalcemia
26
How is the complement in cholesterol emboli syndrome ?
Low C3/C4
27
How is urine sodium in hepatorenal syndrome?
Na U < 10
28
How long do you give cyclophosphamide in anti GBM therapy ?
2-3 months
29
How long do you give steroids in anti GBM disease ?
6 months usually
30
How much proportion of albuminuria is normal ?
Generally, minimum 50% proteinuria is albumin
31
How should you manage anticoagulants for a kidney biopsy ?
- Warfarin
- IV heparin
- LMWH
- DOAC
STOP ANTIPLATELET 5 DAYS before and resu;e 5 DAYS after biopsy
- Warfarin : allow INR < 1.5, bridge depends on patient
- IV heparin : stop 6h prior and allow aPTT to N, resume 12-24h later
- LMWH : stop the day prior and resume 48-72h later
- DOAC : no data
32
How should you manage antiplatelets for a kidney biopsy ?
Stop antiplatelets 5 days before and resume 5 days post biopsy
Research shows that no increased bleeding with continuing ASA
33
Hyaline cast : etiology ?
RBC cast : etiology ?
Granular cast : etiology ?
Tamm Horsfall : etiology ?
Hyaline cast in CKD
RBC cast in GN
Granular cast in ATN
Tamm Horsfall is normal
34
In case of ANCA vasculitis : treatment of induction ?
- Methylprednisolone up to 1g x 3 days
- + Cyclophophamide or rituximab
RPGN and creat > 354 : cyclo preferred
Ritux preferred if men/women wanting preserved fertility, frail older adults, relapsed disease, no RPGN
35
Is drug related acute interstitial nephritis dose dependent ?
Not a dose dependent effect
36
Landmark trials :
- Is accelerated renal replacement therapy associated with lower risk of death ?
- Is postponing of RRT associated with benefits ?
- No not associated with lower risk of death at 90 days
- No longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm
37
Management of GN disorders : what to advise concerning diet ?
Na < 2g
Heart healthy
**Adequate protein if nephrotic range proteinuria (0.8-1g/kg/d)
38
Membranous nephropathy : nephrotic or nephritic ?
Nephrotic
39
Minimal change nephropathy : nephrotic or nephritic ?
Nephrotic
40
MPGN (membro proliferative), what are the complement values ?
LOW C4 and normal C3 (but can be low too)
41
MPGN : underlying etiology ?
HCV, HIV, cryos
Other infection, complement dysregulation, monoclonal gammapathies
AI disorders, TMS, APLS, sicke cell, polycythemia
42
Nephritic syndrome : typical etiology if..
- Low C3 ?
- Low C4 ?
- Low C3 and C4 ?
- Normal complement ?
C3 : post streptococcal/infectious GN
C4 : MPGN
C3/C4 : SLE
Normal : IgA
43
Nephritic syndrome and low C3 / C4 : etiology ?
SLE most common
44
Nephritic syndrome and LOW C4 : etiology ?
MPGN : membrano proliferative
Multiple etiologies : HCV, HIV, cryo, infections, complement dysreg, AI…..
45
Nephritis syndrome and LOW C3 : diagnosis ?
Post streptococcal / infectious GN
46
SLE nephritis : treatment principles for class III/IV ?
- Hydroxychloroquine for all
- Induction with steroids (IV pulse x 3 days then pred)
- ADD CYC or MMF
(Choose MMF if at risk of infertility / fertility consideration or Asian/African/Hispanic ancestry)
- ACEi for proteinuria
Maintenance with same agent to induce unless CYC : MMF or ASA
47
SLE nephritis : treatment principles for class V ?
Hydroxychloroquine for all
ACEi/ARB for proteinuria and good BP control
Statin
If nephrotic range proteinuria : add glucocorticoid + 1 of MMF/ASA/CYC/Ritux/ASA/Cnl
48
SLE nephritis type V and progressive renal dysfunction : what should you R/O ?
R/O renal vein thrombus with renal US
Consider repeating renal biopsy (possible concurrent class)
Need additional immunosuppresion
49
TARGETS IN CKD :
- K
- HCO3
- PO4 / Ca
- PTH
- K < 5
- HCO3 > 22
**RCT evidence to slow decline in GFR
- PO4 and Ca toward normal range
- PTH target unknown for pre dialysis CKD
PTH target for dialysis patients is 2-9 x ULN
50
TARGETS IN CKD : Hb ?
Hb 100-110 with tsat > 30 %
51
What are 3 causes of + blood on dipstick with negative erythrocytes ?
Rhabdomyolysis, hemolysis, mechanical valve
52
What are 4 causes of ketones on urinalysis dipstick ?
Starvation
DKA
Alcohol
Poisoning
53
What are common drugs causing acute interstitial nephritis ?
« ANTI »
- inflammatory : NSAIDs, COX 2 i
- biotics : penicillins, cephalo, rifampin, cipro, septra
- gout : allopurinol
- acid : PPI’s
- edema : loop and thiazides
- immunotherapy
54
What are secondary causes of FSGS ?
Infx : HIV, parvo 19, EBV
Drugs : heroin, pamidronate…
HYPERFILTRATION with obesity, single kidney, reflux nephropathy
55
What are secondary causes of membranous nephropathy ? Name 5 causes.
SLE
CANCER solid tumors > heme (CLL)
Drugs : NSAIDs, anti TNFs
Sarcoidosis
Infection : HBV, HCV, syphilis, HIV
56
What are secondary causes of minimal change nephropathy ?
Heme cancer : HODGKINS, leukemia
Drugs : NSAIDs, COX2i
Infections rare like TB
57
What are the antibodies in EGPA ?
p ANCA / anti MPO in 40 %
58
What are the antibodies in MPA ?
P ANCA and C ANCA
59
What are the antibodies positive in GPA ?
C ANCA / anti PR3 in 80 %
60
What are the CI to a kidney biopsy ?
UTI, uncooperative pt, bleeding diathesis
Uncontrolled HTN, poor visualization
Infection
RELATIVE : solitary kidney, hydronephrosis, small kidneys
61
What are the clinical features of ANCA vasculitis ?
Constitutional sx
Arthalgies, rash
Sinusitis, asthma, pulmonary hemorrhage
Nephritis
Mononeuritis multiplex
62
What are the diagnostic level for albuminuria in diabetes ?
Microalbuminuria :
Urine dipstick for protein -
ACR 2-20 mg/mmol
30-300mg/d on 24 h collection
Overt nephropathy :
Urine dipstick for protein +
ACR > 20
> 300mg/day on 24h collection
63
What are the different types of hepato renal syndromes ?
Type 1 HRS : two fold increase in creat to a level > 221 umol/L over less than 2 weeks
Type 2 HRS : gradual kidney decline with ascites refractory to diuretics
64
What are the DLP recommendations in case of CKD ?
Age ≥ 50 years and non dialysis eGFR < 60 or ACR > 3 : STATIN
65
What are the grades of albuminuria ?
Grade I : ACR < 3
Grade II : ACR 3-30
Grade III : ACR > 30
66
What are the indications of iron in CKD ?
IRON STUDIES IF HB < 100
Ferritin ≤ 500, Tsat ≤ 30 %
Prefer IV iron if feasible
67
What are the indications of urgent dialysis ? AEIOU
Acidosis (severe)
Electrolyte problems (hyperK)
Intox : methanol, ethylene glycol, Li, ASA
Overload
Uremia (pericarditis, encephalopathy/seizures)
68
What are the indications to start non steroidal MRA (finerenone) in CKD patients ?
For DM2, GFR > 25, normal K, albuminuria ≥ 30mg/g ( ≥ 3 mg/mmol) despite max RASi
69
What are the lab findings in cholesterol emboli syndrome ?
Urine eosinophils
Elevated ESR
Peripheral eosinophilia
Decreased C3/C4
70
What are the main 4 CATEGORIES of nephrotic syndrome on the algorithm ?
- Minimal change
- FSGS
- Membranous
- Other / nodular (amyloid / MGRS / db)
71
What are the risks of kidney biopsy ?
Bleeding (hematuria is expected), pain at site
1% need for transfusion
< 1% need intervention to control bleeding
0.06% death
72
What are the SGLT2 and GLP1 that have shown reduced MACE in Db and CKD ?
SGLT2 : empa and cana
GLP 1 : liraglutide, semaglutide
73
What are the three causes of acute interstitial nephritis ?
- Drugs #1 cause
- Infections
- Systemic illnesses : the S’s : SLE, sarcoid, Sjogren, IgG4 disease
74
What are the THREE conditions on the algorithm, typical of nephritic syndrome ?
- Anti-GBM / Goodpasture
- ANCA (GPA, EGPA, drugs, microscopic poluyangiitis, rarely infection)
- Immune complex
LOW COMPLEMENT : infection, malignancy, MPGN, SLE…
NORMAL COMPLEMENT : IgA, some monoclonal diseases
75
What causes AKI in amyloid patients ?
Fibril deposition
Congo red positive + nephrotic range proteinuria
76
What causes AKI in Waldenstrom patients ?
Hyperviscosity
77
What do you do with SGLT2 when you reach dialysis ?
Continue until dialysis or transplant
78
What does SGLT2 prevent in CKD ?
Prevent composite of decline in eGFR,progression to ESRD, kidney death, all cause mortality, non fatal MI, hosp for HF (CCS 2022)
79
What ethnicity linked to IgA nephropathy ?
Asians > Caucasians, rare if African descent
80
What if PTH is >9x ULN in dialysis patients ?
- Calcitriol but only if PO4 and Ca are not high
- Cinecalcet (calcimimetic, activates Ca-sensing receptor to shut off PTH secretion)
- Surgical parathyroidectomy in selected patients
81
What is generally the acceptable GFR for biphosphonates ?
eGFR 30-35
82
What is IgA nephropathy associated with ?
Celiac disease, AI disease, hepatitis, HIV, cirrhosis …
83
What is the acid base disorder seen in rhabdomyolysis ?
Metabolic acidosis
84
What is the antibody in primary membranous ?
PLA2R and THSD7A
85
What is the BP target for IgA nephropathy ?
SBP < 120
86
What is the BP target of GN disease patients ?
Target < 120 if safe (no HTO, not frail…)
87
What is the BP target before a kidney biopsy ?
Should be controlled < 160 pre biopsy
88
What is the clinical picture of nephrotic syndrome ?
- Nephrotic range proteinuria > 3.5g
- Edema
- Hypoalbuminemia
- DLP and lipiduria
89
What is the clinical presentation of acute interstitial nephritis ?
AKI, sometimes with fever/rash
Hematuria, non nephrotic range proteinuria
Pyuria, WBC casts
Eosinophs may be increased in blood/urine (not always)
90
What is the clinical presentation of cholesterol emboli syndrome / atheroemboli disease ?
Subacute, STEP WISE decline
TAKES WEEKS
Livedo reticularis, blue toes
91
What is the clinical presentation of hepatorenal syndrome ?
Rise in serum creat with normal urine sediment
Tubular function is preserved (no/minimal hematuria or proteinuria)
Urine sodium < 10
92
What is the clinical presentation of SLE nephropathy ?
Presents as nephritic and or nephrotic
Requires bx
Elevated ds DNA
93
What is the definition of CKD per KDIGO ?
Abnormalities in either kidney structure or function for > 3 MONTHS :
- Albuminuria ACR > 3 mg/mmol
- Urine sediment abnormalities
- E+ abnormalities due to tubular disorders
- Structural abnormalities detected by imaging
- Kidney transplant hx
- eGFR < 60
94
What is the definition of Goodpasture ?
RPGN accompanied by pulmonary hemorrhage
95
What is the first line for HTN in CKD ?
ACEi or ARB first line
Diuretics if evidence of increased salt/water retention
96
What is the GFR cut off for :
EMPAgliflozin
DAPAgliflozin
CANAgliflozin
EMPA : 10 daily, GFR > 20
DAPA : 10 daily, GFR > 25
CANA : 100 daily, GFR > 30
97
What is the GFR cut off to be able to start SGLT2 ?
GFR ≥ 20
98
What is the imaging modality in case of kidney stone ?
Non contrast CT
99
What is the infectious disease associated with PAN ?
HBV
1-5% patients with HBV develop PAN
100
What is the link between IgA nephropathy and infection ?
Flares with ANY infection ‘syn pharyngitic’
101
What is the maintenance therapy in ANCA vasculitis ?
- AZA or continue rituximab if induction agent
- Taper glucocorticoids (1mg/kg/d first week then taper)
No maintenance therapy in dialysis dependent pts x 3 months with no extra renal manifestations
102
What is the maintenance therapy in antiGBM disease ?
No maintenance therapy
103
What is the management of hyperPO4 in CKD ?
Target NORMAL PO4
Low PO4 diet
Oral phosphate binders WITH meals
- TUMS / calcium carb 1s line
avoid if hyperCa, adynamic bone disease, vascular calcification
- non Ca containing : sevelamer
104
What is the management of post streptococcal/infectious GN ?
Supporte care
Diuresis if edema
Tx infection if still active
Resolves in 3-4 weeks
Bx ONLY if considering other glomerular disorders or varies from typical trajectory
105
What is the most common GN worlwide ?
IgA nephropathy
106
What is the most common primary nephrotic syndrome ?
Membranous most common overall
FSGS most common in african/american
107
What is the nephropathy associated with HCV ?
MPGN +/- cryoglobulinemia
– Classically low C4 (but not always); high RF
– Clinically: nephritic/proliferative picture, palpable purpura, arthralgias, weakness, peripheral neuropathies
108
What is the pathophysio of AKI with ACEi/ARB ?
Failure of efferent arteriole to constrict if volume contracted
Usually concomitant hx of poor PO intake and/or GI losses
109
What is the pathophysio of AKI with NSAIDs ?
Prostaglandin inhibition : constriction of afferent arteriole (mechanism of pre renal)
110
What is the pre immunosuppresion workup in GN disease ?
TBST, Hep serologies, HIV
Strongyloides if endemic risk
111
What is the presentation of IgA nephropathy ?
Various : microscopic hematuria, gross hematuria, proteinuria, RPGN or nephrotic syndrome
**** CAN MIMIC nephrolithiasis presentation
**** FLARES with ANY infection (syn pharyngitis)
112
What is the prognosis of IgA nephropathy ?
Dependent on degree of proteinuria and HTN control
- < 0.5 g/d : low risk of progression
- overt proteinuria and/or high Cr : progression to ESRD 15-25% at 10 years
113
What is the PTH target in CKD management ?
Unknown for pre dialysis CKD
2-9x ULN for dialysis patients
114
What is the risk of osteoporosis drugs in CKD patients ?
Beware of the risk of severe hypocalcemia with biphosphonates or denosumab in CKD
115
What is the signification of epithelial cells on urinarlysis microscopy ?
Squamous : contamination
Renal tubular epithelial : ATN
Transitional : ureters
116
What is the target Hb while on ESA for CKD ?
No higher than 115 as associated with stroke, CAD, HTN
117
What is the timing of acute interstitial nephritis ? (when does is occur)
1 weeks to weeks / months following
If previous exposure to drug, can occur sooner
118
What is the timing of cholesterol emboli syndrome ?
- IRA en 1-2 semaine post athéroembolie massive péri-procédure
OU
-IR progressive en palier d’escaliers dont le pic est 3-8 semaines post-procédure secondaire à embolies continues ou avec occlusion incomplète (réaction inflammatoire et atrophie ischémique)
119
What is the timing of contrast induced nephropathy ? How long for it resolve?
1-3 days post contrast load
Most self resolve in 1-2 weeks
120
What is the treatment for PRIMARY minimal change or FSGS nephropathy ?
STEROIDS
121
What is the treatment of acute interstitial nephritis ?
Remove offending agent
Is severe renal failure : often biopsy and consider empiric glucocorticoids
122
What is the treatment of anti GBM disease ?
- Pulse corticosteroids x 6 months
- Cyclophosphamide x 2-3 months
- Plasma exchange (until titers are no longer detectable)
Then no maintenance therapy
Exceptions: conservative tx if 85-100% crescents, no pulm hemorrhage, tx w dialysis at presentation (risk of immunosuppresion > benefits as ESRD already)
123
What is the treatment of HIV associated nephropathy ?
HAART and RAS blockade
124
What is the treatment of rhabdomyolysis ?
IV fluids (diuresis 200cc/h)
Management of electrolytes but DO NOT treat hypocalcemia
125
What is the tx of hepatorenal syndrome ?
Stop diuretics, restrict sodium and water
Tx with albumin + vasoconstrictor (terlipressin not available, midodrine + octreotide)
Liver transplant or TIPS
126
What is the typical mimicker of IgA nephropathy ?
Nephrolithiasis presentation
127
What is the typical presentation in PAN nephropathy ?
Renal infarcts
128
What is the typical presentation of HIV associated nephropathy ?
COLLAPSING FSGS
Black males, advanced HIV (CD4<200), nephrotic, high Cr
129
What is the volemic state goal before giving contrast? Precaution if CKD ?
Ensure euvolemia : 3 ml/hg/hr 1 hour before procedure, 1ml/kg/hr 6 hours after procedure for CKD
130
What is your proteinuria target in IgA nephropathy ?
Titrate ACEi or ARB to proteinuria < 500mg-1g / day
131
What is the proteinuria goal in CKD ?
< 500 mg - 1g/d with ACEi/ARB
DM2 : proteinuria as low as possible
132
What medication is often given to prevent bleeding during a kidney biopsy ?
DDAVP
133
What should you advise concerning smoking in glomerular disease ?
SMOKING CESSATION FOR ALL
134
What should you monitor annually if patient on metformin for 4 + years ?
B12 annually
135
What will multiple myeloma do on urine dipstick ?
Proteinuria +
Glycosuria + if tubular dysfunction
136
What will you see on urine microscopy if ATN ?
Muddy brown cast
137
What will you see on urine microscopy if nephritic syndrome ?
RBC casts and dysmorphic RBC
138
What will you see on urine microscopy if nephrotic syndrome ?
Oval fat bodies or fatty casts
139
When does post streptococcal / infectious GN occur?
2-3 weeks post infection (strep throat, strep cellulitis, chronic abscess, endocarditis …)
140
When is ESA indicated in CKD ?
If Hb < 100 and iron replete or after trial : eprex or aranesp
141
When is SGLT2 indicated in CKD ? What are the pre requisite ?
Indicated for ALL CKD
+/- diabetes, eGFR ≥ 20, ACR > 20 mg/mmol
142
When should CKD patients be screened for Hep C ?
At diagnosis of CKD and at time of initiation of renal replacement therapy
All patients should be evaluated for HCV
143
When should you consider biopsy with a nephrotic syndrome ?
Bx usually required for diagnosis
UNLESS PLA2R antibody + normal renal function, can forego bx but still screen for 2 causes
144
When should you consider prophylactic full dose anticoagulation in nephrotic syndrome ?
Name 6 reasons.
Warfarin if albumin < 20-25 AND any of :
- BMI > 35
- Inherited thrombophilia
- NYHA 3-4
- Prolonged immobilization
- Proteinuria >10g/d
- Recent ortho or abdo surgery
If high bleeding risk : suggest ASA 81mg instead
145
When should you consider steroids in IgA nephropathy ?
Steroids x 6 months if high risk of progressive CKD (refractory proteinuria > 0.75-1g despite optimal medical therapy with RAAASi x 90d)
146
When should you introduce ACE or ARB for DM/CKD patients ?
If HTN + albuminuria
Consider for albuminuria without hypertension
147
Which agent should you choose if anticoagulation is indicated in nephrotic syndrome ?
Warfarin
DOAC not studied and protein bound : not ideal in hypoalbuminemia
148
Which condition is characterized by nephritic syndrome and normal complement ?
IgA
149
Which nephropathy is associated with anti TNFs ?
2nd membranous
150
Which nephropathy is associated with HIV ?
FSGS
151
Which nephropathy is associated with Hodgkins ?
2nd minimal change
152
Which nephropathy is associated with NSAIDs ?
2nd minimal change
2nd membranous
Also possible : AIN, ATN, pre renal
