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Les deux ennemis > Nephro : HTN/lumps/nephrolithiasis > Flashcards

Nephro : HTN/lumps/nephrolithiasis Flashcards

1
Q

ADPKD : affects x live births ?

A

1/1000

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2
Q

Are ACEi or ARB contraindicated with bilateral renal artery stenosis ?

A

No but caution at initiation, close K and Cr follow up

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3
Q

Diabetes and HTN : if combinaison with ACEi needed, which agent should you choose ?

A

DHP CCB preferred over thiazide
If high K, long acting thiazide-like diurectic would be appropriate

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4
Q

Diagnosis algorithm for HTN dx : what value is diagnosis of HTN in office ?

A

mean office BP ≥ 180/110

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5
Q

Does SGLT2 is used specifically to reduce BP in HFrEF patients ?

A

No
To reduce sx, risk of hospitalizations, CV death

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6
Q

How can you suspect HTN at your office ?

What if the patient is diabetic ?

A

AOBP ≥ 135/85 or OBPM ≥ 140/90

If diabetic : OBPM ≥ 130/80

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7
Q

How can you suspect HTN in case of diabetes at your office ?

A

OBPM ≥ 130/80 for ≥ 3 measurements on differents days -> PROBABLE HTN

Then do out of office measurements

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8
Q

How do you diagnose HNT if outpatient reading is not available ?

A

Visit 2 : dx if mean BP ≥ 140/90 WITH macrovascular disease, CKD, DM2
Visit 3 : dx if mean BP ≥ 160/100
Visit 5 : dx if mean BP ≥ 140/90

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9
Q

How do you screen for hyperaldosteronism ?

A

Plasma aldosterone and plasma renin activity or concentration

If positive do confirmatory test with
- Saline loading test (2L NS over 4h, mesure plasma aldo afterward, abN if > 280 pmol/L)
- Captopril suppression test

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10
Q

How do you screen for pheochromocytoma ?

A

24h urine total metanephrines and catecholamines (+ creat U)
Maybe plasma free metanephrines and free normetanephrines may be considered
NOT urinary VMA (Vanillylmandelic acid)

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11
Q

How do you treat cystine nephrolithiasis ?

A

Urine alkalinisation (K citrate)

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12
Q

How do you treat hypertensive emergency ?

A
  • Lower BP by 20-25% ONLY within first 1-2 hours
    (then to 160/100 over the next 2-6 hours then gradually to normal over few days)
  • IV medication : labetalol, esmolol, nicardipine, hydralazine, nitroglycerin
  • Transition to PO medication and transfer to ward
  • Consider work up of secondary HTN
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13
Q

How do you treat struvite nephrolithiasis ?

A

Treat UTI

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14
Q

How do you treat uric acid nephrolithiasis ?

A
  • Urine alkalinizaion (K citrate)
  • Allopurinol

Increase oral fluids for urine output > 2L/d

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15
Q

How do you treat UTI for a ADPKD patient ?

A

4 weeks if infected cyst

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16
Q

How is ADPKD diagnosed ?

A

By unified criteria based on family history and US imaging
- If age 15-39 ≥ 3 cysts total
- If age 40-59 ≥ 2 cysts per kidney

No validated criteria in absence of family history

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17
Q

How is renovascular HTN managed ?

A

Atherosclerotic RAS managed medically (no benefit in stenting)
Angioplasty and stenting to consider if ANY of the following :
- Uncontrolled HTN resistant to max tolerated pharmacotherapy (ex: starting 4th drug)
- Progressive renal function decline
- Acute pulmonary edema

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18
Q

How many measurements should you take with AOBP technique for BP measurement ?

A

3-6 measurements, at least 1-2 min between measurements

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19
Q

How often should you do follow up for HTN patients ?

A

If no HTN, no evidence of target organ damage : BP assessed yearly

If tx HTN with medical therapy : q1-2 months until 2 consecutive readings with BP < targets, them q3-6 months

If HTN using non pharm tx : q3-6 months

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20
Q

How often should you do follow up imaging in ADPKD patients ?

A

Should not exceed a frequency of once yearly

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21
Q

How should you screen for renovascular HTN ?

A

Any of : renal doppler US, captopril renogram, MRA, CTA

Avoid captopril and CTA if GFR < 60

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22
Q

How should you take BP at home with HBPM ?

A

Measure twice in AM and twice in PM for 7 days. Discard day 1 and average other values

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23
Q

How to work up for fibromuscular dysplasia ?

A

CTA or MRA

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24
Q

HTN treatment : what to choose between long-acting thiazide (chlorthalidone) and HCTZ?

A

Thiazide like diuretics / chlorathalidone preferred over HCTZ

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25
Q

Hypertensive emergency and cocaine, which drug ?

A

IV phentolamine + benzodiazepines
Practically if phentolamine hard to source : labetalol both alpha + bb

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26
Q

Hypertensive emergency and dissection, which drug ?

A

IV BB to lower HR first, then nitroglycerin

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27
Q

Hypertensive emergency and MI/CHF, which drug ?

A

IV nitroglycerin
No IV yet : give 3 sprays of nitro to get started

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28
Q

Hypertensive emergency and pre eclampsia, which drug ?

A

IV labetalol or hydralazine
CHEW IR nifedipine 5mg capsule

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29
Q

Hypertensive emergency and scleroderma renal crisis, which drug ?

A

IV enalaprilat or captopril

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30
Q

In case of CAD, what is the first line agent to treat HTN ?

A

ACE or ARB 1st line
BB, CCB

ACEi + DHP-CCB recommended over ACEi + thiazide

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31
Q

In case of ischemic stroke, what is the long term preferred agents ?

A

Combination ACEi and thiazide preferred 1st line
Target <140/90 within a few days to 1 week

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32
Q

In case of recent MI, what is the first line agent to treat HTN ?

A

Both BB and ACEi

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33
Q

Once fibromuscular dysplasia is confirmed, what is the next step in management ?

A

Screen vasculature from head to pelvis with either CTA or MRA (cervicocephalic lesions, intracranial aneurysms, lesions in other vascular beds)

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34
Q

Once you have diagnosed hyperaldosteronism, what is the next step in management ?

A

If hyperaldosteronism, definite adrenal mass and eligible for surgery : adrenal vein sampling to assess lateralization of aldosterone hypersecretion

Then adrenalectomy

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35
Q

Waist circumferences that can prevent HTN ?

A

< 102cm for M, < 88 for F

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36
Q

What are COMMON symptoms of ADPKD ?

A
  • HTN
  • PAIN (abdo pain with cyst rupture)
  • Hematuria, proteinuria
  • STONES (uric acid +++, Ca oxalate)
  • UTI (infected cyst)
  • Concentrating deficit : thirt, polyuria, polydipsia, nocturia
  • Erythrocytosis
  • Extra renal manifestations : cerebral aneurysms, pancreatic cyts, diverticuli, liver cysts
    Mitral valve prolapse / AI
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37
Q

What are the considerations in using ACEi monotherapy as first line therapy for HTN ?

A

Do not use in black patients without other indications
Careful NOT first line in isolated systolic HTN!

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38
Q

What are the diagnostic values of 24h Ambulatory BP monitor (ABPM) for a patient without diabetes?

A

≥ 135/85 if daytime
≥ 130/80 if 24 hour

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39
Q

What are the drugs that interfere with plasma aldost/renine ?
Which drugs should you stop ?

A

MRAs > ACEi/ARB&raquo_space; BB, CCB
Hold MRA, K sparing and K wasting diuretics at least 4 weeks prior to testing
If result non diagnostic, hold ACEi/ARB, BB, DHP-CCB 2 weeks and repeat testing

BP meds that do not interfere : alpha blockers, non DHP CCBs, hydralazine

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40
Q

What are the extra renal manifestations of ADPKD ?

A

Cerebral aneurysms
Liver cysts, diverticuli, pancreatic cysts
Mitral valve prolapse / AI

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41
Q

What are the first line drugs to treat HTN in case of non diabetic CKD with proteinuria ?

A

ACEi (ARB if intolerant)
Thiazide for additive therapy if necessary
If volume overload, can use loop instead

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42
Q

What are the most common cardiac anomalies in ADPKD ?

A

Mitral valve prolapse / AI

43
Q

What are the stones found in ADPKD ?

A

Uric acid stones ++
Ca oxalate

44
Q

What are the thresholds for HTN diagnosis with out of office measurements ?

A

ABPM : daytime mean ≥ 135/85, 24h mean ≥ 130/80

or

HBPM series : means ≥ 135/85

45
Q

What disease is associated with calcium phosphate nephrolithiasis ?

A

Type 1 RTA
HyperPTH

46
Q

What disease is associated with struvite nephrolithiasis ?

A

UTI
Proteus, Klebsiella

47
Q

What disease is associated with uric acid nephrolithiasis ?

A

Heme disorders
ADPKD

48
Q

What imaging modality is used for Bosniak classification ?

A

CT with contrast
But can also classify based on US

49
Q

What is an adequate cuff bladder size for BP measurement ?

A

width 40% of arm circ, length 80-100% of arm circumference

50
Q

What is the BP target for diabetes ?
What is the BP threshold for pharm tx ?

A

Target < 130 / 80
Start pharm tx if SBP ≥ 130 DPB ≥ 80

51
Q

What is the BP target for high risk patients ?
What is the threshold for pharm tx ?

A

Target SBP < 120
Tx if SBP ≥ 130

52
Q

What is the BP target for low risk patients ?
(= no end organ damage or low CV risk)

What is the threshold for pharm tx ?

A

BP target < 140 / 90

Start tx if SBP ≥ 160 DBP ≥ 100

53
Q

What is the BP target for moderate-high risk patients ?
(= end organ damage )

What is the threshold for pharm tx ?

A

Target < 140 / 90
Tx if SBP ≥ 140 DBP ≥ 90

54
Q

What is the BP target if history of spontaneous ICH ? (chronic management)

A

130/80

55
Q

What is the BP target in acute post ischemic stroke with OR without thrombolysis ?

A

WITH thombolysis < 185/100
WITHOUT thombolysis < 220/120

56
Q

What is the BP target in ADPKD ?

A

≤ 110 / 75
if 18-50y with eGFR > 60 and without significant CV morbidities

57
Q

What is the BP target in case of CKD ?

A

< 120 if SPRINT candidate (non DM, proteinuria <1g, non HD, not transplant)
< 130/80 if diabetic

** however KDIGO 2021 : SBP < 120 for all CKDs and up titrate ACE/ARB as high as tolerated

58
Q

What is the BP target in case of hemorrhagic stroke ?
- Acute
- Chronic

A

Acute goal < 140-160 for first 24-48h
Use IV agents to reduce BP acutely, check BP q15min until you achieve target and monitor closely
Chronic < 130/80

59
Q

What is the BP target in case of ischemic stroke (chronic management) ?

A

< 140 / 90

60
Q

What is the BP target in case of polycystic kidney disease ?

A

< 110/75

61
Q

What is the BP target in pregnancy ?

A

DBP < 85
Start tx if SBP > 140 or DBP > 90

62
Q

What is the BP target post renal transplant ?

A

< 130/80

Use DHP-CCB or ARB first line

63
Q

What is the definition of HIGH RISK patient / SPRINT TRIAL candidate ?

A

> 50 age AND SBP 130-180 AND one or more of the following :
- Clinical or subclinical cardiovascular disease
- CKD (non diabetic, proteinuria < 1g/d, GFR 20-60 ml/min)
- Estimated 10y global cardiov risk ≥ 15%
- Age ≥ 75

64
Q

What is the first line for diabetes and HTN ?

A

ACEi or ARB 1st line for CV disease or risk factors, CKD/microalbuminuria
Otherwise DHP CCB, thiazide also 1st line

65
Q

What is the follow up necessary for Bosniak 2F lumps ?

A

Needs active surveillance, repeat imaging at 6mo, 12mo then yearly

66
Q

What is the lifestyle tx of HTN ?

A
  • Exercice 30-60 min 4-7d/w
  • Weight loss
  • ROH : reducing to < 2 drinks per day to PREVENT HTN
  • BP diet : DASH diet
  • Consider increasing potassium intake if not at risk of hyperk
  • Salt ≤ 5g/day or ≤ 2g sodium
  • Stress reduction
  • Smoking cessation
67
Q

What is the management of angiomyolipoma on kidney ?

A

No further w/u needed

68
Q

What is the management of solid renal mass ?

A
  • < 1 cm : active surveillance
  • > 1 cm : vast majority are cancer
    Use CT or MRI
    Check for metastases
    If life expectancy > 5 y, partial nephrect
    If life expectancy < 5 y or not fit : active survaillance, thermal ablation….

If clearly angiomyolipoma : no further w/u

69
Q

What is the most common nephrolithiasis ?

A

Calcium oxalate

70
Q

What is the nephrolithiasis that is radiolucent ?

A

Uric acid
All the other ones : radio opaque

71
Q

What is the radiologic description of a Bosniak 1-2 lump ?
(wall, calcification, septae…)

A

Simple cyts with thin walls, no or fine calcifications, no or thin septae, no enhancement
NO NEED to follow up

72
Q

What is the radiological description of a Bosniak 3 and 4 lump ?

A

One or more ENHANCING thick or irregular walls or septa
Bosniak 4 also have a solid enhancing nodule

73
Q

What is the radiological description of Bosniak 2F lump ?

A

Smooth, minimally thickened wall
May have multiple septa, but smooth without contrast enhancement

74
Q

What is the risk of cancer depending on Bosniak classification ?

A

Bosniak 1-2 : < 5%
Bosniak 2F : 10 %
Bosniak 3 : 50 %
Bosniak 4 : 90 %

75
Q

What is the risk of cancer in case of a Bosniak 1-2 lump in the kidney ?

A

< 5%
Unless 2F : 10 %

76
Q

What is the risk of cancer in case of a Bosniak 3 lump in the kidney ?

A

50 %

77
Q

What is the risk of cancer in case of a Bosniak 4 lump in the kidney ?

A

90%

78
Q

What is the signification of nocturnal dip in HTN ?

A

Nocturnal dip : > 10 % drop
If no nocturnal dip, associated with increased risk of CV events

79
Q

What is the treatment of ADPKD ?

A
  • Sodium restriction < 2g/day
  • High fluid intake
  • 18-50y with eGFR > 60 and without significant CV morbidities : target BP of ≤ 110/75
  • Tolvaptan therapy for specific patients
80
Q

What is the treatment of calcium phosphate nephrolithiasis ?

A
  • Decrease Na and meat intake
  • Thiazides

Increase oral fluids for urine output > 2L/d

81
Q

What is the tx of calcium oxalate nephrolithiasis ?

A
  • Decrease Na and meat intake
  • Oxalate restriction / limit vitamin C
  • Thiazides (if no hypercalcemic)
  • Do not limit Ca intake as would worsen oxaluria

Increase oral fluids for urine output > 2L / days

82
Q

What is the urine pH usually with calcium oxalate nephrolithiasis ?

A

Variable

83
Q

What kind of CCB should you avoid if patient already on BB ?

A

Avoid combination of non-DHP CCB + BB
Risk of bradycardia

84
Q

What nephrolithiasis is associated with Crohn’s / ileal disease ?

A

Oxaluria (calcium oxalate)

85
Q

What nephrolithiasis is associated with type 1 RTA and hyperPTH ?

A

Calcium phosphate

86
Q

What nephrolithiasis is commonly seen in context of UTI / proteus / klebsiella ?

A

Struvite

87
Q

What nephrolithiasis is seen in congenital autosomal recessive disease ?

A

Cystine

88
Q

What type of nephrolithiasis if commonly seen in ADPKD ?

A

Uric acid

89
Q

When should you do a work-up for fibromuscular dysplasia in HTA ?

A

Work up if HTN and ONE OF MORE :
- Kidneys asymmetrical (>1.5cm difference)
- Abdominal bruit but no atherosclerosis risk factors
- Confirmed FMD in another vascular bed
- Family hx of FMD

90
Q

When should you NOT use plasma renin concentration as risk of false positive ?

A

Women on OCP
OCP affects Renin concentration but not the Renin activity (what is measured)

91
Q

When should you use BB to treat HTN as first line therapy ?

A
  • First line only if < 60 y old
  • Usually for diastolic HTN +/- systolic hypertension
    Not in table for isolated systol HTN

***- AVOID BB in LVH
But if LV systolic dysfunction EF < 40% : 1st line is BB and ACEi/ARB

92
Q

When should you use tamsulosin for nephrolithiasis ?

A

Tamsulosin for stones 0.6 - 1 cm may help clear

93
Q

Which Boskinal lump should be referred for partial nephrectomy?

A

Bosniak 3 and 4

94
Q

Which cysts need follow up based on Bosniak classification ?

A

Bosniak 2F, 3 and 4

95
Q

Which kind of ADPKD progresses faster ?

A

PDK1 progresses faster than PKD2

96
Q

Which nephrolithiasis are associated with acidic urine pH ?

A

Uric acid < 5
Cystine < 6.5

97
Q

Which nephrolithiasis can be treated with thiazides ?

A

Calcium oxalate and calcium phosphate

98
Q

Which nephrolithiasis do you treat with urine alkalinization ?

A

Uric acid and cystine
Those are the two stones that have an acidic urine pH (< 5 and < 6.5)

99
Q

Who are the patients excluded from SPRINT study ?

A

Diabetes
History of stroke
GFR < 20
Proteinuria > 1g/d, GN, PKD

Also CI : standing SBP < 100, secondary HTN, life limiting disease, non adherent

100
Q

Who should you screen for hyperaldosteronism ?

A

Patients with hypertension AND 1 or more :
- Unexplained spontaneous hypoK < 3.5 or marked diuretic relatied hypoK < 3
- HTN and resistant to tx with ≥ 3 drugs
- Incidental adrenal adenoma and HTN

101
Q

Who should you screen for pheochromocytoma ?
Name 5 reasons

A
  • Paroxysmal, unexplained, labile and/or severe (≥ 180/110) sustained HTN refractory to usual therapy
  • HTN + sx of catecholamine excess
  • HTN triggered by BB, MAO-Is, surgery, anesthesia, micturition
  • Incidental adrenal adenoma
  • Hereditary causes (Von Hippel Lindau, MEN 2A oe 2B, neurofibromatosis type 1)
102
Q

Who should you screen for renovascular HTN ?

A

Patients with **2 or more of the following:
- Suddent onset or worsening HTN age > 55 or < 30
- Abdominal bruit
- HTN resistant to ≥ 3 drugs
- Increase in Cr ≥ 30% with ACEi or ARB
- Other atherosclerotic vascular disease
- Recurrent pulm edema associated w HTA emergency

103
Q

Within 72 h of ischemic stroke, how should you manage TA in case of thrombolysis ?

A

Treat if > 185/110
< 185/110 prior to giving tPA and keep below 180/105 for next 24h

TR neuro : TPA in ED is <180/105 !!!

104
Q

When should you add MRA for HTN and LV systolic dysfunction EF < 40% ?

A

1st line is BB and ACEi/aRB
MRA can be added if recent CHF exacerbation/MI, high BNP, NYHA II-IV

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