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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
Hypertensive emergency and cocaine, which drug ?
IV phentolamine + benzodiazepines Practically if phentolamine hard to source : labetalol both alpha + bb
26
Hypertensive emergency and dissection, which drug ?
IV BB to lower HR first, then nitroglycerin
27
Hypertensive emergency and MI/CHF, which drug ?
IV nitroglycerin No IV yet : give 3 sprays of nitro to get started
28
Hypertensive emergency and pre eclampsia, which drug ?
IV labetalol or hydralazine CHEW IR nifedipine 5mg capsule
29
Hypertensive emergency and scleroderma renal crisis, which drug ?
IV enalaprilat or captopril
30
In case of CAD, what is the first line agent to treat HTN ?
ACE or ARB 1st line BB, CCB ACEi + DHP-CCB recommended over ACEi + thiazide
31
In case of ischemic stroke, what is the long term preferred agents ?
Combination ACEi and thiazide preferred 1st line Target <140/90 within a few days to 1 week
32
In case of recent MI, what is the first line agent to treat HTN ?
Both BB and ACEi
33
Once fibromuscular dysplasia is confirmed, what is the next step in management ?
Screen vasculature from head to pelvis with either CTA or MRA (cervicocephalic lesions, intracranial aneurysms, lesions in other vascular beds)
34
Once you have diagnosed hyperaldosteronism, what is the next step in management ?
If hyperaldosteronism, definite adrenal mass and eligible for surgery : adrenal vein sampling to assess lateralization of aldosterone hypersecretion Then adrenalectomy
35
Waist circumferences that can prevent HTN ?
< 102cm for M, < 88 for F
36
What are COMMON symptoms of ADPKD ?
- 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
37
What are the considerations in using ACEi monotherapy as first line therapy for HTN ?
Do not use in black patients without other indications Careful NOT first line in isolated systolic HTN!
38
What are the diagnostic values of 24h Ambulatory BP monitor (ABPM) for a patient without diabetes?
≥ 135/85 if daytime ≥ 130/80 if 24 hour
39
What are the drugs that interfere with plasma aldost/renine ? Which drugs should you stop ?
MRAs > ACEi/ARB >> 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
40
What are the extra renal manifestations of ADPKD ?
Cerebral aneurysms Liver cysts, diverticuli, pancreatic cysts Mitral valve prolapse / AI
41
What are the first line drugs to treat HTN in case of non diabetic CKD with proteinuria ?
ACEi (ARB if intolerant) Thiazide for additive therapy if necessary If volume overload, can use loop instead
42
What are the most common cardiac anomalies in ADPKD ?
Mitral valve prolapse / AI
43
What are the stones found in ADPKD ?
Uric acid stones ++ Ca oxalate
44
What are the thresholds for HTN diagnosis with out of office measurements ?
ABPM : daytime mean ≥ 135/85, 24h mean ≥ 130/80 or HBPM series : means ≥ 135/85
45
What disease is associated with calcium phosphate nephrolithiasis ?
Type 1 RTA HyperPTH
46
What disease is associated with struvite nephrolithiasis ?
UTI Proteus, Klebsiella
47
What disease is associated with uric acid nephrolithiasis ?
Heme disorders ADPKD
48
What imaging modality is used for Bosniak classification ?
CT with contrast But can also classify based on US
49
What is an adequate cuff bladder size for BP measurement ?
width 40% of arm circ, length 80-100% of arm circumference
50
What is the BP target for diabetes ? What is the BP threshold for pharm tx ?
Target < 130 / 80 Start pharm tx if SBP ≥ 130 DPB ≥ 80
51
What is the BP target for high risk patients ? What is the threshold for pharm tx ?
Target SBP < 120 Tx if SBP ≥ 130
52
What is the BP target for low risk patients ? (= no end organ damage or low CV risk) What is the threshold for pharm tx ?
BP target < 140 / 90 Start tx if SBP ≥ 160 DBP ≥ 100
53
What is the BP target for moderate-high risk patients ? (= end organ damage ) What is the threshold for pharm tx ?
Target < 140 / 90 Tx if SBP ≥ 140 DBP ≥ 90
54
What is the BP target if history of spontaneous ICH ? (chronic management)
130/80
55
What is the BP target in acute post ischemic stroke with OR without thrombolysis ?
WITH thombolysis < 185/100 WITHOUT thombolysis < 220/120
56
What is the BP target in ADPKD ?
≤ 110 / 75 if 18-50y with eGFR > 60 and without significant CV morbidities
57
What is the BP target in case of CKD ?
< 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
What is the BP target in case of hemorrhagic stroke ? - Acute - Chronic
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
What is the BP target in case of ischemic stroke (chronic management) ?
< 140 / 90
60
What is the BP target in case of polycystic kidney disease ?
< 110/75
61
What is the BP target in pregnancy ?
DBP < 85 Start tx if SBP > 140 or DBP > 90
62
What is the BP target post renal transplant ?
< 130/80 Use DHP-CCB or ARB first line
63
What is the definition of HIGH RISK patient / SPRINT TRIAL candidate ?
> 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
What is the first line for diabetes and HTN ?
ACEi or ARB 1st line for CV disease or risk factors, CKD/microalbuminuria Otherwise DHP CCB, thiazide also 1st line
65
What is the follow up necessary for Bosniak 2F lumps ?
Needs active surveillance, repeat imaging at 6mo, 12mo then yearly
66
What is the lifestyle tx of HTN ?
- 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
What is the management of angiomyolipoma on kidney ?
No further w/u needed
68
What is the management of solid renal mass ?
- < 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
What is the most common nephrolithiasis ?
Calcium oxalate
70
What is the nephrolithiasis that is radiolucent ?
Uric acid All the other ones : radio opaque
71
What is the radiologic description of a Bosniak 1-2 lump ? (wall, calcification, septae…)
Simple cyts with thin walls, no or fine calcifications, no or thin septae, no enhancement NO NEED to follow up
72
What is the radiological description of a Bosniak 3 and 4 lump ?
One or more ENHANCING thick or irregular walls or septa Bosniak 4 also have a solid enhancing nodule
73
What is the radiological description of Bosniak 2F lump ?
Smooth, minimally thickened wall May have multiple septa, but smooth without contrast enhancement
74
What is the risk of cancer depending on Bosniak classification ?
Bosniak 1-2 : < 5% Bosniak 2F : 10 % Bosniak 3 : 50 % Bosniak 4 : 90 %
75
What is the risk of cancer in case of a Bosniak 1-2 lump in the kidney ?
< 5% Unless 2F : 10 %
76
What is the risk of cancer in case of a Bosniak 3 lump in the kidney ?
50 %
77
What is the risk of cancer in case of a Bosniak 4 lump in the kidney ?
90%
78
What is the signification of nocturnal dip in HTN ?
Nocturnal dip : > 10 % drop If no nocturnal dip, associated with increased risk of CV events
79
What is the treatment of ADPKD ?
- 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
What is the treatment of calcium phosphate nephrolithiasis ?
- Decrease Na and meat intake - Thiazides Increase oral fluids for urine output > 2L/d
81
What is the tx of calcium oxalate nephrolithiasis ?
- 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
What is the urine pH usually with calcium oxalate nephrolithiasis ?
Variable
83
What kind of CCB should you avoid if patient already on BB ?
Avoid combination of non-DHP CCB + BB Risk of bradycardia
84
What nephrolithiasis is associated with Crohn’s / ileal disease ?
Oxaluria (calcium oxalate)
85
What nephrolithiasis is associated with type 1 RTA and hyperPTH ?
Calcium phosphate
86
What nephrolithiasis is commonly seen in context of UTI / proteus / klebsiella ?
Struvite
87
What nephrolithiasis is seen in congenital autosomal recessive disease ?
Cystine
88
What type of nephrolithiasis if commonly seen in ADPKD ?
Uric acid
89
When should you do a work-up for fibromuscular dysplasia in HTA ?
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
When should you NOT use plasma renin concentration as risk of false positive ?
Women on OCP OCP affects Renin concentration but not the Renin activity (what is measured)
91
When should you use BB to treat HTN as first line therapy ?
- 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
When should you use tamsulosin for nephrolithiasis ?
Tamsulosin for stones 0.6 - 1 cm may help clear
93
Which Boskinal lump should be referred for partial nephrectomy?
Bosniak 3 and 4
94
Which cysts need follow up based on Bosniak classification ?
Bosniak 2F, 3 and 4
95
Which kind of ADPKD progresses faster ?
PDK1 progresses faster than PKD2
96
Which nephrolithiasis are associated with acidic urine pH ?
Uric acid < 5 Cystine < 6.5
97
Which nephrolithiasis can be treated with thiazides ?
Calcium oxalate and calcium phosphate
98
Which nephrolithiasis do you treat with urine alkalinization ?
Uric acid and cystine Those are the two stones that have an acidic urine pH (< 5 and < 6.5)
99
Who are the patients excluded from SPRINT study ?
Diabetes History of stroke GFR < 20 Proteinuria > 1g/d, GN, PKD Also CI : standing SBP < 100, secondary HTN, life limiting disease, non adherent
100
Who should you screen for hyperaldosteronism ?
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
Who should you screen for pheochromocytoma ? Name 5 reasons
- 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
Who should you screen for renovascular HTN ?
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
Within 72 h of ischemic stroke, how should you manage TA in case of thrombolysis ?
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
When should you add MRA for HTN and LV systolic dysfunction EF < 40% ?
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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