Nephrology Flashcards
what are three signs that renal failure is chronic?
- kidneys smaller
- hematocrit drops (due to decreases erythropoietin production)
- calcium level drops (due to loss of vitamin D hydroxylation)
what are possible causes of pre-renal azotemia (pre-renal renal failure)? (6)
- hypotension (SBP
What are the diagnostic tests and associated findings associated with pre-renal azotemia (pre-renal renal failure)?
- BUN to creatinine rate > 15:1 (bc urea reabsorbed due to ADH; usualy > 20:1)
- low urinary sodium ( 500
What are the three diagnostic tests that should always be performed if it is a renal case?
- urinalysis
- chemistries
- renal ultrasound
What are four possible causes of post-renal azotemia (obstructive uropathy)?
- stone in bladder or stone in ureters (bilaterally)
- strictures
- cancer of bladder/ prostate/ cervix
- neurogenic bladder (occurs in diabetes and multiple sclerosis)
What are lab and physical exams findings associated with post-renal azotemia (obstructive uropathy)? (4)
- elevated BUN to creatinine ratio (>15:1)
- distended bladder on exam
- large volume diuresis (after catheterization)
- bilateral hydronephrosis on ultrasound
What the diagnostic test findings that are suggestive of intrarenal type renal failure? (3)
- BUN to creatinine ratio of 10:1
- urinary sodium > 40
- urine osmolality
…. is an intrarenal cause of renal failure that can be caused by either …. or …. resulting in death of tubular cells
Acute tubular necrosis (ATN); hypoperfusion; toxins
What are four common causes of toxin-induced renal insufficiency?
- aminoglycosides (associated w/ hypomagnesemia; genatmicin, tobramycin)
- amphotericin
- contrast agents (urine sodium low
What is the urinalaysis finding associated with acute tubular necrosis?
muddy brown/ granular casts
A pt presents with elevated BUN and creatinine along with a new rash and fever after starting treatment with penicillin/sulfa drug/ quinolone/ rifampin/ allopurinol/ phenytoin/ cyclosporine/ quindine most likely suffers from…
allergic interstitial nephritis
hypersensitivity reaction to meds
What is the best initial test and its associated finding for allergic interstitial nephritis?
urinalaysis showing white cells
What is the most accurate test for allergic interstitial nephritis?
Wright stain or Hansel’s stain of urine showing eosinophils
A pt presents with elevated BUN, creatinine, and CPK after a crush injury/ seizure/ cocaine use/ prolonged immobility/ hypokalemia/ recently starting a statin for hyperlipidemia most likely suffers from ….
Rhabdomyolysis
large volume muscular necrosis releases myoglobin which is directly toxic to kidney tubule
What is the best initial test for rhabdomyolysis and its associated finding?
urinalaysis showing large amounts of blood with no cells
What is the most accurate test for rhabdomyolysis?
urine myoglobin
What diagnostic test should be ordered if rhabdomyolysis is suspected?
- urinalaysis
- CPK (elevated)
- potassium (hyperkalemia due to K release on cell lysis)
- calcium (hypocalcemia bc damaged muscle binds Ca)
- chemistries (decreased serum bicarbonate)
What is the best treatment for rhabdomyolysis? (3)
- bolus of normal saline
- mannitol and diuresis (decreases myoglobin contact time with tubule)
- alkalinization of urine (decrease myoglobin precipitation at tubule)
What is the most urgent step in the management of a pt with rhabdomyolysis?
obtain EKG (to assess for signs of hyperkalemia with peaked T waves –> death)
What is the treatment for hyperkalemia leading to EKG changes (peaked T waves)? (3)
- calcium gluconate
- insulin
- glucose
A pt presents appearing intoxicated with metabolic acidosis, elevated anion gap, and elevated BUN and creatinine most likely suffers from ….
Oxalate crystal induced renal failure
secondary to antifreeze/ ethylene glycol ingestion
What is the best initial test for oxalate crystal induced renal failure?
urinalalysis showing enveloped shaped oxalate crystals
What is the best initial treatment for oxalate crystal induced renal failure?
ethanol/ fomepizole with immediate dialysis
A pt presents with elevated BUN and creatinine following chemotherapy for lymphoma/ disseminated cancer most likely suffers from …
Uric acid crystal induced renal failure secondary to tumor lysis syndrome
What is the best treatment for uric acid cyrstal induced renal failure secondary to tumor lysis syndrome?
hydration, allopurinol and rasburicase (breaks down uric acid)
What is the best step in management to prevent contrast induced renal failure in a pt that must have a radiologic procedure with contrast and has reason for renal insufficiency (elderly w/ hypertension or diabetes)?
- hydration with normal saline
2. and bicarbonate, N-actyl cysteine or both
A pt presents with cough, hemoptysis, shortness of breath, and lung findings in the setting of hematuria and red cell casts in the urine most likely suffers from …
Goodpasture’s syndrome
linear deposit type glomerulonephritis
What is the best initial test for Goodpasture’s syndrome?
anti-basement membrane antibodies
What is the most accurate test for Goodpasture’s syndrome?
renal biopsy showing linear deposits
What is the treatment for Goodpasture’s syndrome?
plasmapheresis and steroids
A pt presents with asthma symptoms, cough, eosinophilia, and renal abnormalities in the setting of hematuria and red cell casts most likely suffers from …
Churg-Strauss syndrome
asthmatic, eosinophil type of glomerulonephritis
What is the best initial test for Churg- Strauss syndrome?
CBC for eosinophil count (elevated)
most accurate is biopsy
What is the best initial treatment for Churg-Strauss syndrome?
Glucocorticoids
What is the next best step in management for Churg-Strauss syndrome if glucocorticoids fail to improve symptoms?
add cyclophosphamide
A pt presents with history of upper respiratory problems (sinusitis, otitis media), lung problems (pneumonia, cough, hemoptysis, abnormal chest X-ray) in the setting of hematuria and red cell casts (possibly with other systemic involvement) most likely suffers from …
Wegener’s Granulomatosis
c-ANCA type of glomerulonephritis
What is the best initial test for Wegener’s Granulomatosis?
c-ANCA (c- antineutrophil cytoplasmic antibodies)
most accurate is biopsy
What is the best initial treatment for Wegener’s Granulomatosis?
cyclophosphamide and steroids
A pt presents with fever, weight loss, fatigue, multiple motor and sensory neuropathy with pain, and systemic involvement other than the lungs in the setting of hematuria and red cell casts most likely suffers from …
Polyarteritis Nodosa (PAN)
systemic non lung type glomerulonephritis
What is the best initial test for Polyarteritis Nodosa (PAN)?
ESR and markers of inflammation (CRP)
What is the most accurate test for Polyarteritis Nodosa (PAN)?
biopsy of sural nerve or kidney
What diagnostic test can be performed prior to a biopsy of sural nerve or kidney to help diagnose polyarteritis nodosa?
angiography showing beading
What two diseases are highly associated with polyarteritis nodosa and testing for them should be performed if diagnosed with polyarteritis nodosa?
- hepatitis B
2. hepatitis C
What is the best treatment for polyarteritis nodosa?
cyclophosamide and steroids
An asian pt presents with painless recurrent hematuria that occurs shortly 1-2 days after viral respiratory infections most likely suffers from …
IgA Nephopathy (Berger’s Disease)
elevated IgA sometimes detected
What is the only diagnostic test specific for IgA nephropathy (Berger’s disease)?
renal biopsy
What is the treatment for IgA nephropathy (Berger’s disease)? (3)
- steroids boluses (if worsening proteinuria)
- ACE inhibitors
- fish oil (delay progression)
A child/ adolescent presents with raised, nontender purpuric skin lesions (especially on butt), abdominal pain, possible bleeding, joint pain and hematuria (and other renal involvement) most likely suffers from….
Henoch-Schonlein Purpura
no tx bc resolves; biopsy most accurate
A pt presents with dark tea/cola colored urine (hematuria), periorbital edema, and hypertension weeks after a throat or skin infection most likely suffers from …
Post-streptococcal Glomerulonephritis (PSGN)
subepithelial depositis of IgG and C3 glomerulonephritis
What is the best initial tests for post-streptococcal glomerulonephritis? (4)
- antistreptolysin O (ASLO)
- anti-DNAse
- antihyaluronidase
- complement (low)
What is the most accurate test for post-streptococcal glomerulonephritis?
biopsy showing subepithelial deposits of IgG and C3
What is the best initial treatment for post-streptococcal glomerulonephritis?
- penicillin/ antibiotics
2. and diuretics (to control HTN and fluid overload)
A pt presents with history of hepatitis C, joint pain, purpuric skin lesions and hematuria (or other rneal involvement) most likely suffers from ..
Cryoglobulinemia
What is the best initial test for cryoglobulinemia?
serum cyroglobulin component levels (immunoglobulins & light chains, IgM) and low complement (C4)
(most accurate is biopsy)
What is the treatment for cryoglobulinemia?
treat hep C with interferon, ribavirin and oral protease inhibitor (boceprevir/ telaprevir/ simeprevir/ sofosbuvir)
A pt with a history of butterfly rash,hematologic findings,etc presenting with hematuria/ proteinuria suggesting renal involvement most likely suffers from …
Lupus Nephritis
What is the best initial test for lupus nephritis?
ANA and anti-dsDNA
What diagnostic test is used to determine the extent of disease and guide the therapy for lupus nephritis?
biopsy
What is the treatment for lupus nephritis?
just sclerosis: no tx
mild disease, early stage, nonproliferative: steroids
severe, advanced, proliferative: mycophenolate mofetil and steroids
A pt presents with history of ocular disturbances and deafness/ hearing loss and develops renal failure in the 2nd or 3rd decade of life and has a family history with similiar presentation most likely suffers from..
Alport’s syndrome
no tx
A pt presents with intravascular hemolysis (fragmented cells on smear), elevated creatinine, and thrombocytopenia after infection with E.Coli 0157:H7 most likely suffers from …
Hemolytic Uremic Syndrome (HUS)
tx: plasmaphersis; avoid platelets and antibiotics
A pt presents with intravascular hemolysis (fragments cells on smear), elevated creatinine, thrombocytopenia, fever, and neurological abnormalities after infection with E. Coli 0157:H7 most likely suffers from …
Thrombotic Thrombocytopenic Purpura (TTP)
tx: plasmaphersis; avoid platelets and antibiotics
A pt presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Nephrotic sydrome (due to severe glomerular disease)
What is the best initial test for nephrotic syndrome?
urinalaysis showing markedly elevated protein level
What is the next best test after urinalaysis for nephrotic syndrome?
- spot urine for protein to creatinine ratio > 3.5:1
- 24 hour urine protein collection showing >3.5 g of protein
(most accurate test is biopsy)
A child presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Minimal Change Disease
An adult cancer pt with history of lymphoma presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Membranous (Nephrotic) disease
A pt with history of hepatitis C presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Membranoproliferative (nephrotic) disease
A HIV positive/ heroin user pt presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Focal segmental (Nephrotic) disease
A pt with no specific history findings presenting with hyperproteinuria (> 3.5 g of protein in urine a day), hypoproteinemia (low protein in serum), low albumin level, hyperlipidemia and edema most likely suffers from …
Mesangial (Nephrotic) disease
What is the best initial treatment for any type of nephrotic syndrome?
steroids
What is the next best treatment for any type of nephrotic syndrome if there is no decrease in urine protein excretion after 12 weeks?
add cyclophosphamide
What are the four steps for proteinuria evaluation?
- repeat urinalysis
- evaluate for orthostatic proteinuria (is persists then split urine- if protein in afternoon but not morning, then orthostatic)
- get a protein to creatinine ratio (if proteinuria persists and is not orthostatic)
- perform renal biopsy (if ratio is elevated)
What are causes for transient mild proteinuria? (5)
- congestive heart failure (CHF)
- fever
- exercise
- infection
- orthostatic proteinuria (for job where stand all day)
What are the indications for dialysis? (7)
- hyperkalemia
- metabolic acidosis
- uremia with encephalopathy
- fluid overload
- uremia with pericarditis
- no renal failure but pt has toxicity w/ lithium/ ethylene glycol/ aspirin
- uremia induced malnutrition
What are manifestations of uremia and their corresponding treatments? (7)
- pericarditis (dialysis)
- encephalopathy (dialysis)
- malnutrition (dialysis)
- hyperphosphatemia (calcium acetate/ calcium carbonate phosphate binders)
- hypermagnesemia (dietary Mg restriction)
- anemia (erythropoietin replacement)
- hypocalcemia (vitamin D replacment)
What are three causes of hypernatremia? (3)
- dehydration (secondary to poor oral intake, fever, pneumonia, burns)
- central diabetes insipidus
- nephrogenic diabetes insipidus
What is the major symptom associated with hypernatremia?
neurological abnormalities (confusion, dizziness, disorientation, seizures, coma)
What are the diagnostic findings that suggest a pt with hypernatremia is likely suffering from diabetes insipidus? (4)
- low urine osmolality
- low urine sodium
- increased urine volume
- no change in urine osmolality with water deprivation
How do you distinguish between central diabetes insipidus and nephrogenic diabetes insipidus?
administer vasopressin (DDAVP)
central: decrease in urine volume; increase in urine osmolality
nephrogenic: no change in urine volume or osmolality
What is the treatment for central diabetes insipidus (inability to produce antidiuretic hormone (ADH) in brain)?
vasopression (DDAVP)
What is the treatment for nephrogenic diabetes insipidus (insensitivity to antidiuretic hormone (ADH) at kidney)?
- correct underlying cause (hypokalemia, hypercalcemia, stop offending agent)
- thiazide diurectics
What are three major causes of nephrogenic diabetes insipidus?
- lithium toxicity
- hypokalemia
- hypercalcemia
What are three causes of hypervolemic hyponatremia?
- congestive heart failure (CHF)
- nephrotic syndrome
- cirrhorsis
What are three causes of hypovolemic hyponatremia?
- diuretics (urine sodium elevated)
- GI loss of fluids via vomiting or diarrhea (urine sodium low)
- skin loss of fluids via burns, sweating (urine sodium low)
What are four causes of euvolemic (normal volume status) hyponatremia?
- syndrome of inappropriate ADH release (SIADH)
- hypothyroidism
- psychogenic polydipsia (drinking too much water)
- Hyperglycemia (sodium drops 1.6 point for each 100 mg above normal glucose)
A pt presenting with hyponatremia with hyperkalemia and mild metabolic acidosis most likely suffers from ..
Addison’s disease (adrenal insufficiency leading to insufficient aldosterone production)
A pt with history of CNS abnormality/ lung disease/ cancer/ use of sulfonylureas, SSRIs or carbamazepine presenting with neurological abnormalities and hyponatremia most likely suffers from …
Syndrome of Inappropriate ADH release (SIADH)
What are the diagnostic findings suggestive of syndrome of inappropriate ADH release (SIADH)? (4)
- high urine sodium (> 20 mEq/L)
- high urine osmolality (>100 mOsm/kg)
- low serum osmolality (
What is the treatment for mild hyponatremia (nonsymptomatic) due to syndrome of inappropriate ADH release (SIADH)?
fluid restriction
What is the treatment for moderate to severe hyponatremia (symptomatic) due to syndrome of inappropriate ADH release (SIADH)?
- saline infusion (3% hypertonic saline) with loop diuretics
- ADH blockers (conivaptan, tolvaptan; inhibit ADH at V2 receptor of collecting duct)
- check serum sodium frequently
What is a major complication of correcting the sodium too quickly (more than 10-12 mEq/L in first 24 hours or more than 18 mEq/L in first 48 hours)?
central pontine myelinosis
What is the best treatment for chronic syndrome of inappropriate ADH release (SIADH) such as in cancer?
demeclocycline
What are causes of hyperkalemia? (10)
- metabolic acidosis (transcellular shift out of cells for H+)
- adrenal aldosterone deficiency (decreases excretion)
- beta blockers (decrease Na/K ATPase)
- digoxin toxicity (no K pumped into cells)
- insulin deficiency (no K pumped into cells)
- diuretics (spironolactone)
- ACE inhibitors and ARBs (inhibit aldosterone)
- prolonged immobility/ seizures/ rhabdomylysis/ crush injury/ cancer treatment (release K with cell lysis)
- type IV renal tubular acidosis (decrease aldosterone)
- renal failure (prevents K excretion)
What is the best initial step in management of a pt who is found to have hyperkalemia on lab studies?
repeat lab (may be pseudohyperkalemia due to hemolysis of RBCs in lab or prolonged tourniquet placement during phlebotomy)
What is the major symptom of hyperkalemia and hypokalemia?
cardiac arrhythmia
hypokalemia can also cause loss of ability to inhibit muscle contraction leading to rhabdomyolysis
What are the EKG changes associated with hyperkalemia? (3)
- peaked T-waves (initial)
- loss of P wave (secondly)
- widened QRS (lastly)
What is the treatment regimen for severe hyperkalemia (EKG abnormalities are present)? (3)
- calcium gluconate IV (protect heart)
- insuline with glucose IV (to push K into cells)
- Kayexalate orally (to help excrete K)
(in this order)
What is the treatment regimen for moderate hyperkalemia (no EKG abnormalities)?
- insulin and glucose IV (push K into cells)
- bicarbonate (if due to acidosis, rhabdomyolysis, hemolysis, cause of alkalinized urine; H+ out so K+ in)
- oral kayexalate (to help excrete K)
What are causes of hypokalemia?
- dietary insufficiency
- diuretics
- high aldosterone state (Conn syndrome- primary hyperaldosteronism)
- vomiting (–> alkalosis –> H+ out and K+ in)
- proximal and distal renal tubular acidosis
- amphotericin (causes renal tubular acidosis)
- bartter syndrome
What is Bartter syndrome?
inability to absorb Na and Cl at loop of Henle (–> secondary hyperaldosteronism and renal K wasting)
What are the EKG changes associated with hypokalemia?
U-wave (extra wave after T-wave signifying Purkinje fiber repolarization)
What should be avoided in hypokalemic states?
glucose containing fluids (will increase insulin release and worsen hypokalemia by pushing K into cells)
What is the treatment for hypokalemia?
Slow IV potassium replacement (to avoid hyperkalemia) or oral potassium replacement
What is the signs and symptoms of hypermagnesemia (usually do to overuse of Mg-containing laxatives or Mg used as tocolytic)? (2)
- muscular weakness
2. loss of deep tendon reflexes (routinely check in pregnant pt being treated with Mg)
What is the treatment for hypermagnesemia?
- restrict Mg intact
- saline administration (to provoke diuresis)
- dialysis
What are causes of hypomagnesemia? (5)
- loop diuretics
- alcohol withdrawal, starvation
- genatmicin, cisplatin or amphotericin use
- pancreatitis
- parathyroid surgery
What are the signs and symptoms of hypomagnesemia? (2)
- hypocalcemia
2. cardiac arrythmia
What are the causes of metabolic acidosis with increased anion gap? (MUDPILES)
- methanol intoxication
- uremia
- diabetic ketoacidosis
- propylene glycol
- Isoniazid (INH) or iron poisoning
- lactic acidosis (due to hypoperfusion –> anaerobic metabolism)
- ethylene gylcol
- salicylates (aspirin)
What is the treatment for metabolic acidosis with increased anion gap secondary to aspirin overdose?
bicarbonate (corrects acidosis and increases urinary excretion of aspirin)
An intoxicated appearing pt presents with visual disturbances and metabolic acidosis with an increased anion gap most likely suffers from ..
methanol intoxication
toxic products of formic acid and formaldehyde
What is the diagnostic test and treatment for methanol intoxication?
methanol level; fomepizole/ ethanol with dialysis
A pt presenting with elevated serum glucose, fruity breath, metabolic acidosis with increased anion gap most likely suffers from …
diabetic ketoacidosis
What is the single fastest test to detect if a pt with diabetic ketoacidosis’s hyperglycemia is life threatening?
low serum bicarbonate
What is the best treatment for a diabetic ketoacidosis pt with metabolic acidosis with increased anion gap?
placement in ICU; saline hydration and insulin
An intoxicated pt presents with renal abnormalities, oxalate crystals in the urine, renal failure, metabolic acidosis with increased anion gap and hypocalcemia in the setting of a suicide attempt most likely suffers from …
Ethylene Glycol intoxication
What is the treatment for ethylene glycol intoxication?
fomepizole or ethanol
What are the two major causes of metabolic acidosis with a normal anion gap?
- diarrhea (increased bicarb & K loss; hypokalemia; increased Cl reabsorption; hyperchloremia)
- renal tubular acidosis
What is the best test for distal renal tubular acidosis type I?
IV administration of acid (ammonium chloride –> urine pH remains abnormally basic)
What is the pathophysiologic problem in distal renal tubular acidosis type 1?
inability to excrete H+ in the distal tubules
metabolic acidosis; low K bc excreted instead; alkaline urine –> stones; low serum bicarb bc bound to H+
What is the treatment for distal renal tubular acidosis type I?
bicarbonate
What is the best test for proximal renal tubular acidosis type II?
give bicarbonate (urine pH will rise due to bicarbonate malabsorption)
What is the pathophysiologic problem in proximal renal tubular acidosis type II?
inability to reabsorb bicarbonate in proximal renal tubule
(initially elevated urine pH –> low urine pH bc run out of bicarb in body; metabolic acidosis; Ca leak out of bone –> osteomalacia; hypokalemia)
What is the treatment for proximal renal tubular acidosis type II?
thiazide diuretic (volume contractions to raise serum bicarb)
A diabetic pt presents with normal anion gap metabolic acidosis and hyperkalemia most likely suffers from …
Hyporeninemic hypoaldosteronism (Type IV renal tubular acidosis)
What is the pathophysiologic problem in renal tubular acidosis type IV?
decreased aldosterone production or effect
also known as hyporeninemic hypoaldosteronism
What is the treatment for renal tubular acidosis type IV?
fludrocortisone (aldosterone properties)
What diagnostic calculation can be used to distinguish between diarrhea and renal tubular acidosis as the causes of a normal anion gap metabolic acidosis?
urine anion gap (UAG)
UAG= urine Na+ - urine Cl-
What does a positive urine anion gap (UAG) suggest as the cause of a normal anion gap metabolic acidosis?
renal tubular acidosis
kidney no working so cant excrete Cl- b/c cant excrete H+
What does a negative urine anion gap (UAG) suggest as the causes of a normal anion gap metabolic acidosis?
diarrhea
kidney works so can excrete Cl- with excretion of H+
What are causes of metabolic alkalosis? (6)
- volume contraction (secondary hyperaldosteronism)
- Conn syndrome (primary hyperaldosteronism)
- Cushing syndrome (hyperaldosteronism –> H+ loss)
- hypokalemia (K+ out and H+ in)
- Milka-alkali syndrome (too much liquid antacid)
- vomiting (loss of H+ via stomach & volume contraction)
What is the most common cause of death in cystic disease?
end stage renal disease
A pt presents with recurrent hematuria, stones, infections, mitral valve prolapse and diverticulosis and cysts are found in liver, ovaries and circle Willis most likely suffers from..
Cystic disease
no tx
A pt presents with urinary incontinence associated with pain followed by the urge to urinate; however there is no relationship to coughing/ laughing/ straining most likley suffers from ..
Urge incontinence
What is the best test for urge incontinence?
urodynamic pressure monitoring
What are the treatment options for urge incontinence? (2)
- behavior modification
2. anticholinergic meds (tolterodine/ trospium/ darifenacin/ solifenacin/ oxybutynin)
A pt presents with history of urinary incontinence that occurs with coughing/ laughing/ straining and not associated with pain most likely suffers from ..
Stress incontinence
What is the best test for stress incontinence?
observe leakage with laughing
What are the treatment options for stress incontinence? (2)
- Kegel exercises
2. estrogen cream
What is the best initial step if a pt presents with hypertension for the first time?
repeat blood pressure measurement 1-2 weeks later
What is the best initial treatment for hypertensions?
lifestyle modifications (sodium restriction, weight loss, dietary modification, exercise, relaxation techniques)
What is the most effective lifestyle modification for hypertensions?
weight loss
What is the next best step of management for hypertension if there is no effect with lifestyle modifications over 3-6 months?
initiate medical therapy
thiazide for general population and osteoporesis: hydrochlorothiazide or chlorthalidone
ACE inhibitor/ ARB for diabetic pt
beta blocker for CAD, CHF, migraine, hyperthyroidism
alpha methyldopa for pregnancy
alpha blockers for BPH
What is the next best step of management for a pt with hypertension who can not be controlled while on 3 anti-hypertensive medications (beta blocker, ACE inhibitor, ARBs, calcium channel blocker)?
investigate for secondary causes
What is the best initial therapy for a pt with hypertensions whose baseline blood pressure is > 160/100?
Start with 2 anti-hypertensive medications
What diagnostic tests are routine in a newly hypertensive patient? (4)
- urinalysis
- EKG
- eye exam (retinopathy)
- cardiac exam (murmur or S4 gallop)
What are the indications for investigating for secondary hypertension in a newly hypertensive patient? (8)
- young (60)
- failure to be controlled with 3 meds
- renal bruit (renal artery stenosis)
- episodic hypertension (pheochromocytoma)
- hypokalemia (Conn syndrome)
- buffalo hump, truncal obestity, striae (cushing’s)
- upper extremity BP> lower extremity (coarctation of aorta)
- hirsuitism (congenital adrenal hyperplasia)
What is the best initial test for renal artery stenosis?
renal ultrasound with doppler
What is the most accurate test for renal artery stenosis?
renal angiogram
What is the best initial therapy for renal artery stenosis?
renal artery angioplasty and stenting
What is the next best step in management of a pt with suspected renal artery stenosis who is found to have a small kidney on renal ultrasound with doppler?
- magnetic resonance angiography (MRA)
- duplex ultrasonogram
- nuclear renogram
(either of the above)
