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Royal College Exam > Nephrology > Flashcards

Nephrology Flashcards

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1
Q

What is the ambulatory 24H BP threshold for diagnosis of hypertension?

A

> =135/85 (awake)

>=130/80 (24hr)

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2
Q

With what criteria can you diagnose HTN at 2nd office visit?

A

If avg of 1st and 2nd visit >= 140/90 WITH macrovascular disease, DM, eGFR<60

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3
Q

With what criteria can you diagnose HTN at 3rd office visit?

A

If avg BP of all 3 visits >= 160/100

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4
Q

With what criteria can you diagnose HTN at 5th office visit?

A

If avg of all visits >=140/90

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5
Q

hat clinical/exam/imaging characteristics are suggestive of fibromuscular dysplasia of renal artery? What is the confirmatory test?

A 
Age <30, non obese women
HTN resistant to >= 3 drugs
Kidneys asymmetrical (>1.5cm diff)
Abdominal bruits, no other athero risk factors
Confirmed FMD of another vascular bed
Family Hx of FMD

Diagnose with CTA

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6
Q

What are waist circumferences limits for men and women in prevention of hypertension?

A

Men <102cm

Women <88cm

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7
Q

How much sodium should you limit for treatment of hypertension?

A

<5g salt a day

<=2g sodium (i.e. <87mmol)

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8
Q

When should you consider intensive BP therapy as per SPRINT trial?

A

Age >= 50 with subclinical/clinical CVD, eGFR 20-60, protein <1g/day, 10 yr CV risk >=15%

Age >= 75

Contraindicated in nonadherence, standing sbp <110, secondary hypertension, inaccurate BP readings

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9
Q

What are first line hypertensive agents for BP management?

A 
Long actiing thiazide
ACEi
ARB
Long acting CCB (better for Blacks over ACE/ARB)
Betablocker (only <60 yr. old)

*Can combine ACEi + CCB, ARB + CCB, ACEi/ARB + diuretic

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10
Q

What are first line treatments for HTN in DM?

A

ACEi or ARB for CV dx, CKD, microalbuminuria, CV risk factors

Otherwise can also use CCB, thiazide

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11
Q

What are BP targets post stroke (first 72 hr)?

A

Thrombolysis: treat if >185/110
No thrombolysis: treat if >220/120, aim for 15-25% reduction over first 24hr
If hemorrhagic, keep SBP < 180

After 72hr, target <140/90. ACEi/thiazide preferred

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12
Q

When can you consider stenting for renovacular HTN?

A

Need ALL 3:

  • uncontrolled BP on maximal therapy (4 or more drugs)
  • progressive renal function decline
  • Acute pulmonary edema
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13
Q

What agents are first line for isolated systolic HTN?

A

Thiazide, LONG acting DHP CCB, ARB

a-blocker, b-blocker, ACEi not first line

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14
Q

What agents are first line for LVH?

A

Thiazide, ACEi, ARB, long actigin CCB

Avoid vasodilators (can worsen LVH). Beta blockers not indicated.

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15
Q

What agents are first line for non diabetic CKD with proteinuria (ACR > 30 or 24hr urine > 500mg/d)?

A

ACEi +/- thiazide

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16
Q

What agents are first line for HTN in CAD?

A

ACE or ARB

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17
Q

What agents are first line for HTN in stable angina?

A

CCB, beta blocker

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18
Q

What agents are first line for HTN in recent MI?

A

beta blocker and ACEi

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19
Q

What agents are first line for HTN in HFrEF?

A

beta blocker and ACEi, +/- MRA

Hydralazine + ISDN if can’t tolerate ACEi/ARB

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20
Q

What are treatments for anti-GBM glomerulonephritis?

A

Pulse corticosteroids
Cyclophosphamide
PLEX

Can usually taper immunosuppresants after 3-6 months

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21
Q

How do you treat ANCA vasculitis/Pauci-immune mediated GN?

A

Pulse steroids +/- cyclophosphamide or rituximab
PLEX (if rapidly rising Cr, need for dialysis or diffuse pulmonary hemorrhage)

PLUS

PJP prophylaxis, calcium, vit D, pantoprazole

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22
Q

What GN is associated with low C3?

A

Post-streptococcal/infectious GN

Normally low C3, normal C4, + ASOT (70%), + anti-DNAse B (90%)

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23
Q

What GN is associated with low C4? What are common causes?

A

Membranoproliferative GN

  • HCV
  • Cryoglobulinemia
  • Cancer
  • Complement dysregulation
  • Infections
24
Q

What GN is associated with low C3 and C4? How do you treat based on classification?

A

SLE nephritis. Can be nephritic and/or nephrotic

Class III/IV (nephritic): Induce with steroids, MMF or cyclophosphamide

Class V (nephrotic): ACEi/ARB for proteinuria and BP control. If worsening renal dysfunction, need to rule out renal vein thrombus and consider renal bx.

25
Q

What conditions are associated with IgA nephropathy?

A

Celiac
HIV
IBD
Cirrhosis

26
Q

How do you treat IgA nephropathy?

A

ACEi/ARB if >0.5-1g/day proteinuria, titrate to <1g/day
Adequate BP control
Fish oil if persistant proteinuria > 1g/day

Steroids ONLY if refractory proteinuria >1g despite treatments

27
Q

What are secondary causes of minimal change nephrotic syndrome?

A

Heme cancer: hodgkin’s
Drugs: NSAIDs, COX inhibitors, Li
Allergies: Bee stings
Infections: Syphilis, TB, Lyme

28
Q

What are causes of FSGS nephrotic syndrome?

A

Infections: HIV, ParvoB19
Drugs: Heroin, pamidronate, anabolic sterois, NSAIDs
Hyperfiltration: obesity, single kidney

29
Q

What are causes of membranous nephrotic syndrome?

A 
SLE
Cancer: solid tumour >> heme malignancy (CLL)
Infections: HBV, HCV, Syphilis
Drugs: gold, penicillamine, NSAIDs
Rare: sarcoidosis
30
Q

What are secondary (noduar) causes of nephrotic syndrome?

A

Amyloid, diabetes.

31
Q

How do you manage nephrotic syndrome?

A
  • Treat underlying cause
  • Na restriction and diuretics
  • Statins for hypercholesterolemia
  • ACEi for proteinuria and BP
  • Prophylactic FULL dose anticoagulation consideration for idiopathic membranous IF albumin <25
32
Q

How do you grade ACR?

A

Grade 1: < 3mg/mmol (normal to mildly increased)

Grade 2: 3-30 (moderately increased)

Grade 3: > 30 (severely increased)

33
Q

What are clinical and biochemical targets for CKD management?

A 
BP < 140/90 (130/80 if diabetic)
Dyslipidemia stage 1-2 CKD as per gen population
LDL <2mmol/L
Smoking cessation
Optimal diabetic control
Proteinuria < 500mg - 1g/day with ACEi
K < 5
HCO3 > 22
PO4 and Ca normal range
PTH target 2-9x ULN for dialysis pts
HGB 100-115, TSAT > 30%, ferritin > 500
34
Q

What are contraindications for calcium carbonate for phosphate binding?

A

Hypercalcemia
Adynamic bone disease (reduced osteoblast/clast activity and bone accumulation in CKD patients)
Vascular calcification

35
Q

What are indications for EPO in CKD? What is the Hgb target?

A

Hgb < 100 AND anemic symptoms.
If concurrent IDA, treat with PO iron, then IV iron prior to starting EPO (target ferritin 500 and TSAT 30%)
Target 100-115 (not higher due to associated stroke, CAD, HTN)

36
Q

How do you treat hyperparathyroidism of CKD? What is the PTH target?

A

Calcitriol but only if PO4 and Ca are not high
Cinecalcet
Surgical parathyroidectomy

Target PTH 2-9x ULN in dialysis patients.

37
Q

How do you grade 24h urine albumin?

A

<30mg/day = normal
30-300 mg/day = microalbuminuria
> 300mg/day = overt nephropathy

38
Q

How do you adjust anion gap for albumin?

A

Adjusted AG = AG + 0.25 x (40 - alb)

39
Q

What are causes of anion gap metabolic acidosis?

A

MUDPILES

Methanol
Uremia
Diabetic Ketoacidosis
Paraldehyde
Iron/Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
40
Q

What causes increased osmolar gap with AGMA? What causes purely increased osmolar gap?

A

Osmolar gap with AGMA:
Methanol
Ethylene glycol
Paraldehyde

No acidosis: 
Ethanol
Isopropyl alcohol
Mannitol
Sorbitol
41
Q

How do you use urine anion gap to determine if bicarb loss is from renal or GI?

A

Urine anion gap = UNa + UK - UCl

If urine AG «< 0, kidneys working fine (secreting NH4+), bicarb loss is GI

If urine AG > 0, (renal loss of bicarb, not secreting acids), = RTA

42
Q

What are causes of type 1 RTA (distal)?

A

Decreased in H+ secretion.

CTD (Sjogren’s, RA, SLE)
Drugs (ampho B)

43
Q

What are causes of type II RTA (proximal)?

A

What are causes of type II RTA (proximal)?
Decrease bicarb absorption proximally

Fanconi’s
Myeloma
Acetazolamide
Tenofovir

44
Q

What are causes of type IV RTA?

A

Hypoaldo states

MRA
RAAS blocker
Calcineurin inhibitor
Heparin
Diabetes
HIV
45
Q

How do you biochemically differentiate Type I, II and IV RTA?

A

Type I - very low K, urine pH>5.3, calcium phosphate stones.

Type II - low K, variable pH, low serum PO4 and vit D, glucosuria.

Type IV - hyperkalemia, pH<5.3.

46
Q

How do you treat RTAs?

A

Type I and II - NaHCO3, K citrate to replace K if low

Type IV: florinef if low BP, thiazide if HTN

47
Q

How much should you correct a day for hyponatremia? what are the risk factors that limit your correction rate?

A

Targe 6, maximum 10

If any of below, target 4 max 8
Hypokalemia
Malnutrition
Alcoholism
Liver disease
Serum Na < 120
48
Q

How fast should you correct for hypernatremia?

A

max 0.5mmol per hour. (12 per day)

49
Q

How does urine K help determine whether hypokalemia is from GI or renal loss?

A

Urine K < 25 = GI loss (acidosis)
Urine K > 30 = renal loss or GI loss (alkalosis)

If Urine K > 30:
Urine Cl < 20 = GI loss (alkalosis)
Urine Cl > 20 = Renal loss

50
Q

How many cysts do you need to diagnosis autosomal dominant PKD?

A

+ FH
Age 15-30 >= 3 cysts unilateral or bilat
Age 40-59 >= 2 cysts per kidney

51
Q

Who do you screen for renovascular HTN?

A

Patients presenting with >=2 of:

  • Sudden onset/worsening HTN age > 55 or < 30
  • Abdominal bruit
  • HTN resistant to >= 3 drugs
  • Increase in Cr >=30% with ACEi or ARB
  • Other atherosclerotic vascular dx
  • Recurrent pul edema with HTN surges

Screen with Doppler US, captopril renogram, MRA, CTA

52
Q

Who do you screen for hyperaldosteronism?

A

Unexplained spontaneous hypoK < 3.5 or marked diuretic related hypoK < 3.0

Resistant to treatment with >= 3 drugs
Incidental adrenal adenoma

Screen with plasma renin, aldo level
Confirm with saline load/captopril supp test.

53
Q

Who do you screen for pheochromocytoma?

A
  • Paroxymal, labile and/or severe >180/110 sustained HTN refractory to therapy
  • HTN + symptoms of catecholamine excess
  • HTN triggered by BB, MAO-I, surgery, anesthesia, micturition, changes in abdo pressure
  • Incidental adrenal adenoma
  • MEN2A or 2B, neurofibromatosis type 1, Von-Hippel-Lindau syndrome

Screen with 24hr urine metanephrines and catecholamines OR plasma metanephrines.

54
Q

How do you treat nephrolithiasis?

A

Increase oral fluids, target urine output >2.5L/d, decrease Na and meat, oxalate restriction (vitamin C), thiazides at high doses if hypercalcemic.

55
Q

What cardiac condition is PCKD associated with?

A

HOCM

56
Q

What are the two presentations of IgA nephropathy and how do you treat?

A

Recurrent asymptomatic hematuria following resp infection or microscopic hematuria with low-moderate grade proteinuria.

Treat:

  • Hematuria/Cr normal = monitor
  • Hematuria/protein>1g/d = ACE/ARB, statin, fish oil.
  • Renal dysfunction = immunosuppressive therapy.
57
Q

What are causes of nephrogenic DI?

A

Lithium, hypercalcemia, hypokalemia, renal diseases (obstruction, sickle cell, PCKD, amyloid), drugs (e.g. amphotericin B)

Royal College Exam (15 decks)

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