Nephrology Flashcards
What is the ambulatory 24H BP threshold for diagnosis of hypertension?
> =135/85 (awake)
>=130/80 (24hr)
With what criteria can you diagnose HTN at 2nd office visit?
If avg of 1st and 2nd visit >= 140/90 WITH macrovascular disease, DM, eGFR<60
With what criteria can you diagnose HTN at 3rd office visit?
If avg BP of all 3 visits >= 160/100
With what criteria can you diagnose HTN at 5th office visit?
If avg of all visits >=140/90
hat clinical/exam/imaging characteristics are suggestive of fibromuscular dysplasia of renal artery? What is the confirmatory test?
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
What are waist circumferences limits for men and women in prevention of hypertension?
Men <102cm
Women <88cm
How much sodium should you limit for treatment of hypertension?
<5g salt a day
<=2g sodium (i.e. <87mmol)
When should you consider intensive BP therapy as per SPRINT trial?
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
What are first line hypertensive agents for BP management?
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
What are first line treatments for HTN in DM?
ACEi or ARB for CV dx, CKD, microalbuminuria, CV risk factors
Otherwise can also use CCB, thiazide
What are BP targets post stroke (first 72 hr)?
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
When can you consider stenting for renovacular HTN?
Need ALL 3:
- uncontrolled BP on maximal therapy (4 or more drugs)
- progressive renal function decline
- Acute pulmonary edema
What agents are first line for isolated systolic HTN?
Thiazide, LONG acting DHP CCB, ARB
a-blocker, b-blocker, ACEi not first line
What agents are first line for LVH?
Thiazide, ACEi, ARB, long actigin CCB
Avoid vasodilators (can worsen LVH). Beta blockers not indicated.
What agents are first line for non diabetic CKD with proteinuria (ACR > 30 or 24hr urine > 500mg/d)?
ACEi +/- thiazide
What agents are first line for HTN in CAD?
ACE or ARB
What agents are first line for HTN in stable angina?
CCB, beta blocker
What agents are first line for HTN in recent MI?
beta blocker and ACEi
What agents are first line for HTN in HFrEF?
beta blocker and ACEi, +/- MRA
Hydralazine + ISDN if can’t tolerate ACEi/ARB
What are treatments for anti-GBM glomerulonephritis?
Pulse corticosteroids
Cyclophosphamide
PLEX
Can usually taper immunosuppresants after 3-6 months
How do you treat ANCA vasculitis/Pauci-immune mediated GN?
Pulse steroids +/- cyclophosphamide or rituximab
PLEX (if rapidly rising Cr, need for dialysis or diffuse pulmonary hemorrhage)
PLUS
PJP prophylaxis, calcium, vit D, pantoprazole
What GN is associated with low C3?
Post-streptococcal/infectious GN
Normally low C3, normal C4, + ASOT (70%), + anti-DNAse B (90%)
What GN is associated with low C4? What are common causes?
Membranoproliferative GN
- HCV
- Cryoglobulinemia
- Cancer
- Complement dysregulation
- Infections
What GN is associated with low C3 and C4? How do you treat based on classification?
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.
What conditions are associated with IgA nephropathy?
Celiac
HIV
IBD
Cirrhosis
How do you treat IgA nephropathy?
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
What are secondary causes of minimal change nephrotic syndrome?
Heme cancer: hodgkin’s
Drugs: NSAIDs, COX inhibitors, Li
Allergies: Bee stings
Infections: Syphilis, TB, Lyme
What are causes of FSGS nephrotic syndrome?
Infections: HIV, ParvoB19
Drugs: Heroin, pamidronate, anabolic sterois, NSAIDs
Hyperfiltration: obesity, single kidney
What are causes of membranous nephrotic syndrome?
SLE Cancer: solid tumour >> heme malignancy (CLL) Infections: HBV, HCV, Syphilis Drugs: gold, penicillamine, NSAIDs Rare: sarcoidosis
What are secondary (noduar) causes of nephrotic syndrome?
Amyloid, diabetes.
How do you manage nephrotic syndrome?
- 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
How do you grade ACR?
Grade 1: < 3mg/mmol (normal to mildly increased)
Grade 2: 3-30 (moderately increased)
Grade 3: > 30 (severely increased)
What are clinical and biochemical targets for CKD management?
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
What are contraindications for calcium carbonate for phosphate binding?
Hypercalcemia
Adynamic bone disease (reduced osteoblast/clast activity and bone accumulation in CKD patients)
Vascular calcification
What are indications for EPO in CKD? What is the Hgb target?
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)
How do you treat hyperparathyroidism of CKD? What is the PTH target?
Calcitriol but only if PO4 and Ca are not high
Cinecalcet
Surgical parathyroidectomy
Target PTH 2-9x ULN in dialysis patients.
How do you grade 24h urine albumin?
<30mg/day = normal
30-300 mg/day = microalbuminuria
> 300mg/day = overt nephropathy
How do you adjust anion gap for albumin?
Adjusted AG = AG + 0.25 x (40 - alb)
What are causes of anion gap metabolic acidosis?
MUDPILES
Methanol Uremia Diabetic Ketoacidosis Paraldehyde Iron/Isoniazid Lactic acidosis Ethylene glycol Salicylates
What causes increased osmolar gap with AGMA? What causes purely increased osmolar gap?
Osmolar gap with AGMA:
Methanol
Ethylene glycol
Paraldehyde
No acidosis: Ethanol Isopropyl alcohol Mannitol Sorbitol
How do you use urine anion gap to determine if bicarb loss is from renal or GI?
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
What are causes of type 1 RTA (distal)?
Decreased in H+ secretion.
CTD (Sjogren’s, RA, SLE)
Drugs (ampho B)
What are causes of type II RTA (proximal)?
What are causes of type II RTA (proximal)?
Decrease bicarb absorption proximally
Fanconi’s
Myeloma
Acetazolamide
Tenofovir
What are causes of type IV RTA?
Hypoaldo states
MRA RAAS blocker Calcineurin inhibitor Heparin Diabetes HIV
How do you biochemically differentiate Type I, II and IV RTA?
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.
How do you treat RTAs?
Type I and II - NaHCO3, K citrate to replace K if low
Type IV: florinef if low BP, thiazide if HTN
How much should you correct a day for hyponatremia? what are the risk factors that limit your correction rate?
Targe 6, maximum 10
If any of below, target 4 max 8 Hypokalemia Malnutrition Alcoholism Liver disease Serum Na < 120
How fast should you correct for hypernatremia?
max 0.5mmol per hour. (12 per day)
How does urine K help determine whether hypokalemia is from GI or renal loss?
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
How many cysts do you need to diagnosis autosomal dominant PKD?
+ FH
Age 15-30 >= 3 cysts unilateral or bilat
Age 40-59 >= 2 cysts per kidney
Who do you screen for renovascular HTN?
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
Who do you screen for hyperaldosteronism?
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.
Who do you screen for pheochromocytoma?
- 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.
How do you treat nephrolithiasis?
Increase oral fluids, target urine output >2.5L/d, decrease Na and meat, oxalate restriction (vitamin C), thiazides at high doses if hypercalcemic.
What cardiac condition is PCKD associated with?
HOCM
What are the two presentations of IgA nephropathy and how do you treat?
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.
What are causes of nephrogenic DI?
Lithium, hypercalcemia, hypokalemia, renal diseases (obstruction, sickle cell, PCKD, amyloid), drugs (e.g. amphotericin B)
