Nephrology Flashcards
Approach to NAGMA
1) Urine AG –> Negative = GI (ileal conduit, diarrhea) or dilutional after fluids; Positive = Renal
2) If renal, look at K-> Low = Type 1/2 RTA, High = Type 4
3) If Low K: Look at associated features
a) Type 1: ++ low K, Bicarb <10, Urine PH >5.5
- Clues: Stones, hypercalciuria
- Assoc diseases: Sjogrens, RA, SLE
b) Type 2: + low K, Bicarb 10-20, Urine pH variable
- Clues: Glucosuria, hypoPO4, hypouricemia, low vitD
- Assoc Dz: Fanconi’s, MM, Tenofovir, Acetazolamide
Tx for both types: NaHCO3, K citrate (if K low)
4) If High K = Type 4 RTA - med review/ROS to ID cause
- Drugs: MRA, RAAS blockade, heparin, calcineurin inhib
- Diseases: DM, Adrenal Insufficiency
- Tx: low BP = florinef; HTN = thiazide
Hyponatremia - calculating volume to give
[(0.5 or 0.6 x Weight) x (target Na - current Na) ] / [Na infusate]
*Na infusate: RL = 130, NS= 154, 3% 513
Hypernatremia - free water deficit
[(0.5 or 0.6 x Weight) x (current Na - target Na)] / (Target Na)
HypoK Approach
1) Urine K: If <20 = GI (villous adenoma, diarrhea, laxatives).
2) If >20 = renal: Acidotic = RTA 1/2
Alkalotic –> look @ BP
a) Low/Normal BP: Look @ UCl. If >20 = diuretic, Barters, Gittlemans. If <20 = past diuretic, vomiting.
b) High BP: Look at renin and aldo.
Both high = RAS/reninoma.
Both low = steroid/cushings/licorice, Liddle’s.
High aldo and low renin = Conn’s.
Manifestations of Glomerulonephritis
PHAROH Proteinuria (<3g/day) Hypertension AKI Red cell casts/dysmorphia Oliguria Hematuria
Manifestations of Nephrotic Syndrome
Hypoalbuminemia
Edema
HyperLipidemia
Proteinuria >3.5g/24 hr
Differential Diagnosis Glomerulonephritis
Pauci-Immune:
- ANCA associated SVV (GPA, eGPA, MPA)
- ANCA negative SVV
- Anti-GBM Disease
Immune Complex Mediated
- IgA nephropathy
- Post strep GN
- SLE/APLA
- IE
- MPGN (Hep C, Hep B, Cryo, aHUS, Complement dysregulation, monoclonal gammopathies)
Normal C3 and C4 GN
-what it’s assoc’d w/ and treatment
IgA Nephropathy (assoc’d w/ celiac, HIV, cirrhosis) - RPGN OR nephrotic syndrome; SYN-pharyngitic
Tx: ACEi/ARB if >0.5g/d (target <500mg/d)
-Target BP <120
-Consider steroids x6mo if high risk progresive CKD (ie >0.75-1g proteinuria despite OMT x90d)
Low C3 and Normal C4 GN
-presentation, tests
Post-Strep/infectious GN (eg strep throat/cellulitis, abscess, IE)
+anti-DNase B, +ASOT,
-Hematuria, proteinuria, HTN
Low C3 and C4 GN
Nephritic: Class 3/4 SLE (steroids, cyclo/mmf)
Nephrotic: Class 5 SLE (ACE/ARB, antiHTN, statin)
-progressive dyscn –> renal US r/o thrombus or repeat bx
Normal C3 and low C4 GN
MPGNs (MC Type 1)
- Infections: Hep C > Hep B
- Autoimmune: Cryoglobulinemia, TMA/HUS, complement dysregulation syndrome
- Haem: Monoclonal gammopathies
Treatment of ANCA associated GN
*induction and maintenance
Induction: Steroids 1g/d x3d –> 1mg/kg PO pred
RPGN (Cr>354): Cyclophosphamide > ritux unless (young M/F for fertility, frail elderly, relapsed disease; no RPGN)
PLEX if antiGBM overlap, consider if: Cr >500, risk of ESRD, or severe pulmonary hemorrhage
Maintenance phase: Add Aza or Ritux (no maintenance in HD dependent x3mo w/o extrarenal manifestations)
Treatment of anti-GBM associated GN
Steroids (pulse –> taper)
Cyclophosphamide or ritux
PLEX for all (until titers not detectable)
NO maintenance therapy as low risk recurrence
Manifestations of IgA Nephropathy
“Synpharyngitic” GN
Spectrum: asymptomatic hematuria, flank pain, RPGN, nephrotic syndrome
If accompanied by systemic dz (=HSP) - purpura + arthritis
Indications to biopsy suspected IgA nephropathy
Systemic manifestations
Heavy proteinuria
Progressive AKI (not recovering spontaneously)
Classes of Lupus Nephritis
I/II: Bland sediment, proteinuria <3.5g/day, no AKI
III/IV: GN - AKI, Hypertension, Proteinuria, Hematuria
V: Membranous - nephrotic range proteinuria
Treatment Class III/IV SLE Nephritis
Induction:
Steroids pulse –> 1mg/kg
MMF or cyclo
Maintenance:
ACEi for proteinuria
Steroid taper
MMF or Aza
Treatment Class V SLE Nephritis
ACEi/ARB for proteinuria
BP control - target <130/80
HCQ
Immunosuppression only if worsening renal function (consider re-bx 1st to r.o class 3/4)
Treatment post-strep GN
Supportive care
Diuresis
Biopsy if not resolving spontaneously after 3-4 weeks or requiring dialysis (unusual)
Treatment MPGN
Treat underlying cause
Consider steroids, CNI, MMF, Cyclo if refractory
Differential Diagnosis Nephrotic Syndrome
DM Amyloidosis Minimal Change DZ - Primary/Secondary MC = Membranous - Primary/Secondary FSGS - Primary/Secondary - MC in blacks
Secondary Causes Minimal Change Disease
Malignancy: Hogkin’s Lymphoma, Leukemia
Drugs: COX inhibitors, NSAIDs, Li
Bee stings
Secondary Causes Membranous Nephropathy
Malignancy: Solid tumors > Haem cancers (CLL)
AI Disease: SLE, Sarcoid
Infection: Hep B > Hep C, Syphillis
Drugs: NSAIDs, Anti-TNF, Gold, Penicillamine
Secondary Causes FSGS
Infection: HIV (HIVAN - CD4<200), parvo, EBV
Drugs: Pamidronate, heroin, anabolic steroids
Hyperfiltration: Obesity, Solitary kidney, reflux nephropathy
Treatment of Nephrotic Syndrome
- ACEi/ARB
- Na restriction and diuretics for edema
- BP control (<130/80)
- Statin for hyperlipidemia
- Look for VTE and treat
- Warfarin full dose ppx if Alb <20 in PRIMARY disease AND any of: BMI>35, NYHA3-4, proteinuria>10g/d, thrombophilia, recent ortho/abdo sx, immobilization), if high risk bleed: ASA 81mg daily
- Treat underlying cause (ie. HAART for HIV, chemo for Ca, drug withdrawal, tx Hep B/C, weight loss)
Causes of non-nephrotic range proteinuria (without active urine sediment)
Transient (ie. with fever, exercise)
Orthostatic
Overflow - pigment (rhabdo, hemolysis), MM
Tubulointerstitial - heavy metals, sarcoid, sjogrens, nsaids
Post-renal
Differential Dx Pre-renal AKI
True hypovolemia
Intravascular depletion (CHF, cirrhosis)
NSAIDs (altered renal flow)
Causes of ATN
Prolonged/Severe pre-renal state
Drugs: Contrast, ACE, ARB
Pigment: Hemolysis, Rhabdomyolysis, TLS, Myeloma
Causes and presentation of AIN
Drugs: PPI, allopurinol, ABX, NSAIDs, diuretics
AI Disease: SLE, Sarcoid, Sjogren’s
Infection
+/- fever, rash, hematuria, non-nephrotic proteinuria, sterile pyuria, WBC casts or eosinophilia/eosinophuria
Sick Day Meds
SADMANS SGLT2s ACE Diuretics Metformin ARB NSAIDs Sulfonylureas
Treatment of hyperkalemia in CKD
Target K <5
- K-restricted diet (no oranges, tropical fruit, avocadoes, tomatoes, potatoes, beans, leafy greens, seeds, milk)
- Diuretics (if producing urine)
- Avoid NSAIDs, careful use of ACE/ARB/MRA, avoid septra and amiloride
- K binders eg lokelma aka Na zirconium cyclosilicate (S/E: edema, GI, costs) or Patiromer (binds colonic K)
- Dialysis
Treatment of metabolic acidosis in CKD
Target normal HCO3 >22
- Baking soda or Na Bicarb tabs (slows GFR decline)
- Dialysis
Treatment of anemia in CKD
Target Hgb 100-115, Ferritin >500, Tsat >30%
- Ensure Iron replete - if ferritin <=500 or Tsat < =30% give iron (IV > oral)
- Once iron replete, if Hgb still <100, start EPO* (Hgb >115 risk of stroke, CAD, HTN)
*caution if active Ca, previous stroke, or uncontrolled BP
PTH/Ca/PO4 targets in CKD
PTH 2-9 x ULN if on HD, pre-HD target unknown
PO4 and Ca toward normal range
Treatment of hyperphosphatemia in CKD
Low PO4 diet (cheese, milk, deli meat, liver, shellfish)
Oral PO4 binders with meals
- Non-Ca containing (sevalamer, lanthanum) preferred but costly
- Ca containing: Tums, Ca Carbonate (avoid in hyperCa, adynamic bone disease, heavy vasc calcifications)
Treatment of hypocalcemia in CKD
Calcitriol (1,25-OH VitD) - cannot use if hyperPO4
Treatment of CKD-MB
Treat hypocalcemia (Calcitriol)
Treat hyperphosphatemia (tums, sevalamer, lanthanum)
Target PTH 2-9xULN in HD pt, if PTH > 9x ULN despite above:
- Cinecalcet (activates Ca receptor to shut off PTH)
- Parathyroidectomy
- Calcitriol (if PO4 and Ca not high)
Can use bisphosphonate down to eGFR 30 (risedronate, pamidronate) or denosumab (risk hypoCa), but NOT for IHD patients
Indications for hypertonic Saline
GCS <=8
Seizures
*Target 4-5 correction ASAP
Causes hyponatremia
1) Pseudo: High Tg, High paraprotein (eg MM), icteric sample (eg obstructive jaundice)
2) Hypertonic: High glucose, mannitol
3) Hypotonic - most
a) Hypovolemic (Una <20) - give fluids
b) Hypervolemic (UNa <20) - fluid restrict, diurese
c) Euvolemic (UNa >20)
- Approp ADH (UOsm=SOsm <100-300): Psychogenic polydispsia, beer potomania , tea/toast
- SIADH (UOsm»_space;SOsm): Pain, NV, hypoT4, AI, lung or brain disorders, SCLC, drugs (carbamazepine, SSRI, TCA, MDMA, thiazides)
Rate of Na correction in chronic Na disorders
HypoNa: 4-8/day
HyperNa: 8-12/day
Positive Water deprivation test to diagnose DI
Serum Na >=145 and Plasma Osm >=295
Uosm remains <250-300
Causes of central DI
Post pituitary resection
Pituitary infarct or bleed
Trauma
Barter’s Electrolyte Profile
“Like lasix”
Can cause low serum Na/K/Cl/Ca
High urine Na, K, Cl, Ca
Gittleman’s Electrolyte Profile
“Like thiazide”
Can cause low serum Na/K/Cl, normal or high Ca
High urine Na/K/Cl, normal or low urine Ca
BP Cutoffs by various approaches
Automated in office: >=135/85 (130/80 for DM)
Office BP monitor: >=140/90
At home ABPM: >=135/85 daytime, >=130/80 24hr
HBPM: >=135/85
2nd AOBP visit >140/90 w/ macrovascular dz, CKD, DM2
3rd AOBP visit mean BP of all visits >160/90
4th AOBP visit mean BP of all visits >140/90
Definition Hypertensive Urgency
BP>=180/110 with no end organ dysfunction
Treatment Isolated Systolic HTN without compelling indications
1st line: ARB, CCB, Thiazide
2nd line: Combination of above
3rd line: ACEi, Alpha-blocker, non-DHP CCBs
Treatment diastolic (+/- systolic) HTN without compelling indications
1st line: ACE/ARB, CCB, Thiazide
2nd line: combo above [(ACE or ARB) + (CCB or thiazide)]
3rd line: Add on other drug above (CCB if on thiazide or vice versa)
4th line: Alpha blocker
Treatment HTN in patient with DM
If ACR >2, eGFR <60, CV dz, or CV RF:
1st line: ACE or ARB
2nd line: Add CCB (thiazide appropriate if hyperK)
3rd line: Add thiazide
If no significant other vascular RFs/renal complications:
1st line: ACE, ARB, CCB, Thiazide
2nd line: Add 2nd 1st line agent (CCB>Thiazide)
3rd line: Add other first line agent
Treatment HTN in patient with non-diabetic CKD (ACR >30, protein >150mg/24 hr)
1st line: ACE or ARB
2nd: Thiazide (or loop if vol overload)
3rd: Add CCB
Treatment of Chronic HTN Post Stroke/TIA
1st line: ACE, ARB, Thiazide
2nd line: Combine above (ACE/ARB + Thiazide)
w/i 72h of ischemic stroke:
target <185/110 before tpa and <185/105 after
target 15-25% reduction over 24h if no tpa, tx only if >220/120
long term target <140/90 in few days to 1 week
Hemorrhagic: target <140-160 for 1st 24-48h, long term target <130/80
Treatment in HTN in patient with CAD +/- angina/MI
CAD alone: ACE/ARB first, then BB or CCB >thiazide
Stable angina: BB + CCB
MI: ACE + BB or CCB
Avoid short acting nifedipine. Caution if DBP <60
Treatment of HTN post ACS (within 1 year)
1st line: ACE/ARB, BB
2nd line: Add long acting CCB (avoid non-DHP CCB)
Treatment of HTN in patient with HFrEF
1st line: ACE/ARB, BB, MRA
2nd line: Hydralazine/ISDN (if ACE/ARB intolerant)
3rd line: Add thiazide +/- DHP-CCB
Treatment of HTN in LVH
1st line: ACE, ARB, CCB, Thiazide
2nd line: Combo of above
*avoid vasodilators (hydralazine, minoxidil), BB
SPRINT Indications (to target sBP <120)
Age >=75
BP >=130/80 and 1 of:
- Non-diabetic CKD (GFR 20-59, ACR >20 or >500mg/day but <1g/day)
- Clinical or subclinical CVD
- Global 10 year CV risk >=15%
SPRINT Exclusions
Diabetic Proteinuria >1g/day eGFR <20 EF <35% MI in last 3 months Past stroke Institutionalized elderly, frail Dementia with prognosis <3y Orthostatic hypotension with SBP <110 Nonadherence GN, PKD
BP Targets for HTN Treatment
All CKD (not dialysis/post-transplant): sBP <120
SPRINT candidate: sBP <120
Diabetic <130/80
All others <140/90
PCKD <110
CKD post-transplant: <130/80 (use CCB or ARB)
Threshold to initiate BP treatment
Hypertensive urgency SPRINT candidate and >=130/80 Low risk (no end organ or CV RFs) >=160/100 DM >=130/80 CV RFs >=140/90
Definition resistant HTN
Persistent HTN above target on >=3 drugs at optimal doses (1 should be diuretic if no c/i)
Indications to screen for renovascular HTN
2+ of:
- Onset of or worsening HTN at <30 or >55
- > =30% increase Cr after initiation of ACE/ARB
- Abdominal bruit
- Resistant HTN to >=3drugs
- Recurrent pulmonary edema
- Other established atherosclerotic disease, esp in smokers or DLPD
Diagnosis Renovascular HTN
CTA, MRA, Doppler, Captopril radioisotope scan
*NO captopril/CTA if GFR<60
Treatment atherosclerotic renovascular HTN
1st line: Medical Tx (ACEi/ARB not C/I, follow Cr/K)
2nd line: Angioplasty & stenting if ANY:
- Resistant HTN (on >=3 drugs)
- Deteriorating renal function
- Acute pulmonary edema
- angioplasty WITHOUT stenting in FMD
Treatment renovascular HTN related to FMD
1st line: Angioplasty without stenting
2nd line: Surgical revascularization
Imaging for confirmed FMD
CTA or MRA from head to pelvis (must include intracranial, neck, abdomen/pelvis)
When to suspect FMD
Asymmetric kidney size (>1.5 cm)
Abdominal bruit without atherosclerosis rf
FHx
FMD in another vascular bed
*workup with CTA/MRA
Renal Cysts (Bosniak Criteria)
1-2: Simple cysts with thin walls, no/thin septae, no/fine calcifications, no enhancement –> NO FU
2F: 3+ septae or calcifications, no contrast enhancement –> Rpt img q6mo x2 then q1 yr
3: CONTRAST ENHANCING, thick walls, calcification, multiple septae –> partial nephrectomy
4: As per 3 but with solid enhancing component –> partial nephrectomy
If 3/4 but poor surgical candidate, percut bx then thermal ablation
Treatment Polycystic Kidney Disease (PCKD)
++Fluids
Na restriction <2g/day
Target BP <=110/75 if <50 years old with eGFR <60 without major CV comorbidities
Tolvaptan therapy for some
Calcium Oxalate Stones Disease Associations
Crohn’s Disease
Ileal disease (oxalauria)
PCKD
Calcium phosphate kidney stones - disease associations
Type 1 RTA
HyperPTH
Uric Acid stones disease associations
Gout
Haem malignancies
TLS
PCKD
only type radiolucent
Struvite stones disease associations
UTIs (proteus, Klebsiella = struvite splitting organisms)
Treatment of nephrolithiasis
Increase fluid intake >2g/day
For Ca oxalate: Decrease Na and meat intake, decrease VitC, thiazides (not if hyperCa)
For Ca phosph: Decrease Na and meat intake, thiazides
For uric acid: Allopurinol, urine alkalization with K citrate
For struvite: Treat UTI
Prevention of CIN (Contrast induced Nephropathy)
Hold ACE/ARB, NSAIDs, Metformin, diuretics
Ensure euvolemia with isotonic fluids pre/post
Manifestations cholesterol emboli syndrome post cath
High urine eos/serum eos High ESR Low C3/C4 Normal urine micro Livedo, blue toes
Causes of AKI in renal transplant and manifestations
1) REJECTION (bx to dx): proteinuria, hematuria, pyuria, AKI, HTN, no fever/pain over graft, oligouric
2) Meds (Tac, Cyclo): bland urine
3) Infection (bacterial, BK virus late): pyuria, mild proteinuria or hematuria, tender over graft if pyelo
4) Renal A/V thrombosis (early): req urgent US
5) Recurrence of primary DZ
6) Post-transplant lymphoproliferative disorder (PTLD) - late
7) Hydro
Indications to do renal biopsy
Nephrotic Syndrome
Nephritic syndrome (except post-strep GN)
Progressive CKD without cause
(relative) Contra-indications to renal biopsy
Uncontrolled Severe HTN Solitary Kidney Hydronephrosis Active pyelonephritis Bleeding disorder or on antiplatelet (hold 5-7 days ) Pregnancy Plts <80-100 Small hyperechoic kidneys <9cm
FeNa Calculation and interpretation
FeNa% = 100 * [(SCr x Una)/(UCr x SNa)]
Interpretation:
<1% = pre-renal
>1% = renal
Fluid administration in post-obstructive diuresis
1) Fluid restrict until euvolemic
2) Once euvolemic: Replace 75% urinary losses with 1/2 NS until diuresis resolves
Causes of nephrogenic DI
- Meds: Li, Aminoglycosides, Rifampin, Cisplatin, Colchicine, Lasix, Clozapine
- Electrolytes: HyperCa, HypoK
- Post-obstructive
- Infiltrative disease: MM, Amyloid, Sjogrens, Sarcoid
- Sickle Cell Disease
Management of Cr rise with ACEi initiation
1) If rise >=50%: Stop ACE, screen for renovascular HTN
2) If rise >=30 but <50%: Reduce dose by 50%, reassess in 2-3 weeks. If still >=30%, stop.
3) If rise <30% - continue current dose
HTN followup
No HTN or organ dmg - yearly
HTN w/ exercise/lifestyle mx - q3-6mo (1-2mo if higher BP)
HTN on meds q1-2mo until at target, then q3-6mo
Secondary HTN causes
Renovascular Endocrine: Pheo, Thyroid, Cushing Primary Hyperaldo OSA Coarctation of aorta
Lifestyle Tx for HTN
Exercise: 30-60min, 4-7d/wk, ~150min/wk Weight: BMI 18.5-24.9, waist <102cm M, <88F to PREVENT HTN EtOH: abstain or <2/d to PREVENT DASH diet Salt <5g/d (<2g sodium, ie 87mmol Na) Stress reduction Smoking cessation NO NEED for Ca or Mg
anti-HTN meds caution
No BB as 1st line if age>60
NonDHP CCB + BB = risk of brady
No ACEi as monotherapy in black w/o other indication
No alpha blocker as 1st line
ANCA associations
c-ANCA/PR3: MPA, GPA
p-ANCA/MPO: MPA, eGPA
Nephritic/Nephrotic Lifestyle
- Smoking cessation
- Na restrict
- Prot restrict if nephrotic range proteinuria (0.8-1.0g/kg/d)
- BP <120 if no orthostasis/frailty
- Vaccines: pneumococcal, influenza, shingrix, COVID, hep B
- Pre-immunosuppresant: TBST, Hep serology, HIV, strongy
- On Tx: contraception, gonadal protection, PJPp for steroids/ritux/cyclo, bone health
CKD definition
> 3mo of abnormal kdiney structure/fcn:
- Albuminuria ACR>3mg/mmol (>30 = severe)
- AbN urine sediment
- Lyte abN 2/2 tubular d/o
- Structural abN on imaging
- Kidney Tx hx
- GFR <60mL/min/1.73m2
Stage 1 >90, Stage 2 60-89, Stage 3 30-60, Stage 4 15-30, Stage 5=5<15
Statins in CKD
Target LDL<2 or apoB <0.8, o nonHDL <2.6 if:
- > 50yo, stage 3-5 (ie GFR<60) or ACR >3mg/mmol, but NOT on HD
- DO not start in patients on HD (continue if alrdy on statin)
Uremic Sx on Hx
- Anorexia, pruritus, N/V, wt/appetite loss
- Metallic taste in mouth
- Pericarditis (without diffuse ST elevation)
- Peripheral neuropathy
- Bleeding (plt dysfcn)
- CNS (mental status change, sz, mood d/o)
- Amenorrhea, decreased libido, ED
- Nocturia, RLS
Indications for IHD
AEIOU Acidosis Electrolyte problems (hyperK) Intox (methanol, ethylene glycol, Li, ASA) Overload, vol Uremia (pericarditis, encephalopathy/sz)
DM CKD Screening, Tx, FU
T1DM - screen 5y after dx
T2DM - screen at dx then yearly: eGFR <60 or ACR>2 in 2/3 samples >3mo = CKD
Tx:
- Maximally tolerated ACEi/ARB (up to 30% Cr increase)
- Start SGLT2 if eGFR>30, can continue if GFR drops unless adverse events
- Nonpharm: Na<2g/d, Prot <0.8g/kg/d, Exercise 150min/wk
FU: check Cr/K at baseline then 1-2 weeks after starting/titrating or during illness
Anion Gap
Na-Cl-HCO3
For every albumin drop of 10, add 2.5 to AG
Delta Delta
12-AG: 24-bicarb
Delta AG > Delta HCO3 - Concurrent metabolic alk (HCO3 higher than expected) with AGMA
Delta AG = Delta HCO3 - Pure AGMA
Delta AG < Delta HCO3 - Concurrent nonAGMA with AGMA
Osmolar Gap
(2xNa + Gluc + BUN) - measured serum osm
Normal = 10
With high AG: methanol, ethylene glycol, paraldehyde, EtOH Ketoacidosis
WIth normal AG: EtOH, Isopropyl alcohol, mannitol, sorbitol, EARLY toxic alcohol
Urine AG
Na + K - Cl
NeGUTive = the gut
RF for ODS
HypoK, malnutrition, alcoholism, liver dz, low starting Na
Max correction 4-6 if any RF, otherwise 6-8
HyperK causes
1) Intake: supplements, transfusions
2) Decreased Excretion: CKD, vol deplete, drugs (ACEi, ARB, NSAID, MRA), hypoaldo (RTA 4, adrenal insuff)
3) Shifting: lysis (rhabdo, burns, TLS), metabolic (acidosis, low insulin), hyper osmolar (glucose, mannitol), familial hyperK periodic paralysis
4) Factitious: hypercellular blood (eg heme malignancies –> leuko/thrombocytosis, do VBG/ABG), hemolyzed, fist clenching/tourniquet
HyperK/HypoK ECG findings
Hyper: Peaked Ts, flat Ps, prolonged PR, bradyarrhythmia, prolonged QRS
Hypo: TWI, STD, U wave
HypoK causes
1) Intake
2) Low Mg
3) Shifting:
- Endocrine: insulin, thyrotoxic periodic paralysis
- Stress, catecholamines
- Metabolic alk
- EtOH w/d
- Hypothermia
- Drugs (amphetamines, antipsychotics)
Solid Renal Mass WU
CT/MRI
<1cm = active surveillance
>=1cm = likely cancer –> partial nephrectomy if life expectancy >5y (if <5y or not fit for surgery: biopsy then abalate)
PCKD Sx
HTN, abdo pain (cyst rupture), hematuria, proteinuria
Stones (uric acid, Ca oxalate)
UTI - 4 weeks abx if infected cyst
Erythrocytosis (increased EPO)
Extra-renal: liver cysts, colonic diverticuli, cerebral aneurysm, pancreatic cysts, MVP and aortic regurg
PCKD Dx and WU
Dx if positive family history and:
- Age 15-39 >2 cysts total or
- Age 40-59>1 per kidney
*yearly US with baseline MRI/CT for tot kidney vol
Who to Screen Hyperaldo
HTN +1 of:
- Unexplained spontaneous hypoK <3.5 or diuretic related hypoK <3.0
- HTN resistant to >=3 drugs
- Incidental adrenal adenoma and HTN
How to Screen Hyperaldo
Screen with: plasma aldo and plasma renin activity (or concentration)*
*OCP causes false positive
Hold MRA/K sparing/K wasting diuretics 4weeks before test. If non-diagnostic, hold ACE/ARB, BB, DHP-CCB 2 weeks and retest
Alpha blockers, nonDHP CCB, hydralazine OK
How to confirm positive hyperaldo screen
- Saline loading test (2L NS over 4h, abN if plasma aldo >280)
- Captopril suppression test
- Plasma aldo:renin ratio >270 w/ plasma aldo >440pmol/L
Who to screen Pheo
- Paroxysmal, labile, severe HTN (>180/110) refractory to tx
- HTN + H/A, palpitation, sweating, flushing
- HTN from BB, MAOi, surgery, anesthesia, micturition
- Incidental adrenal adenoma
- Hereditary: MEN2A/2B, NF-T1, Von hippel lindau
How to screen pheo
-24h urine tot metanephrines and catecholamines
- Consider plasma free metanephrines and free normetanephrines
- NOT urinary VMA
