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Nephrology Flashcards

1
Q

Approach to NAGMA

A

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

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2
Q

Hyponatremia - calculating volume to give

A

[(0.5 or 0.6 x Weight) x (target Na - current Na) ] / [Na infusate]
*Na infusate: RL = 130, NS= 154, 3% 513

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3
Q

Hypernatremia - free water deficit

A

[(0.5 or 0.6 x Weight) x (current Na - target Na)] / (Target Na)

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4
Q

HypoK Approach

A

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.

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5
Q

Manifestations of Glomerulonephritis

A 
PHAROH
Proteinuria (<3g/day) 
Hypertension
AKI
Red cell casts/dysmorphia
Oliguria
Hematuria
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6
Q

Manifestations of Nephrotic Syndrome

A

Hypoalbuminemia
Edema
HyperLipidemia
Proteinuria >3.5g/24 hr

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7
Q

Differential Diagnosis Glomerulonephritis

A

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)
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8
Q

Normal C3 and C4 GN

-what it’s assoc’d w/ and treatment

A

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)

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9
Q

Low C3 and Normal C4 GN

-presentation, tests

A

Post-Strep/infectious GN (eg strep throat/cellulitis, abscess, IE)
+anti-DNase B, +ASOT,
-Hematuria, proteinuria, HTN

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10
Q

Low C3 and C4 GN

A

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

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11
Q

Normal C3 and low C4 GN

A

MPGNs (MC Type 1)

  • Infections: Hep C > Hep B
  • Autoimmune: Cryoglobulinemia, TMA/HUS, complement dysregulation syndrome
  • Haem: Monoclonal gammopathies
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12
Q

Treatment of ANCA associated GN

*induction and maintenance

A

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)

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13
Q

Treatment of anti-GBM associated GN

A

Steroids (pulse –> taper)
Cyclophosphamide or ritux
PLEX for all (until titers not detectable)
NO maintenance therapy as low risk recurrence

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14
Q

Manifestations of IgA Nephropathy

A

“Synpharyngitic” GN
Spectrum: asymptomatic hematuria, flank pain, RPGN, nephrotic syndrome
If accompanied by systemic dz (=HSP) - purpura + arthritis

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15
Q

Indications to biopsy suspected IgA nephropathy

A

Systemic manifestations
Heavy proteinuria
Progressive AKI (not recovering spontaneously)

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16
Q

Classes of Lupus Nephritis

A

I/II: Bland sediment, proteinuria <3.5g/day, no AKI
III/IV: GN - AKI, Hypertension, Proteinuria, Hematuria
V: Membranous - nephrotic range proteinuria

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17
Q

Treatment Class III/IV SLE Nephritis

A

Induction:
Steroids pulse –> 1mg/kg
MMF or cyclo

Maintenance:
ACEi for proteinuria
Steroid taper
MMF or Aza

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18
Q

Treatment Class V SLE Nephritis

A

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)

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19
Q

Treatment post-strep GN

A

Supportive care
Diuresis
Biopsy if not resolving spontaneously after 3-4 weeks or requiring dialysis (unusual)

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20
Q

Treatment MPGN

A

Treat underlying cause

Consider steroids, CNI, MMF, Cyclo if refractory

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21
Q

Differential Diagnosis Nephrotic Syndrome

A 
DM
Amyloidosis
Minimal Change DZ - Primary/Secondary
MC = Membranous - Primary/Secondary
FSGS - Primary/Secondary - MC in blacks
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22
Q

Secondary Causes Minimal Change Disease

A

Malignancy: Hogkin’s Lymphoma, Leukemia
Drugs: COX inhibitors, NSAIDs, Li
Bee stings

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23
Q

Secondary Causes Membranous Nephropathy

A

Malignancy: Solid tumors > Haem cancers (CLL)
AI Disease: SLE, Sarcoid
Infection: Hep B > Hep C, Syphillis
Drugs: NSAIDs, Anti-TNF, Gold, Penicillamine

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24
Q

Secondary Causes FSGS

A

Infection: HIV (HIVAN - CD4<200), parvo, EBV
Drugs: Pamidronate, heroin, anabolic steroids
Hyperfiltration: Obesity, Solitary kidney, reflux nephropathy

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25
Q

Treatment of Nephrotic Syndrome

A
  • 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)
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26
Q

Causes of non-nephrotic range proteinuria (without active urine sediment)

A

Transient (ie. with fever, exercise)
Orthostatic
Overflow - pigment (rhabdo, hemolysis), MM
Tubulointerstitial - heavy metals, sarcoid, sjogrens, nsaids
Post-renal

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27
Q

Differential Dx Pre-renal AKI

A

True hypovolemia
Intravascular depletion (CHF, cirrhosis)
NSAIDs (altered renal flow)

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28
Q

Causes of ATN

A

Prolonged/Severe pre-renal state
Drugs: Contrast, ACE, ARB
Pigment: Hemolysis, Rhabdomyolysis, TLS, Myeloma

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29
Q

Causes and presentation of AIN

A

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

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30
Q

Sick Day Meds

A 
SADMANS
SGLT2s
ACE
Diuretics
Metformin
ARB
NSAIDs
Sulfonylureas
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31
Q

Treatment of hyperkalemia in CKD

A

Target K <5

  1. K-restricted diet (no oranges, tropical fruit, avocadoes, tomatoes, potatoes, beans, leafy greens, seeds, milk)
  2. Diuretics (if producing urine)
  3. Avoid NSAIDs, careful use of ACE/ARB/MRA, avoid septra and amiloride
  4. K binders eg lokelma aka Na zirconium cyclosilicate (S/E: edema, GI, costs) or Patiromer (binds colonic K)
  5. Dialysis
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32
Q

Treatment of metabolic acidosis in CKD

A

Target normal HCO3 >22

  1. Baking soda or Na Bicarb tabs (slows GFR decline)
  2. Dialysis
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33
Q

Treatment of anemia in CKD

A

Target Hgb 100-115, Ferritin >500, Tsat >30%

  1. Ensure Iron replete - if ferritin <=500 or Tsat < =30% give iron (IV > oral)
  2. 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

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34
Q

PTH/Ca/PO4 targets in CKD

A

PTH 2-9 x ULN if on HD, pre-HD target unknown

PO4 and Ca toward normal range

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35
Q

Treatment of hyperphosphatemia in CKD

A

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)

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36
Q

Treatment of hypocalcemia in CKD

A

Calcitriol (1,25-OH VitD) - cannot use if hyperPO4

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37
Q

Treatment of CKD-MB

A

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

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38
Q

Indications for hypertonic Saline

A

GCS <=8
Seizures
*Target 4-5 correction ASAP

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39
Q

Causes hyponatremia

A

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&raquo_space;SOsm): Pain, NV, hypoT4, AI, lung or brain disorders, SCLC, drugs (carbamazepine, SSRI, TCA, MDMA, thiazides)

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40
Q

Rate of Na correction in chronic Na disorders

A

HypoNa: 4-8/day
HyperNa: 8-12/day

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41
Q

Positive Water deprivation test to diagnose DI

A

Serum Na >=145 and Plasma Osm >=295

Uosm remains <250-300

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42
Q

Causes of central DI

A

Post pituitary resection
Pituitary infarct or bleed
Trauma

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43
Q

Barter’s Electrolyte Profile

A

“Like lasix”
Can cause low serum Na/K/Cl/Ca
High urine Na, K, Cl, Ca

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44
Q

Gittleman’s Electrolyte Profile

A

“Like thiazide”
Can cause low serum Na/K/Cl, normal or high Ca
High urine Na/K/Cl, normal or low urine Ca

45
Q

BP Cutoffs by various approaches

A

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

46
Q

Definition Hypertensive Urgency

A

BP>=180/110 with no end organ dysfunction

47
Q

Treatment Isolated Systolic HTN without compelling indications

A

1st line: ARB, CCB, Thiazide
2nd line: Combination of above
3rd line: ACEi, Alpha-blocker, non-DHP CCBs

48
Q

Treatment diastolic (+/- systolic) HTN without compelling indications

A

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

49
Q

Treatment HTN in patient with DM

A

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

50
Q

Treatment HTN in patient with non-diabetic CKD (ACR >30, protein >150mg/24 hr)

A

1st line: ACE or ARB

2nd: Thiazide (or loop if vol overload)
3rd: Add CCB

51
Q

Treatment of Chronic HTN Post Stroke/TIA

A

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

52
Q

Treatment in HTN in patient with CAD +/- angina/MI

A

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

53
Q

Treatment of HTN post ACS (within 1 year)

A

1st line: ACE/ARB, BB

2nd line: Add long acting CCB (avoid non-DHP CCB)

54
Q

Treatment of HTN in patient with HFrEF

A

1st line: ACE/ARB, BB, MRA
2nd line: Hydralazine/ISDN (if ACE/ARB intolerant)
3rd line: Add thiazide +/- DHP-CCB

55
Q

Treatment of HTN in LVH

A

1st line: ACE, ARB, CCB, Thiazide
2nd line: Combo of above
*avoid vasodilators (hydralazine, minoxidil), BB

56
Q

SPRINT Indications (to target sBP <120)

A

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%
57
Q

SPRINT Exclusions

A 
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
58
Q

BP Targets for HTN Treatment

A

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)

59
Q

Threshold to initiate BP treatment

A 
Hypertensive urgency
SPRINT candidate and >=130/80
Low risk (no end organ or CV RFs) >=160/100
DM >=130/80
CV RFs >=140/90
60
Q

Definition resistant HTN

A

Persistent HTN above target on >=3 drugs at optimal doses (1 should be diuretic if no c/i)

61
Q

Indications to screen for renovascular HTN

A

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
62
Q

Diagnosis Renovascular HTN

A

CTA, MRA, Doppler, Captopril radioisotope scan

*NO captopril/CTA if GFR<60

63
Q

Treatment atherosclerotic renovascular HTN

A

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
64
Q

Treatment renovascular HTN related to FMD

A

1st line: Angioplasty without stenting

2nd line: Surgical revascularization

65
Q

Imaging for confirmed FMD

A

CTA or MRA from head to pelvis (must include intracranial, neck, abdomen/pelvis)

66
Q

When to suspect FMD

A

Asymmetric kidney size (>1.5 cm)
Abdominal bruit without atherosclerosis rf
FHx
FMD in another vascular bed

*workup with CTA/MRA

67
Q

Renal Cysts (Bosniak Criteria)

A

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

68
Q

Treatment Polycystic Kidney Disease (PCKD)

A

++Fluids
Na restriction <2g/day
Target BP <=110/75 if <50 years old with eGFR <60 without major CV comorbidities
Tolvaptan therapy for some

69
Q

Calcium Oxalate Stones Disease Associations

A

Crohn’s Disease
Ileal disease (oxalauria)
PCKD

70
Q

Calcium phosphate kidney stones - disease associations

A

Type 1 RTA

HyperPTH

71
Q

Uric Acid stones disease associations

A

Gout
Haem malignancies
TLS
PCKD

only type radiolucent

72
Q

Struvite stones disease associations

A

UTIs (proteus, Klebsiella = struvite splitting organisms)

73
Q

Treatment of nephrolithiasis

A

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

74
Q

Prevention of CIN (Contrast induced Nephropathy)

A

Hold ACE/ARB, NSAIDs, Metformin, diuretics

Ensure euvolemia with isotonic fluids pre/post

75
Q

Manifestations cholesterol emboli syndrome post cath

A 
High urine eos/serum eos
High ESR
Low C3/C4
Normal urine micro
Livedo, blue toes
76
Q

Causes of AKI in renal transplant and manifestations

A

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

77
Q

Indications to do renal biopsy

A

Nephrotic Syndrome
Nephritic syndrome (except post-strep GN)
Progressive CKD without cause

78
Q

(relative) Contra-indications to renal biopsy

A 
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
79
Q

FeNa Calculation and interpretation

A

FeNa% = 100 * [(SCr x Una)/(UCr x SNa)]

Interpretation:
<1% = pre-renal
>1% = renal

80
Q

Fluid administration in post-obstructive diuresis

A

1) Fluid restrict until euvolemic

2) Once euvolemic: Replace 75% urinary losses with 1/2 NS until diuresis resolves

81
Q

Causes of nephrogenic DI

A
  • Meds: Li, Aminoglycosides, Rifampin, Cisplatin, Colchicine, Lasix, Clozapine
  • Electrolytes: HyperCa, HypoK
  • Post-obstructive
  • Infiltrative disease: MM, Amyloid, Sjogrens, Sarcoid
  • Sickle Cell Disease
82
Q

Management of Cr rise with ACEi initiation

A

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

83
Q

HTN followup

A

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

84
Q

Secondary HTN causes

A 
Renovascular 
Endocrine: Pheo, Thyroid, Cushing
Primary Hyperaldo
OSA
Coarctation of aorta
85
Q

Lifestyle Tx for HTN

A 
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
86
Q

anti-HTN meds caution

A

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

87
Q

ANCA associations

A

c-ANCA/PR3: MPA, GPA

p-ANCA/MPO: MPA, eGPA

88
Q

Nephritic/Nephrotic Lifestyle

A
  • 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
89
Q

CKD definition

A

> 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
90
Q

Statins in CKD

A

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)
91
Q

Uremic Sx on Hx

A
  • 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
92
Q

Indications for IHD

A 
AEIOU
Acidosis
Electrolyte problems (hyperK)
Intox (methanol, ethylene glycol, Li, ASA)
Overload, vol
Uremia (pericarditis, encephalopathy/sz)
93
Q

DM CKD Screening, Tx, FU

A

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

94
Q

Anion Gap

A

Na-Cl-HCO3

For every albumin drop of 10, add 2.5 to AG

95
Q

Delta Delta

A

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

96
Q

Osmolar Gap

A

(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

97
Q

Urine AG

A

Na + K - Cl

NeGUTive = the gut

98
Q

RF for ODS

A

HypoK, malnutrition, alcoholism, liver dz, low starting Na

Max correction 4-6 if any RF, otherwise 6-8

99
Q

HyperK causes

A

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

100
Q

HyperK/HypoK ECG findings

A

Hyper: Peaked Ts, flat Ps, prolonged PR, bradyarrhythmia, prolonged QRS

Hypo: TWI, STD, U wave

101
Q

HypoK causes

A

1) Intake
2) Low Mg
3) Shifting:
- Endocrine: insulin, thyrotoxic periodic paralysis
- Stress, catecholamines
- Metabolic alk
- EtOH w/d
- Hypothermia
- Drugs (amphetamines, antipsychotics)

102
Q

Solid Renal Mass WU

A

CT/MRI
<1cm = active surveillance
>=1cm = likely cancer –> partial nephrectomy if life expectancy >5y (if <5y or not fit for surgery: biopsy then abalate)

103
Q

PCKD Sx

A

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

104
Q

PCKD Dx and WU

A

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

105
Q

Who to Screen Hyperaldo

A

HTN +1 of:

  • Unexplained spontaneous hypoK <3.5 or diuretic related hypoK <3.0
  • HTN resistant to >=3 drugs
  • Incidental adrenal adenoma and HTN
106
Q

How to Screen Hyperaldo

A

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

107
Q

How to confirm positive hyperaldo screen

A
  • 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
108
Q

Who to screen Pheo

A
  • 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
109
Q

How to screen pheo

A

-24h urine tot metanephrines and catecholamines

  • Consider plasma free metanephrines and free normetanephrines
  • NOT urinary VMA

RCE (18 decks)

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