Renal

Question 1

Why are patients with chronic pancreatitis at increased risk of calcium oxalate stones?

Answer 1

Diarrhea –> volume depletion which increased quantity of calcium and oxalate in urine. Often have a metabolic acidosis which decreases urinary citrate. In fat malabsorption, calcium binds fat instead of oxalate leaving oxalate to precipitate in the urine.

Question 2

Secondary causes membranous glomerulopathy

Answer 2

Hep B, Hep C, lupus, syphilis, about 25% of patients older than 65 will have a malignancy diagnosed within 1 year of diagnosis of membranous glomerulopathy. So all should undergo age appropriate screening at diagnosis.

Question 3

When to immunosuppress in membranous glomerulopathy?

Answer 3

Need to rule out secondary causes. Then should wait at least 3-6months post initial diagnosis as up to 1/3 of patients have spontaneous remission

Question 4

Heparin and hyperkalemia?

Answer 4

Heparin use is associated with decreased aldosterone synthesis. This then leads to hyperkalemia. IT is more likely in patients iwth CKD, on diabetes, on ACEi or ARBs

Question 5

Pyroglutamic acidosis

Answer 5

presents with mental status changes and an increased anion gap in patients on chronic acetaminophen. Susceptible with critical illness, poor nutrition, CKD or liver disease

Question 6

Conditions with reset osmostat mild hyponatremia

Answer 6

pregnancy, quadriplegia, chronic malnutrition, advanced age, tuberculosis, and psychiatric disorders

Question 7

Lab test for primary membranous glomerulopathy

Answer 7

anti-phospholipase A2 Receptor (PLA2R) approaches 100% specificity for primary form

Question 8

Treatment for atherosclerotic renovascular disease

Answer 8

ARB/ACEi - studies have not shown benefit to angioplasty/stenting in patients with stable kidney function on optimized medication regimen. There is some benefit in patients who cannot tolerate ACEi/ARBs, patients with flash pulmonary edema and resistant HTN despite maximal HTN therapies

Question 9

Type 1 RTA

Answer 9

distal acidification defect. low bicarb, compensatory elevated chloride (leading to normal AG). Unable to acidify urine (so pH >6) and an elevated urine AG. Also hypokalemic

Question 10

Most common disease associated with type 1 RTA

Answer 10

Sjogren Syndrome

Question 11

Type 2 RTA

Answer 11

proximal defect in reclaiming bicarb. Normal AG metabolic acidosis, hypokalemia, glycosuria (Without hyperglycemia), low molecular weight proteinuria and phosphate wasting. DISTAL acidification is intact, so pH <5.5

Question 12

Type 4 RTA

Answer 12

Associated with aldosterone deficiency or resistance. Hyperkalemic and urine pH <5.5

Question 13

Subnephrotic proteinuria with no clinical symptoms

Answer 13

Likely FSGS

Question 14

Nephrotic syndrome with greatest risk for VTE

Answer 14

Membranous glomerulopathy

Question 15

Main causes of distal RTA’s in adults

Answer 15

autoimmune diseases (Sjogren’s RA), drugs (amphotericin) or toxin ingestion (toluene)

Question 16

Factors that increase the Cr without decreasing the GFR

Answer 16

Trimethoprim, cimetidine, ketone bodies, cefoxitin and flucytosine. Cr increase usuall 0.1-0.2mg/dL, but can be up to 0.5mg/dL

Question 17

Treatment of salicylate poisoning

Answer 17

Supportive care, often intubation as salicylates act in medulla and cause marked increase in minute ventilation. Alkalinzation of the urine with IV bicarb which traps the ionic form of salicylic acid in tubular fluid and enhances renal elimiation. OK even though alkalemic from respiratory status. HD for AMS, pulmonary/cerebral edema, renal failure and salicylate level >100

Question 18

Recommended IVFs in post-obstructive diureses

Answer 18

Aim for replacing about 50% of the urine output volume with 0.45 or 0.9% NS

Question 19

Simple renal cysts features on US and management

Answer 19

Round, thin, smooth, regular border. No septa, calcifications or solid components. Posterior enhancement on US. no Contrast enhancement or CT/MRI. Reassurance is all that’s needed <1% malignancy risk

Question 20

Complex renal cysts features on US and management

Answer 20

Few septa, calcifications. No contrast enhancement on CT/MRI. If less than 3 CM Category II and reassurance is all that’s needed. If >3 cm, repeat imaging in 6-12 months (5-10% malignancy risk)

Question 21

Cystic Mass features on US and management

Answer 21

Thick, irregular wall. Mulitple thick septa, often with calcifications. Enhancement on CT/MRI. Surgical excision of mass or nephrectomy. 90% malignant risk

Question 22

When do you refer to urology for evaluation of abnormal prostate testing?

Answer 22

Men with PSA >7 or abnormal DRE should be referred to urology for possible biopsy. If PSA 3-7, it should be repeated in a few weeks and referred to urology if remains >3

Question 23

Treatemtn for scleroderma renal crisis

Answer 23

ACEi regardless of current Cr at time of diagnosis

Question 24

Treatment to reduce recurrence of calcium oxalate stones

Answer 24

Increase free water fluid intake, decrease sodium and animal protein intake, increase dietary calcium intake (binds GI oxalate),

Question 25

Empiric antibiotics for prostatitis

Answer 25

TMP-SMX or fluoroquinolones

Question 26

Isolated proteinuria (up to 3g/day) without hematuria or elevated Cr or other symptoms in a young health individual

Answer 26

Orthostatic proteinuria. Check a spot urine Pro/Cr ration first hting in AM and in PM

Question 27

Post renal transplant presenting with rising Cr and tubulointerstitial nephritis typically 10-15 months post transplant. Often with intranuclear inclusions on urine cytology

Answer 27

BK polyoma virus. Need biopsy + positive immunohistochemical testing using Ab directed against BK virus for diagonsis

Question 28

Envelope shaped crystals in urine

Answer 28

Calcium oxalate stones

Question 29

Rhomboid crystals, radiolucent stones

Answer 29

Uric acid stones

Question 30

Staghorn calculi. Coffin lid crystals

Answer 30

Struvite stones

Question 31

Hexagonal green/yellow crystals. Large branched calculi

Answer 31

Cystine stones

Question 32

Next steps with K >8, but no EKG changes

Answer 32

Consider pseudohyperkalemia and recheck value with free flowing arterial draw

Question 33

Initial management of bilateral renal artery stenosis

Answer 33

Medical management with a diuretic and an ACEi or ARB. If fail this - or recurrent flash pulmonary edema then should undergo angioplasty with stenting