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Nephrology Board Review

Nephrology Board Review. Emily Chang June 18, 2010.

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Nephrology Board Review

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  1. NephrologyBoard Review • Emily Chang • June 18, 2010

  2. 14. A 23 yo man with HIV comes for a f/u exam. He was hospitalized a week ago with Pneumocystis jiroveci pneumonia, which is being treated with trimethoprim-sulfamethoxazole and a prednisone taper. During his hospitalization, he was diagnosed with hyponatremia. He feels well, and his condition has significantly improved since his discharge 3 days ago. On physical exam, T 36.6, P 84, R 12, BP 110/60. He appears thin and in no apparent distress. Cardiac examination is normal. The lungs are clear to auscultation. There is no peripheral edema. CD4 87, Glu 182, BUN 12, Cr 0.7, Na 111, K 3.6, Cl 96, Bicarb 22, Alb 3.3, Phos 2.6 Serum osm 246, UNa 117, UK 24, Uosm 453 Which of the following is the most likely cause of his hyponatremia? A. Syndrome of inappropriate antidiuretic hormone secretion B. Volume depletion C. Adrenal insufficiency D. Pseudohyponatremia E. Psychogenic polydipsia

  3. Hyponatremia Free water intake + underlying impairment of free water excretion. 1. Check serum osm. If >280, then hyperglycemia or mannitol. Hyperglycemia correction is 1.6 for every 100 of glu over 100. 2. Check urine osm. If <100, then psychogenic, water intoxication or reset osmostat because the kidneys are functionally able to dilute urine. 3. Check volume status. If hypovolemic, check UNa. <25, then extrarenal fluid loss. >25, then renal fluid losses. If normovolemic, causes are many: renal failure, hypothyroid, adrenal insufficiency, pain/stress/trauma, positive-pressure ventilation, exogenous desmopressin, post-op. If all absent, then check UNa. >25 = SIADH. If hypervolemic, heart failure, cirrhosis or nephrotic syndrome.

  4. 34. A 61 year old woman is hospitalized for a 5-day history of nausea and vomiting and a 2-day history of postural lightheadedness. Her Cr is 7mg/dL (baseline Cr 1 month ago was 1 mg/dL). She has a h/o HTN and type 2 DM. Medications include aspirin, atenolol, glipizide, enalapril and chlorthalidone. On physical examination, P 68, BP 85/60. She is not in distress. Skin turgor is decreased. Cardiac and pulmonary examinations are normal. There is no peripheral edema. On neurological examination, she is alert and oriented. Glu 56, BUN 85, Cr 8, Na 120, K 3.7, Cl 86, Bicarb 26 UA several hyaline casts/hpf UCr 40, UNa 40 Which of the following is the next best step in this patient’s management? A. IV 3% NaCl, 100 mL B. Bolus therapy with 1000mL of NS (0.9%) C. Dialysis D. Fluid restriction E. Dopamine titrated to maintain a MAP of >60 mmHg

  5. Why is her UNa so high if she is volume depleted? - Use of diuretics - May represent a transitional state between pre-renal renal failure to ischemic tubular injury - In early ischemic tubular injury, urine sediment may be bland

  6. 39. A 34-year old woman who underwent elective laparoscopic bilateral tubal ligation 1 day ago develops severe HA and nausea the next morning. During the surgery, 5% dextrose in 1/4 strength normal saline therapy is initiated and maintained at 125 mL/h. She remains in recovery until late in the afternoon because she is too sedated to be discharged. IV meperidine is administered with adequate relief of her pain. Glu 115, BUN 12, Cr 1.0, Na 126, K 3.9, Cl 96, Bicarb 22 Which of the following is the most appropriate next step in the management of this patient? A. D/c 5% dextrose in 1/4 strength NS; begin 3% saline via infusion pump B. D/c 5% dextrose in 1/4 strength NS; begin IV 0.9% saline at 200mL/h C. Emergent CT scan of the head D. Administer naloxone E. Switch meperidine to fentanyl

  7. 48. A 73-year old woman is brought to the ED after falling at home. Her family states that she has been very confused and disoriented over the past 2 days and that she began therapy with a new medication 1 week ago. She also has type 2 DM. On physical exam, T 37C, P 68, R 12, BP 115/65. She is confused and unable to appropriately answer questions. Cardiac examination is normal. The lungs are clear to auscultation. There is no edema. Glu 94, BUN 17, Cr 1.1, Na 107, K 2.9, Cl 76, Bicarb 21. Therapy with which of the following agents was most likely recently started in this patient? A. Furosemide B. Acetazolamide C. Spironolactone D. Hydrochlorathiazide E. Amiloride

  8. HCTZ can cause severe hyponatremia. How? It works at level of cortical collecting duct by blocking Na/Cl co-transporter. Therefore it impairs kidneys diluting capacity but not concentrating ability. Relative volume depletion can be induced, leading to stimulation of ADH, which leads to urinary concentration, water retention and hyponatremia.

  9. 28. A 64 yo man is admitted to the ICU with pneumonia and septic shock. Over the past 4 days, he has had increasing SOB and fever. He has HTN. Surgical history is significant for a previous cholecystectomy. Medications are amlodipine and hctz. On physical examination, T 38.8C, P 110, R 22, BP 85/50. Cardiac exam reveals a greade 2/6 systolic murmur. On pulmonary exam, there are crackles over the entire right lung field. There is trace pedal edema. Glu 115, BUN 22, Cr 1.4, Na 135, K 4.8, Cl 103, Bicarb 10, Alb 3.8 pH 6.94, pCO2 48, pO2 51 Which of the following conditions is most likely present in this patient? A. Anion gap metabolic acidosis B. Mixed non-anion gap metabolic acidosis and respiratory acidosis C. Mixed anion gap metabolic acidosis and respiratory alkalosis D. Mixed anion gap metabolic acidosis and respiratory acidosis E. Mixed non-anion gap metabolic acidosis and respiratory alkalosis

  10. Acid/Base • Look at ABG for pH and pCO2 to determine if respiratory • Look at Bicarb for metabolic component • Calculate AG (remember to correct for Alb) • Calculate Delta-Delta to determine if non-gap component • Determine if respiratory compensation is adequate: • Winter’s formula: Expected pCO2 = 1.5 (HCO3) + 8 +/- 2

  11. 62. A 44 yo woman with cirrhosis 2/2 autoimmune hepatitis is hospitalized for a progressively worsening 2-day h/o fever and abdominal pain. She is currently on the orthotopic liver transplant list and has been clinically stable for the past month. She has previously undergone transjugular intrahepatic portosystemic shunt placement and a cholecystectomy. Medications are oral spironolactone 100mg BID, furosemide 80mg BID and oral lactulose 30 mL BID. On physical exam, T 38.2C, P 72, R 24, BP 74/55. She appears cachectic. Cardiac and pulmonary exams are normal. The abdomen is distended, and there is diffuse tenderness. There is 1+ pitting edema in the lower extremities. SBP is suspected, and she is admitted to the hospital. Glu 84, BUN 20, Cr 1.3, Na 128, K 5.1, Cl 104, Bicarb 12, Alb 1.4 pH 7.25, pCO2 28, pO2 78 Which of the following is the most likely diagnosis in this clinical scenario? A. Mixed anion gap metabolic acidosis and respiratory alkalosis B. Mixed anion gap metabolic acidosis and respiratory acidosis C. Mixed non-anion gap metabolic acidosis and respiratory acidosis D. Anion gap metabolic acidosis E. Non-anion gap metabolic acidosis

  12. 65. A 21 yo man is evaluated in the ED for severely diminished mental status. He has a 3-day h/o nausea and has been unable to eat well. This morning, he vomited several times. On physical exam, T 37.4, P 105, R 28, BP 122/57, He is thin and appears in moderate distress. Cardiac and pulmonary examinations are normal. The abdomen is soft and nontender. A stool specimen is negative for occult blood. During the examination, he begins to vomit large amounts, aspirates a significant amount of his stomach contents, and develops respiratory failure. He is intubated and started on mechanical ventilation. Labs 1 hour after initiation of mechanical ventilation: Glu 980, BUN 11, Cr 1.7, Na 138, K 3.7, Cl 91, Bicarb 16 ABG on O2 pH 7.53, pCO2 19, pO2 67 Which of the following is the most likely acid-base disturbance present in this patient? A. Mixed anion gap metabolic acidosis/non-anion gap metabolic acidosis/respiratory acidosis B. Mixed anion gap metabolic acidosis/metabolic alkalosis/respiratory alkalosis C. Mixed anion gap metabolic acidosis with respiratory alkalosis D. Mixed metabolic alkalosis with respiratory acidosis

  13. Compensation • Metabolic Acidosis • Every 1 mmol/L decrease in HCO3 -> 1 mm Hg decrease in pCO2 • pCO2 should approach last two digits of pH (ex: pCO2 of 24 should correspond to pH of 7.24) • Metabolic Alkalosis • Every 1 mmol/L increase in HCO3 -> 0.7 mm Hg increase in pCO2. • Respiratory Acidosis • Acute: 10 mm Hg increase in pCO2 -> 1 mmol/L increase in HCO3 • Chronic: 10 mm Hg increase in pCO2 -> 4 mmol/L increase in HCO3 • Respiratory Alkalosis • Acute: Every 10 mm Hg increase in pCO2 -> • 2 mmol/L decrease in HCO3 • Chronic: Every 10 mm Hg increase in pCO2 -> • 4 mmol/L decrease in HCO3

  14. 77. A 56 yo man with a h/o alcoholism is found lying on the street with impaired consciousness. On arrival at the ED, he is unresponsive and intubated. On physical exam, T 36.1, P 70, BP 126/80. Fundoscopic exam shows no papilledema. Cardiac, pulmonary, and abdominal exams are normal. There is no peripheral edema. Glu 86, BUN 45, Cr 2.8, Na 138, K 5.4, Cl 94, Bicarb 14 ABG on O2 15 min after intubation: pH 7.28, pCO2 29, pO2 108 Plasma osm 316 UA calcium oxalate crystals Renal ultrasound reveals normal sized kidneys with no obstruction or hydronephrosis. Which of the following is the most appropriate treatment for this patient? A. Fomepizole and HD B. Bicarbonate supplementation C. Ethanol drip D. HD E. Fomepizole and ethanol drip

  15. Calculating osmolal gap: Can be useful if you are suspecting ethylene glycol or methanol intoxication. Measured serum osm - Calculated serum osm Calculated serum osm = 2 x Na + BUN/2.8 + Glu/18 If >10, suggest presence of unmeasured osmole.

  16. 11. A 55 yo man with HTN and diabetic nephropathy comes for a f/u visit. He was diagnosed with type 2 DM 10 years ago. He has no SOB or edema. Medications are glipizide 5mg BID, pioglitazone 30mg daily, metoprolol 100mg daily, fosinopril 80mg daily, hctz 25mg daily, atorvastatin 40mg daily, and asa 81mg daily. On physical exam, P 55, BP 145/85. He is obese. Retinal microaneurysms are present. On cardiac exam, there is a regular sinus rhythm with no murmurs. The lungs are clear to auscultation. There is trace pedal edema. Cr 1.0, Na 140, K 4.0, Cl 106, Bicarb 24 24-Hour urine protein excretion 6g/24 h UA 4+ protein, 1-2 erythrocytes and 8 leukocytes/hpf On abdominal ultrasounds, the right kidney is 12cm and the left is 12.2cm. There is normal echogenicity and no hydronephrosis, masses or stones. Which of the following is the most appropriate next step in this patient’s management? A. Increase hctz dose to 50mg daily B. Add amlodipine C. Add prazosin D. Increase metoprolol dose to 150mg/day E. Add losartan

  17. 66. A 45 yo woman is evaluated for newly diagnosed HTN. She has a FH of essential HTN, and both her parents have type 2 DM. On physical exam, BP 150/95. BMI is 32. The remainder of the exam is normal. BUN, Cr, electrolytes normal glu (fasting) 90 Total cholesterol 220, HDL 35, LDL 140, TG (fasting) 250 In addition to repeating BP measurement to confirm the diagnosis of HTN and counseling regarding lifestyle modification, therapy with which of the following agents is indicated for this patient? A. HCTZ B. Doxazosin C. Atenolol D. Irbesartan

  18. 13. A 45 yo woman is referred for evaluation for a blood pressure measurement of 150/94. Her husband is a nurse and regularly measures her BP at home. Her usual home BP measurement is between 110/76 and 120/80. She does not smoke cigarettes. Her mother has HTN. On physical exam, her average BP is 148/98. Results of lab studies, including the Cr, are normal. In addition to counseling regarding lifestyle modifications, which of the following is the most appropriate management for this patient? A. Begin hctz B. Begin enalapril C. Perform ambulatory BP monitoring D. Continue home BP measurement

  19. 30. A 65 yo woman is evaluated for resistant HTN. Despite use of antihypertensive therapy for over 20 years, her BP usually is approximately 160/90. For several years she has been taking amlodipine 10, metoprolol 100mg daily. However, her regimen recently was changed to lisinopril 20mg daily and SR verapamil 180mg daily. On physical exam, P 68, BP 178/100. On cardiac exam, PMI is prominent and displaced laterally. Lungs are clear to auscultation. Remainder of the exam is normal. BUN 18, Cr 0.9, Na 147, K 3.3, Cl 100, Bicarb 28 An echocardiogram reveals increased left ventricular mass. Which of the following is the most appropriate next step in this patient’s management? A. MRA B. hctz 25mg daily C. Aldosterone-Renin ratio D. CT scanning

  20. Hypertension • The target BP for the general population is <140/90 and is <130/80 for patients with DM or renal disease. • HTN and proteinuria are important risk factors for progression of diabetic nephropathy to ESRD. First line treatment in patients with diabetic nephropathy should be with ACE-I and ARBs. Combination therapy MAY be more effective than max ACE-I doses alone. • Based on ALLHAT trial, initiation of therapy with a drug that has been associated with improved insulin resistance (ACE-I and ARBs), especially in someone with risk factors for type 2 DM, have been associated with lower incidence of new-onset diabetes compared to diuretics and beta-blockers. • White coat hypertension cannot be proven with home BP monitoring, needs ambulatory BP monitoring • In early onset, severe or resistant HTN, especially with hypokalemia and hypernatremia (although these not always seen), screening for hyperaldo is indicated. ARR is preferred screening test. Levels best measured after BB, ACE-I and diuretics have been d/c’d. These patients will benefit from aldosterone blockade.

  21. 72. An 80 yo woman is evaluated for resistant HTN and fatigue. Home BP measurements are typically approximately 180/70. Medications are metoprolol 50mg daily, lisinopril 20mg daily and hctz 12.5mg daily. On physical exam, P 72, BP 180/70. BUN 12, Cr 0.9, Na 132, K 3.3, Cl 99, Bicarb 26 Plasma renin activity 0.36 ng/mL Which of the following is the most appropriate next step in this patient’s management? A. Double the dose of hctz B. Double the dose of metoprolol C. Double the dose of lisinopril D. Discontinue the hctz; add spironolactone 25mg daily

  22. 81. A 35 yo woman who is 15 weeks pregnant is referred for evaluation of HTN. She discontinued her antihypertensive regimen when she learned that she was pregnant. On physical exam, P 90, BP 160/98. Cardiac and pulmonary exams are normal. There is trace ankle edema. BUN 6, Cr 0.6, Na 136, K 3.7, Bicarb 23 Treatment with which of the following agents is most appropriate for this patient? A. HCTZ B. Lisinopril C. Losartan D. Labetalol E. Atenolol

  23. 9. A 51 yo man with h/o chronic lymphocytic leukemia with transformation to prolymphocytic leukemia is hospitalized for chemotherapy with R-CHOP (cyclophosphamide doxorubicin vincristine prednisone rituximab). Before initation of chemo, he receives allopurinol and NS @250 mL/hr. One day later, his Cr is 2.3 (baseline 0.8) and his UOP over the past 12 hours is 200 mL despite continued saline hydration. On physical exam, he is afebrile, pulse 98, R 16, BP 134/78. There is lymphadenopathy involving the cervical and submental chains and supraclavicular areas bilaterally, as well as bulky axillary and inguinal lymphadenopathy. Cardiac and pulmonary exams are normal. The spleen is palpable approximately 3-4 cm below the left costal margin, and there is no hepatomegaly. There is no edema, cyanosis or clubbing of the extremities. Hct 22, Leukocyte 72, Plt 19 BUN 63, Uric Acid 19, Cr 2.3, K 5.5, Bicarb 17, Alb 4.2, Ca 7.5, Phos 11 UA pH 5, numerous finely granular casts/hpf, no uric acid crystals Which of the following is the most appropriate next step in this patient’s management? A. Switch IV hydration to sodium bicarbonate B. Start furosemide C Start rasburicase D. Start HD E. Start probenecid.

  24. 63. A 83-year-old male nursing home resident w/ a hx of dementia is evaluated in the ED for abdominal pain. According to the nursing home staff, he had become increasingly agitated over the past day. • On PE, T 36.7 C, P 96, and BP 150/92. The patient appears frail and confused and is clutching his abdomen and writhing in pain. He is unable to answer questions. Pulmonary exam reveals crackles at both lung bases. Skin turgor is normal. There is suprapubic tenderness. The prostate is smooth, enlarged, and has an estimated mass of 40 g. There is trace ankle edema bilaterally. • Na 137, K 6.2, Cl 107, HCO3 18, BUN 63, Cr 3.6 • U/A: SG 1.014, Trace protein, 2-3 leukocytes/hpf, 3-5 erythrocytes/hpf • Which of the following is most likely to establish a diagnosis? • Response to normal saline • Blood urea nitrogen-creatinine ratio • Fractional excretion of sodium • Placement of a urinary bladder catheter

  25. 51. A 66 yo man with h/o CAD and HTN is evaluated for abd pain, low-grade fever, myalgias, nausea and generalized weakness. Cr is 6 (baseline 1.4). Two weeks ago, he was hospitalized for anginal chest pain. Cardiac catheterization at that time showed a 30% LAD stenosis and a 90% RCA lesion. A RCA stent was placed. On physical exam today, T 37.8C, BP 140/96. On cardiac exam, a right carotid bruit and S4 gallop are present. On pulmonary exam, the lungs are clear. Abd exam is unremarkable. There is trace pretibial edema bilaterally, and the distal pulses are not palpable. A netlike violaceous rash is visible over the legs, and the right great toe is cool and cyanotic. Hgb 8.3, leukocyte 6.7, Plt 434 C3 low, C4 normal UA 1+ blood, 1+ protein, 3-5 leukocytes/hpf, 5-10 erythrocytes/hpf Which of the following is the most likely diagnosis? A. Radiocontrast nephropathy B. Prerenal acute renal failure C. Acute interstitial nephritis D. Microscopic polyangiitis E. Atheroembolic disease

  26. 68. A 66 yo woman is evaluated for fatigue, decreased exercise tolerance of 1 month’s duration, and new-onset DOE. Therapy with OTC ibuprofen was unsuccessful, and she d/c’d its use. She has a h/o HTN and was diagnosed with type 2 DM that is controlled by diet 2 years ago. Medications are lisinopril 20mg daily and hctz 25mg daily. On exam, P 74, BP 148/86. The conjunctivae are pale. Cardiac exam reveals a grade 2/6 systolic ejection murmur. There is 1+ LE edema. Hgb 7.2, leukocyte count 7.1, Plt 125 BUN 64, Cr 5.2, Na 133, K 4.1, Cl 110, Bicarb 19, Glu 142, Alb 4.0, Ca 11.0, Phos 5.4 UA pH 5.0, SG 1.015, no blood, 1+ protein, 5-10 leukocytes/hpf UPC ratio 2.5 mg/g Which of the following is the most likely cause of this patient’s renal failure? A. Chronic interstitial nephritis B. Hypertensive nephrosclerosis C. Acute interstitial nephritis D. Myeloma kidney E. Diabetic nephropathy

  27. AKI • Pre-renal, post-renal, intrinsic • CLINICAL clues!!! • FeNa <1% suggests pre-renal, >2% c/w tubular injury, but interpret carefully in clinical context • Urine sediment • Renal Ultrasound • Pre-renal causes: • GI losses • Hemorrhage • HF • Renal Artery Stenosis • Drug-induced • Sepsis • HRS • Compartment Syndrome Post-renal causes: Prostate enlargement Pelvic tumor Ureteral tumor, stones or stricture Crystals Drugs Proteins (cast nephropathy) Intrinsic causes: Ischemic Nephrotoxic AIN GNs TMAs Atheroembolic disease

  28. 8. A 52 yo woman with type 2 DM and HTN comes for a routine office visit. She has a 30 pack-year h/o cigarette smoking. Her mother had DM and was on HD. Medications are insulin, metoprolol 100mg daily, fosinopril 40mg daily, hctz 50mg daily, atorvastatin 40mg daily, and asa 81mg daily. On exam, BP 165/95. There are retinal microaneurysms. Cardiac exam reveals a regular rhythm with an S4. The lungs are clear to auscultation. There is no JVD. There is 1+ pedal edema. The distal pulses are absent in both feet. HgbA1c 7.2% Glu 180 Cr 1.2 24-hour urinary protein excretion 1.8g/24 h Which of the following factors is most likely to cause this patient’s CKD to rapidly progress to ESRD? A. Poorly controlled DM B. Family history C. Poorly controlled HTN D. Proteinuria E. Cigarette smoking

  29. 19. A 50 yo woman with type 2 DM and progressive CKD comes for a f/u visit. She has had leg swelling but does not have nausea, vomiting, chest pain, SOB, orthopnea, PND or dysuria. She follows a 0.8mg/kg/d dietary protein restriction and takes lisinopril 80mg daily. On exam, BP 130/70. There are retinal microaneurysms. Cardiac exam reveals a regular sinus rhythm with an S4 and a grade 2/6 systolic murmur at the base. The lungs are clear. There is JVD. The abdomen is large with normal bowel sounds. There is no pedal edema. Pinprick and vibratory sensation are absent in both feet. Hct 35%, Hgb 11 Iron 45, iron binding capacity 290 Ferritin <12 Cr 2.0 Sodium 138, K 5.0, Cl 106, Bicarb 22, Alb 3.5 24-hour urinary protein excretion 3g/24 h An EKF is normal. Which of the following is the most appropriate next step in this patient’s management? A. Refer for permanent vascular access B. Restrict protein intake to 0.6 g/kg/d C. Start erythropoietin treatment D. Add diltiazem 120mg daily

  30. 2. A 60 yo woman with h/o type 1 DM and stage 4 CKD comes for a routine f/u exam. She asks about modalities of RRT. Which of the following is the best option for this patient? A. 0-Ag mismatched deceased donor kidney transplantation B. PD C. HD D. Living donor kidney transplantation after a course of dialysis E. Preemptive living donor kidney transplantation

  31. CKD • An alteration in kidney function or structure of 3months or greater and progressive loss of renal function and/or complications due to decreased renal function. • Strategies to slow progression: • ACE-I or ARB therapy • BP control • Tight glycemic control in diabetics • Low protein diet (0.8-1 g/kg/d) • Cholesterol lowering to <100 • Erythropoietin for goal Hgb >12 • Low sodium diet • Smoking cessation • Weight loss • Reduce elevated Ca-Phos product • Avoid nephrotoxic drugs • Referral for vascular access and transplant eval when GFR reaches 30mL/min range • Preemptive transplant has improved mortality compared to transplant after dialysis. • Living donor transplants are equivalent to or better than well-matched deceased transplants.

  32. 71. A 70 yo woman with HTN and CKD comes for a f/u visit. On exam, P 80, BP 140/80. BMI is 21. Cardiac exam reveals a regular sinus rhythm with no murmur. The lungs are clear. Bowel sounds are normal. There is 1+ pedal edema. BUN 30, Cr 2.5, Na 140, K 5, Cl 105, Bicarb 20, Phos 7, Ca 9, Alb 3.5 Which of the following is the most likely cause of this patient’s hyperphosphatemia? A. Primary hyperparathyroidism B. High Phos intake C. Vitamin D deficiency D. GFR decrease E. Hypocalcemia

  33. Secondary Hyperparathyroidism • In patients with CKD, Phos excretion goes down and retention occurs when GFR <60. • Increase in Phos causes decrease in ionized Ca which stimulates PTH secretion. • Serum levels normalize at expense of elevated PTH levels. • As kidney function worsens, 1,25-vit D deficiency contributes to hypocalcemia, further stimulating PTH secretion. As GFR goes down further, phosphate excretion also decreases leading to hyperphosphatemia.

  34. 18. A 49 yo man with h/o gouty arthritis comes for a f/u evaluation. One week ago, he was evaluated in the ED for left-sided flank pain and hematuria. A plain abdominal X-ray is unremarkable. After radiography is performed, the patient urinates debris and his pain is immediately relieved. Labs obtained in the ED: BUN 12, uric acid 9.0, Cr 1.0, Na 138, K 4.6, Bicarb 26, Alb 4.0, Ca 10.1, Phos 2.1 UA pH 5, 3+ blood, 10-15 erythrocytes/hpf He has had no further symptoms. Which of the following is the most likely diagnosis? A. Calcium oxalate stones B. Uric acid stones C. Calcium phosphorous stones D. Struvite calculi E. Cystine stones

  35. 27. A 25 yo man with h/o active Crohn’s disease with several small-bowel resections is evluated for recurrent calcium oxalate kidney stones. He typically passes 3-4 stones each year and he becomes incapacitated during acute attacks. He requests further therapy for stone prevention. A plain abdominal X-ray is obtained in the office and reveals no calcifications in the GU tract. Uric acid 6.8, BUN 10, Cr 0.8, Na 139, K 4.3, Bicarb 25, Ca 9.9, Phos 2.2 UA pH 5.0, no blood or protein In addition to increasing fluid intake, which of the following recommendations is warranted? A. Ca intake >1g/d B. A high sodium diet C. A high protein diet D. Furosemide 40mg daily

  36. 36. A 56 yo woman is evaluated for recurrent UTIs. Three weeks ago, she had a UTI with Klebsiella, and she has had four previous Proteus UTIs over the past 6 months. Physical exam is unremarkable. UA is significant for LE and 2+ blood, and pH is 7.5. Abdominal CT reveals a 5-cm staghorn calculus in the left kidney. In addition to increasing fluid intake, which of the following is the most appropriate therapy in this setting? A. Potassium citrate B. Allopurinol C. Antibiotics D. Low-calcium diet

  37. 44. A 44 yo man with h/o nephrolithiasis requests nonpharmaceutical interventions for stone prevention. His last symptomatic kidney stone was 2 years ago. He does not recall the exact type of stone that he formed but believes that it contained calcium. Previous labs have showed normal renal function and normal levels of Ca, Phos and uric acid. A plain abdominal X-ray performed 1 year ago revealed no GU calcifications. He does not have a FH of nephrolithiasis but wishes to reduce his chances of developing further kidney stones. In addition to increasing fluid intake to >2L/d, which of the following is the best initial therapy for this patient? A. Increase dietary calcium intake B. Decrease dietary sources of citrate C. Increase dietary animal protein intake D. Increase dietary sodium intake

  38. Nephrolithiasis • Predominantly calcium, but also uric acid, struvite and cystine. • Fluid intake is key. • Risk factors: • high sodium and protein intake and low calcium intake, low fluid intake • Hypercalciuria, hypocitraturia, hyperuricosuria, hyperoxaluria • Gout, obesity, RTA, sarcoidosis, primary hyperPTH, medullary sponge kidney, horseshoe kidney, HIV/AIDs with protease inhibitors, type 2 DM • PCKD, Dent’s disease, cystinuria, primary hyperoxaluria

  39. Hypercalciuria most common abnormality, usually related to increased Ca absorption in gut. Excess Ca from bone and renal tubular defects in Ca absorption can also contribute. • People with gout have increased levels of uric acid in their urine. These stones are radiolucent (can’t be seen on x-ray – need CT or U/S). • Calcium oxalate stones are most prevalent, but elevated urinary oxalate levels only account for 8% of metabolic abnormalities in nephrolithiasis. Associated with low Ca diet (lack of intestinal Ca available for oxalate binding) and malabsorption syndromes that increase oxalate absorption in the gut and prolonged use of Abx that alter enteric flora that degrade oxalate. High affinity for oxalate to bind Ca in urine leads to insoluble precipitates and Ca oxalate stones. • Oxalate rich foods are nuts, chocolate, rhubarb, spinach. • Citrate inhibits crystal formation and binds to urinary Ca. • Staghorn calculi most commonly struvite magnesium, ammonium phosphate, and /or Ca carbonate. Chronic infections from Proteus and Klebsiella which convert urea to ammonia, causing alkaline urine and struvite crystallization. Do NOT further alkalinize with potassium citrate.

  40. 41. A 29 yo black man with HIV infection comes for a routine exam. He has a h/o numerous OIs and was reently treated with a course of IV acyclovir. He also is positive for Hep C. On exam, there is 2+ pitting edema to the knees. The remainder of the exam is normal. BUN 30, Cr 1.8, Alb 2.8 UA no hematuria, 4+ proteinuria, abundant oval fat bodies, no other formed cellular elements, no glycosuria, no amino aciduria, no granular casts C3 110, C4 35 CD4 180 HIV RNA VL 5,000 copies Renal U/s reveals echogenic kidneys Which of the following is the most likely cause of this patient’s renal dysfunction? A. Trimethoprim-sulfamethoxazole B. Pentamidine C. Collapsing FSGS D. Postinfectious membranoproliferative glomerulonephritis

  41. 24. A 34 yo asymptomatic black man is evaluated for peripheral edema of several months’ duration. Medical hx is unremarkable. On exam, P 79, BP 140/90. He is in excellent health and appears muscular. There is 2+ lower extremity edema. The remainder of the exam in normal. BUN 5.1, Cr 1.8, Alb 3.0 UA 3+ proteinuria, several oval fat bodies/hpf UPC ratio 3mg/g Which of the following is the most likely diagnosis? A. Membranous nephropathy B. FSGS C. MCD D. MPGN E. Focal proliferative lupus nephritis

  42. 16. A 65-year-old man is evaluated for hypoalbuminemia, hyperlipidemia, and slowly progressive proteinuria that have developed over 1 year. One year ago, he underwent squamous cell lung cancer resection. • On PE, BP is 150/90. Cardiac exam reveals a normal S1 and S2 w/o rubs or gallops. Pulmonary exam shows decreased breath sounds in the right lower lobe consistent with his previous surgery. Abdominal exam is normal. There is 3+ edema of the lower extremities. • Lab studies: • BUN 17, Cr 1.0 • U/A: Sp Grav 1.020, numerous granular casts and oval fat bodies/hpf • 24-hour urinary protein excretion: 15 g/24 h • CXR reveals a new 1-cm nodule in the left upper lobe. • Which of the following is the most likely cause of this patient’s renal symptoms? • Minimal change glomerulopathy • Focal segmental glomerulosclerosis • Membranous nephropathy • IgA glomerulonephritis • ANCA associated vasculitis

  43. 3. A 21-year-old woman is evaluated for facial and lower-extremity edema of 1 week’s duration. For the past 3 weeks, she has had fatigue. She has no history of diabetes mellitus, cigarette smoking, or illicit drug use. • On PE, blood pressure is 90/55. Cardiac and pulmonary exams are normal. There is periorbital edema. The abdomen is soft and without masses. There is 2+ lower extremity edema. • Cr 0.7 • Total cholesterol 325 • Albumin 2.9 • C3 and C4 normal • Urinalysis: Sp Grav 1.026, 3+ protein, 0-1 erythrocytes/hpf, numerous oval fat bodies/hpf • 24-hour urinary protein excretion 15 g/24 hr • Which of the following is the most likely diagnosis? • Minimal change glomerulopathy • Membranous nephropathy • Focal segmental glomerulosclerosis • Membranoproliferative glomerulonephritis • Systemic lupus erythematosis nephritis

  44. Nephrotic Syndrome • FSGS (most common, younger age) • Membranous (older, assoc with infections – HBV, HCV, syphilis, autoimmune, carcinomas, drugs) • MCD (primarily seen in children, edema, hypoalbuminemia, hypercholesterol, oval fat bodies) • MPGN (usually associated with infections, immunocompromised diseases like SLE, cryo) • Secondary causes: • Diabetic nephropathy • Amyloidosis • HIVAN (typically collapsing FSGS variety, will see proteinuria) • SLE type V • Obesity

  45. 49. A 42-year-old man is evaluated for a 2-month history of rash on his lower extremities and a 6-month history of cold-induced acral cyanosis and discomfort. He also has a 2-month history of alcohol abuse. • On PE, pulse is 78 and BP is 150/90. Cardiac and pulmonary exams are unremarkable. On abdominal exam, the liver is 3 cm below the right costal margin. A spleen tip is not felt. There is 1+ lower-extremity edema. A purpuric rash also is present on the lower extremities. • Hg 11.4, Platelet count 120,000 • Cr 1.7 • C3 86, C4 5 • AST 57, ALT 5 • UA 3+ hematuria, 1+ protein, 7-10 dysmorphic erythrocytes/hpf • Which of the following is most likely causing this patient’s renal abnormalities? • Systemic lupus erythematosus glomerulonephritis • Henoch-Schonlein purpura glomerulonephritis • Cryoglobulinemic glomerulonephritis • Antineutrophil cytoplasmic antibody-associated small-vessel vasculitis • Anti-glomerular basement membrane glomerulonephritis

  46. 6. A 17-year-old man is evaluated for the abrupt onset of a lower-extremity rash and intermittent episodes of mild abdominal pain. He is otherwise asymptomatic. • On PE, respiratory rate is 18, pulse is 78, and BP is 140/90. Cardiac, pulmonary, and abdominal exams are normal. There are lesions resembling palpable purpura on the extremities. • BUN 16, Cr 0.9 • C3 100, C4 31 • UA 1+ protein, 12 dysmorphic erythrocytes and 1 erythrocyte cast/hpf • Which of the following is the most likely diagnosis? • Systemic lupus erythematosis glomerulonephritis • Antineutrophil cytoplasmic autoantibody-associated small-vessel vasculitis • Cryoglobulinomic vasculitis • Henoch-Schonlein purpura • Postinfectious glomerulonephritis

  47. Nephritic Syndrome • IgA nephropathy (most common, normal C3) • Post-strep GN (ASO, low C3) • Lupus nephritis (+ANA, anti-ds DNA, low C3) • Anti-GBM Ab disease (anti-GBM) • HSP (IgA nephropathy, systemic vasculitis, normal C3) • MPGN (low C3) • Cryoglobulin (low C3, HCV Ab) • Endocarditis (fever, + blood cx, low C3) • Small- and Medium-Vessel Vasculitis

  48. (Questions from MKSAP 14) WooHoo!

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