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Topics that our residents did not perform well on during the In-Training exam

Topics that our residents did not perform well on during the In-Training exam. Diagnosis of primary hyperaldosteronism in metabolic alkalosis Predict the composition of renal calculi in the setting of chronic UTI Recognize the limitations of the MDRD equation in estimating GFR

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Topics that our residents did not perform well on during the In-Training exam

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  1. Topics that our residents did not perform well on during the In-Training exam • Diagnosis of primary hyperaldosteronism in metabolic alkalosis • Predict the composition of renal calculi in the setting of chronic UTI • Recognize the limitations of the MDRD equation in estimating GFR • Distinguish between office and home hypertension • Management of hyperphosphatemia in a patient with CKD • diagnose psychogenic polydipsia • Treat hyponatremia • Diagnose mixed acid/base disturbances • Diagnose membranous GN • Evaluate PCKD • Diagnose IgA nephropathy • Manage proteinuria in CKD

  2. Question 1 A 45 y.o. woman is found to have a blood pressure of 150/95 mmHg during office visits on an intermittent basis over 3 months. Her blood pressure on two other office visits has been found to be within normal limits. She is in excellent health and on no medications. Her father has a history of hypertension.

  3. Question 1 The physical exam is remarkable only for a blood pressure of 150/90 mmHg. Labs including electrolytes, BUN, creatinine and urinalysis are normal. An ECG is normal. Which of the following is the most appropriate next step in the management of this patient? • Ambulatory BP monitoring • Echocardiography • Ongoing office follow up. • Start hydrochlorothiazide

  4. Question 2 A 65 y.o. male is referred for evaluation of edema and proteinuria. He complains of fatigue, but otherwise is asymptomatic. On exam the BP is 150/80. There is 1+ ankle edema. Labs show hemoglobin 10 (MCV 74, RDW 20); urine protein:creatinine ratio is 4.4 mg/gm, serum creatinine is 1 mg/dL, and cholesterol is 320 mg/dL. Serum complement levels are normal. Urinalysis shows 3+ protein, hyalofatty casts and oval fat bodies. Which of the following is the most likely cause of this patient’s renal symptoms? • Minimal change glomerulopathy • FSGS • Membranous glomerulopathy • IgA nephropathy • ANCA-associated GN

  5. Question 3 A 19 y.o. female is evaluated for sudden onset periorbital and pretibial edema. 3 weeks ago she was diagnosed with an URI that has since resolved. On PE the BP is 150/100. A soft S3 gallop is present. There are crackles at both lung bases. The liver is enlarged and tender. There is bilateral pitting pretibial edema. There is no rash. Labs show creatinine 1.5, albumin 3.8. C3 and C4 are low. Urinalysis shows rare dysmorphic red cells and trace protein. Which of the following is the most likely diagnosis? • IgA nephropathy • Goodpasture's syndrome • ANCA vasculitis • Postinfectious GN • SLE nephritis

  6. Question 4 A 19 y.o. female presents with a several month history of symmetric arthralgias, Raynaud’s phenomenon, and a Coomb’s positive hemolytic anemia. On physical exam she has a malar rash that crosses the nasal labial folds. The heart and pulmonary exams are unremarkable. Her abdomen is benign. There is 1 + leg edema. Urinalysis shows red cell casts and 2+ protein. A kidney biopsy shows immune complex focal proliferative glomerulonephritis. Which if the following tests provides the most additional diagnostic information? • Low C 3 and C4 • Positive ANA • Positive ss-DNA • Positive anti-Smith antibody • Positive ds-DNA

  7. Question 5 A 58 year old male with stage IV CKD secondary to diabetic nephropathy presents for routine follow up. Laboratory studies show calcium 8.2 mg/dL, phosphorus 5.8 mg/dL, PTH 456 pg/mL, 25-OH vitamin D 42 ng/mL, 1,25-(OH)2-vitamin D 58. Which of the following is the most appropriate next step in the management of this patient? • Start a 1,25-dihydroxy-vitamin D analogue • Start cinacalcet • Dietary phosphate restriction • Phosphate binder therapy • Parathyroidectomy

  8. Question 6 A 38 y.o. man with a history of chronic liver disease secondary to hepatitis C is treated with a 24-wk course of pegalated IFN combined with ribavarin. Four weeks after completing treatment he complains of proximal muscle weakness. On PE the BP is 120/80, pulse 110, RR 18. His general exam is unremarkable. On neurologic exam he has symmetric proximal weakness 3/5. Labs show Na 142, K 2.1, Cl 104, HCO3 20, creat 1. Urine Na 96, urine K 10, urine Cl 110, urine osm 585. Which of the following is the most likely diagnosis? • Distal renal tubular acidosis (type I) • Vomiting • Diuretic abuse • IFN complication • Hypomagnesemnia

  9. Question 7 A 45-yr-old previously healthy woman who weighs 50 kg undergoes surgery for a ruptured ovarian cyst. During surgery, she is given 2 L of lactated Ringer solution, and she is given 5% dextrose in 0.45% NaCl with 20 mEq/L KCl at 250 ml/h postoperatively. Forty-eight hours after surgery, she complains of headache and vomiting. BP is 140/80 mmHg. She is alert and oriented, and the general physical and neurologic examinations are unremarkable. Laboratory data reveal the following: Serum Na 115 mEq/L, plasma osmolality 241 mOsm/kg H2O, and urine osmolality 850 mOsm/kg H2O. The patient is not taking anything by mouth. In addition to stopping the 5% dextrose in 0.45% NaCl infusion, which ONE of the following would be the MOST appropriate treatment? • 5% dextrose in 0.9% saline with 20 mEq KCl at 250 ml/h • 5% dextrose in 0.9% saline with 20 mEq KCl at 50 ml/h • 3% saline at 100 ml/h plus intravenous furosemide until serum sodium concentration is 132 mEq/L • 3% saline at 50 ml/h plus intravenous furosemide until the serum sodium is 120 mEq/L

  10. Treatment of Severe and Moderate Symptoms in SIADH

  11. Treatment of Symptomatic Hyponatremia • Do not use equations • Start 3% saline at 1 ml/kg/hr-this will increase the plasma sodium on average by 1 mEq/L/hr • Monitor the patient • Measure the plasma sodium every hour initially • Stop therapy when symptoms resolve • Rise in plasma Na of about 5 mEq/L usually sufficient • Treat in ICU or step-down setting

  12. Question 8 A 45 year old Caucasian male is referred for further evaluation of a persistent elevation in the serum creatinine of 1.4 mg/dL. The physical exam show a blood pressure of 130/80 mmHg and is otherwise unremarkable. The urinalysis is normal. The estimated GFR is 56 ml/min per the MDRD equation. Renal ultrasound shows the right kidney 11.2 cm in size and the left kidney 10.9 cm in size. The urine protein:creatinine ratio returns at 0.056. Which of the following is the most appropriate step in this patient’s management? • Start enalapril • 24 hour urine for creatinine clearance • Start a thiazide diuretic • No further evaluation

  13. Key Points • The estimated GFR should be calculated using the MDRD equation whenever a serum creatinine is measured in steady state conditions for patients with an eGFR < 60 ml/min. • The MDRD eGFR can be falsely low in individuals with large muscle mass and near normal GFRs. • Consider 24 hour urine collections for creatinine clearance in the following populations: • Near normal GFR • Extremes of age and weight • Amputees • Pregnant women • Cirrhotics

  14. Question 9 A 46 y.o. male is hospitalized for severe necrotizing pancreatitis. He is placed on NG suction and over the first 24 hours of hospitalization he receives 6 liters of NS and then NS at 100 mL/hour. Over the next 24 hours his urine output increases to > 3 liters per day and his plasma sodium concentration rises from 145 meq/L on admission to 153 meq/L. On exam the blood pressure is 140/90. Chest is clear . There is no edema. Labs show sodium 153, potassium 3, chloride 112, bicarbonate 24, BUN 49, creatinine 1.1, urine sodium 50, urine potassium 20, urine osmolality 500 mosm/kg. Which of the following is the most likely cause of this patient’s polyuria? • Central diabetes insipidus • Nephrogenic diabetes insipidus • Post obstructive diuresis • Solute diuresis

  15. Polyuria • Urine output exceeding 3 L per day • Etiology • Water diuresis • diabetes insipidus • central • nephrogenic • primary polydipsia • Solute diuresis

  16. Evaluation of Polyuria Urine Osmolality < 250 mosm/kg > 300 mosm/kg Water Diuresis Solute Diuresis

  17. Urine and Plasma Osmolality in Disorders of Water Balance Normal 1000 Water Deprivation dDAVP 800 Primary polydipsia Uosm(mosm/kg) 600 Central DI 400 Nephrogenic DI 200 280 285 290 295 300 Posm(mosm/kg)

  18. Question 10 A 56 year old female presents with a 2 day history of weakness. On physical exam she is diffusely weak and is unable to sit up. The blood pressure is 160/95 mmHg. There is no edema. Urine [Na+] = 75 mEq/L Urine [Cl-] = 100 mEq/L FeK = 20% • 96 20 • 1.9 32 1.4 • Which of the following is the most likely diagnosis? • Vomiting • Gordon syndrome • Hyperaldosteronism • Gitelman syndrome

  19. Metabolic Alkalosis BP Volume status BP Normal or Low  Effective circulating volume BP High  ECF Loss of HCl Loss of Volume (Na+/H20) Primary Hyperaldosteronism Loss of Gastric secretions (vomiting, NG suction) Diuretics Bartter syndrome Gitelman syndrome

  20. Metabolic Alkalosis: Loss of Gastric Secretions-Maintenance Phase Volume Contraction Reabsorption of sodium, chloride, and bicarbonate along the nephron Secondary increase in aldosterone Metabolic alkalosis Paradoxical aciduria Elimination of sodium, chloride, and bicarbonate from the urine Increased H+ Excretion

  21. Variation in Urine Electrolytes in Vomiting

  22. Metabolic Alkalosis: Primary Hyperaldosteronism Increased Aldosterone Sodium Retention Hypertension Volume Expansion • Starling Forces in Proximal tubule • Atrial Natriuretic Peptide • Down regulation of NaCl CT in DCT Natriuresis

  23. Aldosterone Escape Aldosterone 110 Mean arterial Pressure 100 90 21 ECF Vol (L) 18 15 20 15 Urine [Na+] mEq/L 10 200 Na+ balance 0 -200 Days 8 10 12 14 16 18 2 4 6

  24. Urine Na+ and Cl- in the Differential Diagnosis of Metabolic Alkalosis and Hypokalemia Urine Electrolytes Na+ Cl- Condition (meq/L) Vomiting Alkaline urine >15 <15 Acidic urine <15 <15 Diuretic Drug active >15 >15 Remote use <15 <15 Hyperaldosteronism >15 >15

  25. Question 11 A 42 y.o. female is evaluated for minimal edema and a urinary protein excretion of 5 gm/24 hours. As a child she had frequent urinary tract infections and underwent a surgical procedure to reimplant the ureters to prevent reflux. On PE the BP is 140/95. There is trace peripheral edema. Labs show creatinine 1.5, albumin 3.4, Urinalysis shows 3 + protein and oval fat bodies. Chest x-ray is normal. Renal US shows a normal left kidney and the right kidney small and difficult to visualize. Which of the following is the most likely cause of the proteinuria? • Minimal change disease • Membranous nephropathy • FSGS • Membranoproliferative GN

  26. Question 12 A homeless man is discovered unconscious in the park and is brought to the emergency department. He wreaks of alcohol, is unkempt, and is incoherent. Physical examination shows a BP of 90/50 mmHg, heart rate of 120 bpm, temperature of 39°C, slight scleral icterus and dullness, and bronchial breath sounds over the right lower lung fields. Laboratory data reveal the following: Serum Na 131 mEq/L, K 2.9 mEq/L, Cl 70 mEq/L, CO2 21 mEq/L, blood urea nitrogen 34, creatinine 1.4 mg/dl, glucose 240 mg/dl, serum osmolality 320 mOsm/kg H2O, serum ketones weakly positive, pH 7.53, PaCO2 25 mmHg, PaO2 60 mmHg, and serum albumin 3.8 g/dl. Which ONE of the following choices BEST describes his acid-base disturbance? • Metabolic acidosis • Respiratory alkalosis • Metabolic acidosis and respiratory alkalosis • Metabolic acidosis and metabolic alkalosis • Metabolic acidosis, metabolic alkalosis, and respiratory alkalosis

  27. Question 13 23-year-old Caucasian female referred for further evaluation of hypokalemic acidosis. She was in her usual state of excellent health with normal growth and development until her second month of pregnancy. She had a spontaneous miscarriage, and was found to have a serum potassium of 3.2 mEq/L and a bicarbonate level of 19 mEq/L during a hospitalization for a D and C. She was treated with oral potassium and bicarbonate supplements and then weaned these off after 4 months of therapy. Six weeks later, she developed myalgias and collapsed due to profound weakness. She was found to have a serum bicarbonate level of 14 mEq/L with a serum potassium of 1.9 mEq/L. 140 114 13 Calcium 9.1 1.9 14 1 Phosphorus 3.5 ABG-pH 7.29, PCO2 30, pO2 100 Urine K 46 Urine Na 36 Urine Cl 42 Urine Osm 580 UA ph 6.8 trace protein No casts 10-15 white cells per high power field Which of the following is the correct diagnosis? • Type IV RTA • Diarrhea • Type I RTA • Renal tubular alkalosis • Proximal RTA

  28. Practical Approach (Hyperchloremic metabolic acidosis) Urinary Anion Gap NegativePositive Type 2 RTA Diarrhea DKA/Toluene HCl (Hyperalimentation) Urine pH and Plasma K Urine pH < 5.5, K Urine pH > 5.5, K nl/lowUrine pH > 5.5, K  Type 4 Type 1 (secretory defect Type 1 (voltage) or back-leak)

  29. Type I Classic Distal RTA-Mechanism 1 Tubular lumen Na+ Peritubular Capillary Na+ 3Na+ ATPase (-) 2K+ (-) H+ Retention K+ R-Aldo K+ Wasting Urine pH > 5.5 Ca-P stones Cl- ATPase 3Na+ H+ ATPase H2O 2K+ (-) T HCO3- OH- + CO2 K+ Cl- ATPase (-) H+

  30. Type I Classic Distal RTA-Mechanism 2 Tubular lumen Na+ Peritubular Capillary Na+ 3Na+ ATPase (-) 2K+ (-) H+ Retention K+ R-Aldo K+ Wasting Urine pH > 5.5 Ca-P stones Cl- ATPase 3Na+ H+ ATPase H2O 2K+ (-) T HCO3- OH- + CO2 K+ Cl- ATPase (-) H+

  31. Type I Distal RTA-Mechanism 3 Tubular lumen Na+ Peritubular Capillary Na+ 3Na+ ATPase (-) 2K+ (-) K+ R-Aldo K+ Wasting Urine pH > 5.5 Ca-P stones Cl- Backleak of H+ ATPase 3Na+ H+ H+ ATPase H2O H+ Retention 2K+ (-) T HCO3- OH- + CO2 K+ Cl- ATPase (-) H+

  32. Question 14 A 17-yr-old girl complains of profound weakness, dizziness, and polyuria. She is taking no medications and has no gastrointestinal complaints. Pertinent clinical finding is BP of 90/50 mmHg with orthostatic dizziness. Laboratory data reveal the following: Na 140 mEq/L, K 2.5 mEq/L, Cl 100 mEq/L, CO2 33 mEq/L, blood urea nitrogen 25 mg/dl, and creatinine 0.7 mg/dl. A 24-h urine collection reveals the following: Sodium 90 mEq, potassium 60 mEq, Cl 110 mEq, and calcium 280 mg. Plasma renin and aldosterone are elevated. These findings are MOST suggestive of which ONE of the following? • Adrenal adenoma • Gitelman syndrome • Bartter syndrome • Licorice ingestion • Surreptitious vomiting

  33. Urine Na+ and Cl- in the Differential Diagnosis of Metabolic Alkalosis and Hypokalemia Urine Electrolytes Na+ Cl- Condition (meq/L) Vomiting Alkaline urine >15 <15 Acidic urine <15 <15 Diuretic Drug active >15 >15 Remote use <15 <15 Hyperaldosteronism >15 >15

  34. Question 15 A 72-yr-old woman who has multiple sclerosis and weighs 50 kg receives 400 mg/kg intravenous immunoglobulin infused for 3 h. At the end of the infusion, she has an acute and dramatic worsening of neurologic symptoms. She is suddenly unable to bear weight or coordinate arm and leg movements and describes paresthesias and hyposthesias of all extremities. Blood chemistries are normal except for a serum sodium of 130 mEq/L and a plasma osmolality of 300 mOsm/kg. Which ONE of the following is the BEST treatment for this patient? A. 3% saline in 50-ml bolus B. 3% saline in 150-ml bolus C. 3% saline at 50 ml/h for 4 h D. 0.9% saline, 1000 ml, infused as rapidly as possible with furosemide 80 mg intravenously E. Make patient n.p.o.and observe

  35. Question 16 A 49 y.o. female is admitted to the hospital because of severe right sided abdominal pain requiring administration of narcotic analgesics. The patient is unable to provide a complete medical history, but reports that she has had seizures for as long as she can remember. Physical exam reveals papular skin lesions in the malar area. Bilateral flank masses are noted. There is a 2-cm periungual nodular lesion on the right great toe. Hematocrit is 25%. Serum creatinine is 5.5 mg/dL. CT of the abdomen without contrast reveals enlarged kidneys with bilateral renal cysts of varying size in the cortex and the medulla; several variably sized masses with densities identical to perinephric fat are also detected in areas not involved with cysts. Which if the following is the most likely diagnosis? • ADPCKD • Von Hippel-Lindau disease • Medullary cystic kidney disease • Tuberous sclerosis • Bilateral renal dysplasia

  36. Question 17 A 66-year-old man comes for a follow-up examination for elevated blood pressure. He has a history of chronic kidney disease and hypertension well controlled with hydrochlorothiazide. One week ago, he was evaluated in the office after obtaining several home blood pressure measurements averaging 145/90 mm Hg. Enalapril was added at that time. He has felt well and has no history of cough, lower-extremity edema, or dyspnea. He also takes low-dose aspirin. On physical examination today, temperature is normal, blood pressure is 126/70 mm Hg, respiration rate is 18/min, and pulse rate is 78/min and regular. On cardiac examination, the point of maximal impulse is laterally displaced and an S4 gallop is heard. There is no edema. • In addition to dietary potassium restriction, which of the following is the most appropriate next step in this patient’s management? • Add diltiazem • Discontinue enalapril; switch to metoprolol • Repeat creatinine and potassium measurement in 1 week • Kidney arteriography

  37. Question 18 78-year-old female with a history of longstanding type II diabetes mellitus, hypertension, Takotsubo cardiomyopathy with an EF of 38%, and stage III CKD is seen for routine follow up. From a symptomatic standpoint she was doing well without complaints of chest pain, PND or orthopnea. She has a history of hyperkalemia while on ACE inhibitors, and her heart failure has been managed with hydralazine, furosemide, isosorbide dinitrate, and metoprolol. BP 128/72, pulse 53/min. No JVD. Chest is clear. Cardiac exam shows bradycardia and a I/VI systolic murmur heard along the left sternal border. No edema.

  38. Question 18 Urinalysis Specific gravity 1.014, pH 5.5, 1+ protein. No cells. Few fine granular casts.

  39. Question 18 Which of the following is the most important factor in the pathogenesis of the hyperkalemia? • Decreased GFR • Volume depletion • Hyporeninemic hypoaldosteronism • Redistribution of potassium from cells to the extracellular fluid space

  40. Which Patients are at Risk for Hyperkalemia? • eGFR < 30 ml/min • Diabetes mellitus • Human immunodeficiency virus infection • Congestive heart failure • Older adults • Dietary indiscretion • Medications

  41. Evaluation of Hyperkalemia • Exclude laboratory error • Hemolysis • Excessive tourniquet time • Severe leukocytosis or • thrombocytosis • Redistribution • Tissue injury (rhabdomyolysis, • tumor lysis, hemolysis, GI bleed) • Insulin deficiency • Metabolic acidosis • Hyperosmolarity • Drugs (digoxin toxicity) • Hyperkalemia periodic paralysis K> 5.5 Decreased renal excretion Renal failure GFR < 20 ml/min Decreased urine flow Severe hypovolemia Hyperkalemia distal RTA

  42. Causes of Hyperkalemic Distal Renal Tubular Acidosis Palmer B. N Engl J Med 2004;351:585-592

  43. Causes of Hyperkalemic Distal Renal Tubular Acidosis Hypoaldosteronism • Collecting Duct Defects • Medications • Amiloride • Triamterene • Spironolactone • Eplerenone • Trimethoprim • Pentamidine • Tubulointerstitial disease • Urinary tract obstruction • Defective MR receptor • Low renin • Medications •  NSAIDs •  Cox-2 inhibitors •  Calcineurin inhibitors •  Beta-blockers • Diabetes mellitus • HIV infection • High renin • Adrenal insufficiency • Congenital enzyme • defects • Medications • ACE inhibitors • ARBs • Heparin • Ketoconazole

  44. Hyperkalemia: Key Points • After excluding redistribution and laboratory error, decreased renal excretion of potassium is the most common cause of hyperkalemia • Drugs, collecting duct defects, and hyporeninemic hypoaldosteronism are the most common causes • Therapy of hyperkalemia associated with hyporeninemic hypoaldosteronism includes: • Modify contributing medications • Dietary potassium restriction (~3000 mg per day or 60 mEq) • Diuretics • Sodium polystyrene

  45. Question 19 A 26 year old female presents with a history of intermittent tea-colored urine, often becoming apparent a day or two after onset on upper respiratory tract infections. On exam the blood pressure is 140/90 mmHg, heart and lungs normal, and there is no peripheral edema. There is no rash or synovitis. Urinalysis reveals trace protein and 5-10 dysmorphic red cells per high power field. The serum creatinine concentration is 0.6 mg/dL. Anti-nuclear antibodies and anti-neutrophil antibodies return negative. Serum complement levels are normal. Which one of the following represents the most likely diagnosis? A. membranoproliferative glomerulonephritis B. membranous nephropathy C. IgA nephropathy D. post-infectious glomerulonephritis

  46. Question 20 A 49-year-old white female who has a history of T12 paraplegia secondary to spinal cord injury and neurogenic bladder presents with gross hematuria. On physical exam there is left flank pain. Urinalysis shows pH 7.4, 2+ leukocyte esterase, 1+ nitrite, 15-20 white cells per hpf, and 1 + bacturia.

  47. Question 20-KUB

  48. Question 20 Analysis of the fragments of the patient’s stones is likely to reveal which one of the following components? • Calcium oxalate • Calcium phosphate • Cystine • Magnesium ammonium phosphate • Uric acid

  49. Question 21 A 65 year old man presents for follow up after presenting with a left leg deep venous thrombosis 3 weeks ago. He was treated with low molecular weight heparin followed by warfarin. He has been in good health, and has a remote 30 pack year history of smoking. His physical exam demonstrates increased non-pitting edema in the left lower leg. Laboratory studies show a serum creatinine of 1.4 and normal complete blood count. INR is 2.2. Urinalysis shows trace protein and 1+ blood with 5 red cells per high power field. The urine protein:creatinine ratio is 0.349. Further chart review show that a urine dipstick performed 6 months ago showed 1+ blood and trace protein. Which of the following is the most appropriate next step in the patient’s management? • Discontinue warfarin • Kidney biopsy • Ciprofloxacin • Cystoscopy

  50. Urinary Albumin-Total Protein Ratio in Distinguishing Between Glomerular and Non-glomerular Hematuria A value > 0.59 suggest glomerular hematuria Am J Kidney Dis 2008; 52:235-241

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