Nephrology Board Review

Christopher McFadden, MD May 20, 2008

Outline
Highlights of MKSAP Testable Points Multi-center Trials Questions throughout Questions please

Hypertension
Prevalence
20% adults 60% > 65

Natural history SBP correlates better than DBP

Chobanian: Hypertension, Volume 42(6).December 2003.1206-1252

HTN
Nephropathy now a risk factor 70% aware of diagnosis, 53% on meds, and 27% controlled (NHANES) Initial eval:
Duration, risk factor stratification, and signs of TOD Goal: <140/90, <130/80 w/ DM or CKD

Chobanian: Hypertension, Volume 42(6).December 2003.1206-1252

Initial Management per JNC 7

Chobanian: Hypertension, Volume 42(6).December 2003.1206-1252

Chobanian: Hypertension, Volume 42(6).December 2003.1206-1252

HTN- Major Trials

ALLHAT- thiazides = amlodopine/ ACE AASK- ACE renoprotective w/ proteinuria in AA patients; CCB not SHEP- isolated SBP > 160 in elderly pts
Limited evidence for stage I HTN

RENALL/ IDNT- ARBs beneficial in DM II LIFE- ARB > Beta-blocker w/ LVH

 Question 1

HTN- Secondary Causes

Features
Age < 30 & > 55 Abrupt onset/ resistant TOD Hypokalemia, PCKD, family hx of renal disease, abdominal bruit (particularly diastolic), ACE assoc ARF RVD vs RAS 70% critical Doppler: 90% sens Renal Scan: 85% MRA: preferred: 90% ostial Mgmt: Some BP improvememntrarely corrects Renal outcomes limited Better response in FMD patients

 A 45-year-old woman is referred for evaluation for a blood pressure measurement of 150/94 mm Hg. Her husband is a nurse and regularly measures her blood pressure at home. Her usual home blood pressure measurement is between 110/76 mm Hg and 120/80 mm Hg. She does not smoke cigarettes. Her mother has hypertension. On physical examination, her average blood pressure is 148/98 mm Hg. Results of laboratory studies, including the creatinine level, are normal. In addition to counseling regarding lifestyle modifications, which of the following is the most appropriate management for this patient?
A Begin hydrochlorothiazide B Begin enalapril C Perform ambulatory blood pressure monitoring D Continue home blood pressure measurement

HTN Measurement
Resting comfortably, arm at heart level Palpate for loss of arterial impulse Cuff bladder 80% arm circumference
Cuff too small elevates BP

Inflate cuff 20 mm above level of BP loss Reduce BP 2 mm/sec Up to 30% people have white coat HTN

Kidney Function Assessment

Creat clearance overestimates GFR Creat lowered in malnourished diseases MDRD estimates GFR accurately up to 60-90 ml/min

Proteinuira
> 150 mg/ 24 hours Normally: albumin 30%; large proportion Tamm- Horsfall proteins Exercise induced Orthostatic

Hematuria
>3 erythrocytes/ hpf on centrifuged urine W/U: urine cytology or cysto and upper tract imaging Risk factors: >40, smoking, analgesic use, benzene exposure Sometimes repetitive evaluations

Pigmenturia
Endogenous: Bilirubin, Myoglobin, Hemogloblin, Porphyrins Foods: Beets, Fava Beans, Rhubarb Drugs: Rifampin, Nitrofurantoin, Sulfonamides, Quinine, and others

Casts
Formed by Tamm-Horsfall mucoprotein secreted by distal tubules RBC casts- glomerular disease WBC casts- inflammation or infection Granular casts- tubular injury and death

Granular & RBC casts

Glomerulus

Nephrotic Syndrome
Proteinuria > 3.5 g Hyperlipidemia Edema Hypercoagulability Sec hyperpara Low thyroxine (nl TSH)

 Question 3

 Questin 16

Nephrotic Diseases
Primary
Minimal Change FSGS Membranous Membranoproliferative

Secondary
FSGS Membranous MPGN Amyloid

Treatment
? Immuno + supportive tx

Treatment
Supportive: ACE/ HMG/ HTN control

Membranous & Amyloid

 Case 8

Acute GN
Hematuria- often RBC casts HTN Possible reduced GFR

Glomerulonephritis (cont)
IgA- synpharyngitic hematuria
Secondary dz associated w/ liver dz Treatment controversial; 30% reach ESRD Henoch-Schonlein purpura: IgA deposits

Post-strep: 2-3 weeks after infection Treatment conservative

GN (cont)
SLE- Treatmtent
Stage 1(nl) and 2 (mesangial)- supportive 3 (FPGN) and 4 (DPGN)- Cytoxan/ Pred 5 (Membranous)- controversial 6 Scarred

SLE Nephritis

RPGN
ANCA associated (pauci-immune)
Wegeners Microscopic Polyangitis/ Churg Strauss

Anti GBM
Goodpastures, Idiopathic

Immune Complex
SLE, Post infection, Cryo, HSP

 Question 6

GN Case (# 7)
28 yo w/ arthralgias, cough, hemoptysis, and dark urine for 2 weeks PMH negative BP elevated; exam w/ basilar rales UA 30 RBC, 2 + protein Creat 2.3 mg/ dL, Hgb 9.8 g/ dL Serologic wu: anti GBM positive Renal biopsy: crescents and linear GBM staining

RPGN

 Question 7

Tubulointersitial Disease
Inactive Sediment Cause- injury by infection, crystals, medications, ischemia, immunologic including sarcoid/ sjogrens Triad of eosinophilia, fever, rash limited to PCN AIN Medications
Analgesics Aristocholic Acid Lithium Amphotericin B Cisplatinum

 Question 15

Acute Interstitial Nephritis

Myeloma Kidney Light chains in urine toxic insult (LCDD), cast nephropathy, amyloid Lamda chains: amyloid Kappa chains: LCDD Dipstick NOT adequate

Analgesic Nephropathy Long duration/ combo Lobulated Transitional cell CA of GU tract

Case 8
65 yo w/ cc fatigue & back pain New onset nocturia, polyuria Vitals normal, thoracic back pain Ca 12.8 mg/ dL, Creat 2.6 mg/dL UA: trace protein, no cells

Genetic Renal Disorders

PCKD AD >> AR AD 1:1000 Cerebral aneurysms Hepatic cysts; Valvular dz Men- Renal failure Het women- hematuria Hematuria; not renal failure Tubular d/o (CL B- worse, hypercalciuria transport; nl bp, low G- subtler, lower serum K magnesium Alphagalactosidase Glyoxalate aminotransferase Progressive systemic dz Liver disease

Alports Benign Familial Hematuria Barters/ Gitelmans Fabrys Disease Hyperoxaluria

X linked AR AR

Collagen defect

X-linked AR

PCKD
Abx penetrating the cysts
TMP/SXT Chloramphenicol Ciprofloxacin

 Question 14

Fluid/ Electrolytes- Formulas

Body= 60% water, 2/3 intracellular, 1/3 extracellular Expected dec Na= 1.6 x (plasma gluc- 100)/100 AG= Na (Cl + HCO3) Delta/ Delta= [AG change/ hco3 change] w/ nl 1-2 Winters Formula= 1.5 (HCO3) + 8 +/- 2 = pCO2 Plasma osmol= 2x Na + BUN/ 2.8 + gluc/ 18 Unmeasured anion if calcul vs meaured > 10

Fluid/ Electrolytes- Pearls

Hyponatremia- treat vol status
If euvolemic, check TSH, cortisol levels Drugs causing SIADH: cyclophosphamide, chlorpropamide, vincristine, carbamazepine, haldol, fluoxetine, hctz, and other cns agents Max correction rate- 12 meq/ L in 24 hours

Hypernatremia- acquired NDI from lithiun, foscarnet, hypokalemia, hypercalcemia

Fluid/ Electrolytes- Pearls

Hypokalemia- urine K (20 meq/24 hrs) to differentiate high loss (met alkalosis or RTA) vs GI loss/ shift/ poor intake Hypophosphatemia- redistribution common w/ refeeding, insulin to control hyperglycemia, acute resp alk Hypomagnesemia- renal tubular loss due to cisplatinum, ampho B, aminoglycosides,

Fluid/ Electrolytes- Pearls

Met acidosis- urine contacting GI tract Cl absorption and K/ HCO3 excretion Ethylene glycol associated w/ Ca oxalate crystals Formic acid (methanol) assoc w/ blindnesss RTA
Proximal (2)- variable urine pH Distal (1)- low K, high urine pH Distal (4)- high K, high urine pH

Met acidosis and resp alkalosis

Eval for sepsis or saliclylate intoxication

Acute Renal Failure

ACE-I- efferent vasodilation NSAIDs- afferent vasoconstriction FENA- (U Na/ P Na)/ (U Cr/ P Cr) * 100
Less than 1% in oliguric pre-renal patients

Renal Replacement Therapy

CVVHD not proven to be more effective than intermittent HD Increased ultrafiltration w/ CVVH better outcomes Daily dialysis better outcomes in single center study Renal dose dopamine not effective

Contrast Nephropathy
Creat peaks 4-5 days after exposure Acetyl-cysteine has varying results Limiting risk- decreased contrast volume, use of isotonic contrast, and vol expansion pre-procedure

ARF- Other causes

Aminoglycosides: 1-2 weeks; lower troughs! Amph B: 2 grams cumulative dose; risk w/ vol depletion, elderly, & CSA use Cisplatinum: may have NDI; often recovers MTX: ATN and tubular obstruction Mitomycin C: consider HUS HIV: Indinavir crystals obstruction HRS: low FENa Rhabdo: rapid Cr increase (trauma, cocaine, HMG- CoAs);
Dipstick incosistent

Cancer: r/o obstruction!

Uric acid crystallization (allopurinol/ bicarb) Radiation (> 23 Grays)

ARF Case (# 15)

61 yo w/ ascites and edema Longstanding etoh abuse BP 96/70, P 112 w/ distened abdomen, edema Na 122, K 3.1, Cl 102, CO2 20, Cr 1.2 Urine Na 6, osmol 670 mosm/ kg H20 Previous creat 0.6

Indinavir Crystals

CV Risk Reduction Complications

Prepare for RRT

RRT

Cause of ESRD: 40% DM, 27% HTN, 10% GN

 Question 9

 Question 12

CKD- Internist Managment

Refer Cr > 1.5 (women) or >2.0 (men) HTN
AASK- control w/ ACE better

DM control Protein Restriction Anemia management: goal Hgb 11-12 ROD: Phosphorus restriction/ Binders/ Vitamin D analogues (monitor Ca and Phos)

 A 54-year-old woman is evaluated for a creatinine level of 1.3 mg/dL (114.95 mol/L); 18 months ago, this value was 0.9 mg/dL (79.58 mol/L). She has a 5-year history of type 2 diabetes mellitus; hyperlipidemia; and hypertension well controlled with lisinopril, hydrochlorothiazide, and atenolol. She also uses glipizide and simvastatin. Laboratory studies reveal a normal hemoglobin level. Which of the following diagnostic studies is most appropriate for this patient?
A 24-Hour urine collection for proteinuria B Kidney ultrasonography C Measurement of urine microalbumin D Serum protein electrophoresis E Measurement of hemoglobin A1c

 Question 11

 Question 19

ESRD
Poor survival 20-40 % at 5 years (DM vs non) PD vs HD Main cause of death: CVD & Infection Historically, ESRD worse response w/ PTA; stent effect unclear

 Question 5

Transplant
Better Survival LRRT 5ys: 90% CRT 5ys: 81% DM 5ys: 50% CSA:
HTN, nephrotoxicity hirsutism, gum hypertrophy

Tacrolimus:
HTN, nephrotoxicity, DM

MMF:
diarrhea and leukopenia

Aza:
reduce dose of allopurinol!

Question 2
A 60-year-old woman with a history of type 1 diabetes mellitus and stage 4 chronic kidney disease comes for a routine follow-up examination. She asks about modalities of renal replacement therapy. Which of the following is the best option for this patient?
A 0-Antigen-mismatched deceased donor kidney transplantation B Peritoneal dialysis C Hemodialysis D Living donor kidney transplantation after a course of dialysis E Preemptive living donor kidney transplantation

t
Question 18

Nephrolothiasis
Most patients: hypercalciuria
Tx: low salt, low protein, thiazides NO calcium restriction (increases oxalate)

Struvite stones: chronically infected; staghorn Uric acid- radiolucent

Tx- alkalinize urine and allopurinol

Cystine: metabolic (AR) defect

Tx- volume, alkalinize, d-penicillamine or alpha mercaptoppropionyl glycine (more soluble cysteine disulfide compound)

Nephrolothiasis Images

Nephrolothiasis Images

Nephrolothiasis
Work-up Initial: chemistry, UA, stone analysis (if available), and imaging
Hydration!!! 50% recurrence at 10 years

Recurrent stones: metabolic/ 24 hr urines

Diarrhea think IBD with ca oxalate stones

Renal Disease in Pregnancy

Tx asymptomatic bacteriuria Chronic HTN- present before pregnancy or dx before 20 weeks Gestational HTN- dx after 20 weeks; transient HTN of pregnancy Preeclampsia If before 20 weeks- consider hydatiform mole Tx HTN when DBP 100-110 or symptomatic Meds: 1st line- Methyldopa, Hydralazine

Renal Disease in Pregnancy

Higher risk w/ proteinuria and Creat > 1.4 Mild hydro common- difficult to determine signficance

Emphysematous Pyelonephritis
Similar to pyelo Majority pts have DM Gas in renal/ perirenal tissues Drainage mildmoderate cases; nephrectomy if severe CT if pyelo pts not getting better!

HTN Case (# 3)
76 yo for fu; several elevated BP recently PMH negative; No medications No etoh, tobacco use BP 178/68, no orthostasis No volume overload Creat 1.0

HTN Case cont.

Evaluation BP change recently? Ideal 1st line agent: JNC 6: CCB or diuretics JNC 7: Stage 2: combination Auto regulation