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1/18/10 Suneel M Udani MD MPH. Renal Board Review. Topics to Review . Approach to the patient with proteinuria Approach to the patient with late stage CKD Approach to the patient with metabolic acidosis. Topics to Review. Effect of NSAIDS on the kidney

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1 18 10 suneel m udani md mph
1/18/10

Suneel M Udani MD MPH

Renal Board Review

topics to review
Topics to Review
  • Approach to the patient with proteinuria
  • Approach to the patient with late stage CKD
  • Approach to the patient with metabolic acidosis
topics to review3
Topics to Review
  • Effect of NSAIDS on the kidney
  • Approach to the patient with CKD and bone disease
  • Approach to the patient with renal atherosclerotic disease
topics to review4
Topics to Review
  • Interpretation of urine electrolytes (Fe Na, Fe Urea)
  • Approach to the patient with acute kidney injury
  • Electrolyte disorders
question 1
Question 1

35 y/o woman c hx of DM and Hypertension presents for evaluation of 1-month history of progressive B LE edema. At her last visit 4 months ago, urine alb:Cr ration was 100 mg/g.

Meds: Enalapril, Insulin, ASA

Exam: BP 162/90

CV nl

Resp nl

3+ edema of LE to thighs

question 1 laboratory studies
Question 1—Laboratory studies

Albumin 3 g/dl

Serum Cr 1.1 mg/dl

UA 3+ prot

2+blood

8-10 dysmorphic RBC/hpf

2-5 WBC/hpf

few RBC casts

Hgb A1c 7.1%

Urine protein:Cr ratio

5.2 mg/mg

Ultrasound

R kidney 12.2 cm

L kidney 12.7 cm

question 17
Question 1

Which of the following is the most appropriate next step in this patient’s management?

  • Cystoscopy
  • Kidney Biopsy
  • Spiral CT of A/P
  • Observation
question 18
Question 1

Which of the following is the most appropriate next step in this patient’s management?

  • Cystoscopy
  • Kidney Biopsy
  • Spiral CT of A/P
  • Observation
approach to the patient with proteinuria
Approach to the patient with proteinuria
  • What in this patient is inconsistent with diabetic nephropathy as a cause of proteinuria and worsening renal function?
  • What is the differential for the cause of proteinuria and worsening renal function? (what other tests would you order?)
question 2
Question 2

45 y/o gentleman presents for follow-up of CKD. Dx with CKD 5 years ago with progressive disease.

Meds

Lisinopril, furosemide, lovastatin

calcium acetate (with meals), calcitriol

ferrous sulfate, EPO

Exam

BP 128/68

HR 80 RR 15

BMI 29

CV nl, no edema

Neuro no asterxis

question 212
Question 2
  • EGFR – 29 ml/min
  • Urinalysis
    • Trace protein
    • No RBC
    • No WBC
question 213
Question 2

In addition to discussing this patient’s clinical situation and worsening kidney function, which of the following is the most appropriate next step in management?

  • Contrast-enhanced abdominal CT
  • Discussion of options for kidney replacement therapy
  • 125I-iothalamate kidney scanning
  • Kidney biopsy
question 214
Question 2

In addition to discussing this patient’s clinical situation and worsening kidney function, which of the following is the most appropriate next step in management?

  • Contrast-enhanced abdominal CT
  • Discussion of options for kidney replacement therapy
  • 125I-iothalamate kidney scanning
  • Kidney biopsy
question 3
Question 3

65 y/o gentleman evaluated for 3-month history of progressive malaise, fatigue, weakness. He has 10-year history of hypertension.

Meds

HCTZ

Atenolol

Exam

WNL

question 319
Question 3

Hct 25%

WBC 5.6 X 109/L

Platelets 340 X 109/L

Gluc 110 mg/dL

UA pH 5.5; trace prot; 1+ gluc

U prot/Cr 4.8 mg/mg

Na 135 meq/L

K 3.0 meq/L

Cl 105 meq/L

HCO3 18 meq/L

BUN 22 mg/dl

SCr 1.8 mg/dl

pH 7.33

pCO2 28 mm Hg

Polarized urine sediment nl

question 320
Question 3

Which of the following is the most likely diagnosis?

  • Diabetic nephropathy
  • Distal (type I) renal tubular acidosis
  • Hypertensive nephrosclerosis
  • Proximal (type 2) renal tubular acidosis
question 321
Question 3

Which of the following is the most likely diagnosis?

  • Diabetic nephropathy
  • Distal (type I) renal tubular acidosis
  • Hypertensive nephrosclerosis
  • Proximal (type 2) renal tubular acidosis
approach to patient with metabolic acidosis
Approach to patient with metabolic acidosis
  • Anion Gap
  • Concomitant non-gap acidosis
  • Evaluation of renal acid excretion
assess for 2 nd metabolic disorder
Assess for 2nd metabolic disorder
  • (Actual anion gap – Expected anion gap) + [HCO3-]

= 22-28 meq/L  pure AG metabolic acidosis

< 22 meq/L  concomitant non-AG metabolic acidosis

> 28 meq/L  concomitant metabolic alkalosis

  • Does the fall in [HCO3-] explain the entire anion gap?
  • Na (135) – [ Cl (105) + HCO3 (18) ]

= 12; Non-anion gap metabolic acidosis

renal maintenance of hco 3
Renal maintenance of HCO3-
  • Proximal reclamation of HCO3-
  • Distal acidification
    • Titratable acidity
    • Ammonium excretion
diagnosis of rta
Diagnosis of RTA
  • Urine pH
  • Concomitant electrolyte abnormalities
  • Urinary Anion Gap
    • (UNa + UK) - UCl
    • Estimation of Ammonium excretion
    • Limitations of UAG
clues to proximal vs distal rta
Clues to proximal vs distal RTA

Proximal (type II)

  • Concomitant proximal tubular dysfunction (i.e. Fanconi’s syndrome)
  • Very high bicarbonate requirements
  • Urine pH low in steady state

Distal (type I)

  • Severe hypokalemia
  • Urine pH not maximally acidified
  • History of recurrent stones, bone disease
question 4
Question 4

25 y/o woman evaluated in urgent care because of recent onset of heel pain especially severe when jogging.

She has been taking ibuprofen for the past 7 days.

She does not smoke cigarettes.

She is otherwise healthy and has no history of hypertension.

Meds

low-dose oral contraceptive

MVI

Exam

BP 162/102 HR 90 BMI 24

WNL

Labs nl

question 430
Question 4

Which of the following is the most appropriate management of this patient’s hypertension?

  • Begin captopril
  • Begin HCTZ
  • Begin labetalol
  • Discontinue ibuprofen
question 431
Question 4

Which of the following is the most appropriate management of this patient’s hypertension?

  • Begin captopril
  • Begin HCTZ
  • Begin labetalol
  • Discontinue ibuprofen
renal effects of nsaids33
Renal effects of NSAIDS
  • Hypertension
  • Acute kidney injury
  • Interstitial nephritis
  • Hyperkalemia
question 5
Question 5

59 y/o woman evaluated for a 2-week history of R hip pain. She has history of CKD on PD. No history of aluminum exposure

Meds

Epo, calcium acetate, calcitriol

MVI

Exam

VS nl

Tenderness over R lateral trochanter

Internal and external rotation of hip elicit pain

question 535
Question 5

Labs

Pi 5.6 mg/dl

Ca 10.2 mg/dl

Alk Phos 86 U/L

iPTH 21 pg/ml

1,25 vit D 52 pg/ml

25 vit D 15 ng/ml

Plain radiograph

R hip diffuse osteopenia

Area of lucency seen along medial aspect of the femoral neck on R side c/w stress fracture

question 536
Question 5

Which of the following is the most likely cause of this patient’s bone disease?

  • Adynamic bone disease
  • Β2-Microglobulin-associated amyloidosis
  • Osteitis fibrosa cystica
  • Osteomalacia
question 537
Question 5

Which of the following is the most likely cause of this patient’s bone disease?

  • Adynamic bone disease
  • Β2-Microglobulin-associated amyloidosis
  • Osteitis fibrosa cystica
  • Osteomalacia
question 6
Question 6

76 y/o gentleman with ACS is evaluated in the hospital after undergoing PTCA of RCA. Because of 30 yr hx of hypertension, kidney angiography was performed and revealed L renal artery stenosis with 60-70% luminal narrowing.

2 years ago, he underwent CEA and was told he had “kidney” problems. His hypertension is well controlled. His mother has history of hypertension and died of CVA at 85 years.

Meds:

Lisinopril, HCTZ, Metoprolol

Atorvastatin, clopidogrel, ASA 81

Exam

BP 140/70 HR 60 RR 12 BMI 25

Carotid, abdominal, femoral artery bruits

question 642
Question 6

Na 141 meq/L

K 3.7 meq/L

Cl 100 meq/L

HCO3 28 meq/L

BUN 40 mg/dl

SCr 2.0 mg/dl

Plasma renin activity

2.0 ng/ml/h (nl range 0.6-3.0 ng/ml/h)

EGFR

40 ml/min/1.73 m2

question 643
Question 6

Which of the following is the most appropriate next step in the management of this patient’s hypertension?

  • Kidney angioplasty
  • Referral to a nephrologist
  • Surgical renal revascularization
  • No change in management
question 644
Question 6

Which of the following is the most appropriate next step in the management of this patient’s hypertension?

  • Kidney angioplasty
  • Referral to a nephrologist
  • Surgical renal revascularization
  • No change in management
renal atherosclerotic disease
Renal atherosclerotic disease

806 patients with clinically suspected renal atherosclerotic disease confirmed on angiography (CT, MR of conventional)

Randomized to medical tx vs. revascularization + medical therapy

Evaluated for change in renal function, BP control, CV event

question 7
Question 7

65 y/o gentleman c hx of stage IV CKD and hypertension presents for follow-up.

He was discharged 2 days prior (hospitalized for pneumonia) and since discharge has had n/v/anorexia.

He also reports oliguria.

question 749
Question 7

Exam

T 35.8 BP 110/80 HR 96 (supine)

BP 110/50 HR 100 (standing)

Bilateral basilar rales

SCr 6.0 mg/dl (previously 4.5 mg/dl)

UA

SG 1.016

(--) prot/blood

(--) occ hyaline casts

FeNa

4%

question 750
Question 7

Which of the following is the most likely cause of the patient’s acute kidney injury?

  • Acute interstitial nephritis
  • Acute tubular necrosis
  • Prerenal azotemia
  • Renal vein thrombosis
question 751
Question 7

Which of the following is the most likely cause of the patient’s acute kidney injury?

  • Acute interstitial nephritis
  • Acute tubular necrosis
  • Prerenal azotemia
  • Renal vein thrombosis
question 8
Question 8

55 y/o woman c hx of stage IIB cervical cancer s/p radiotherapy and cisplatin (completed 6 weeks prior) admitted to hospital with 3 week hx of nausea, vomiting and anorexia.

1-week prior, her SCr was 1.3 mg/dl (prev 0.8 mg/dl). Received IV saline with no change in her symptoms.

Meds:

ondansetron prn

question 854
Question 8

Exam

BP 118/68 HR 90, no orthostatic changes

RR 18, BMI 19.5

Cachectic

Bladder dome is not palpable

UA pH 6.0; 1+ prot; 1+blood; 0-5 erythrocytes/hpf;

Hgb 10.2

Plts 165k

Na 140 meq/L

K 5.3 meq/L

Cl 112 meq/L

HCO3 18 meq/L

Bun 122 mg/dl

Cr 5.1 mg/dl

question 855
Question 8

Which of the following is the most likely diagnosis?

  • Cisplatinnephrotoxicity
  • Hypovolemia
  • Membranous nephropathy
  • Obstructive nephropathy
question 856
Question 8

Which of the following is the most likely diagnosis?

  • Cisplatinnephrotoxicity
  • Hypovolemia
  • Membranous nephropathy
  • Obstructive nephropathy
obstructive uropathy
Obstructive uropathy
  • Must be ruled out in an adult male
  • Must be evaluated in women with pelvic pathology
  • Hyperkalemia, distal RTA
  • Failure of response to IVF
question 9
Question 9

47 y/o gentleman c hx of long-standing history of alcoholism hospitalized for abdominal pain, n/v X 7 days.

His last drink was 6 days ago. He has lost approx 10% of body weight due to ETOH intake and decreased food intake.

Exam

37.1 BP 100/70 HR 110

RR 18 BMI 17

Midepigastric tenderness

question 959
Question 9

Amylase 300 U/L

Lipase 150 U/L

UA + ketones

Na 130 meq/L

K 3.4 meq/L

Cl 90 meq/L

HCO3 20 meq/L

Pi 3.5 mg/dl

Ca 9.0 mg/dl

question 960
Question 9

Patient receives immediate thiamine, folic acid, MVI followed by IVF with D5 0.9NS with KCl replacement with Morphine for analgesia.

18 hours later, patient’s abdominal pain has improved, but he becomes restless, agitated, extremely weak and is barely able to raise his extremities against gravity.

question 961
Question 9

Which of the following is the most likely cause of this patient’s new findings?

  • Hypercalcemia
  • Hypokalemia
  • Hyponatremia
  • Hypophosphatemia
question 962
Question 9

Which of the following is the most likely cause of this patient’s new findings?

  • Hypercalcemia
  • Hypokalemia
  • Hyponatremia
  • Hypophosphatemia
slide63

Figure 1Phosphate fluxes and causes of hypophosphatemia

Amanzadeh J and Reilly RF Jr (2006) Hypophosphatemia: an evidence-based approach to its clinical consequences and management Nat Clin Pract Neprol2:136–148 doi:10.1038/ncpneph0124

question 10
Question 10

44 y/o gentleman is evaluated in the hospital because of disorientation and hallucinations. He was admitted to the hospital 4 days ago for a subarachnoid hemorrhage that was repaired with surgical clipping. His medical history is otherwise unremarkable

Meds

none

Exam

VS BP 140/80 HR 90 RR 16 supine

BP 120/60 HR 110 standing

question 1066
Question 10

Na 118 meq/L

K 4.1 meq/L

Cl 85 meq/L

HCO3 23 meq/L

Serum osm 248

Urine Na 105 meq/L

Urine K 20 meq/L

Urine Cl 90 meq/L

Urine osm 633 mosm/kg

question 1067
Question 10

Which of the following is the most likely cause of this patient’s hyponatremia?

  • Adrenal insufficiency
  • Cerebral salt wasting
  • Hypothyroidism
  • SIADH
question 1068
Question 10

Which of the following is the most likely cause of this patient’s hyponatremia?

  • Adrenal insufficiency
  • Cerebral salt wasting
  • Hypothyroidism
  • SIADH
electrolyte free water clearance
Electrolyte free water clearance

Ctotal = CH20 + Celec

Ctotal – Celec = CH20

V – V (U/P) = CH20

V (1 – U/P) = CH20

V [1 – U (Na + K) / P (Na + K) = CH20

UNa + UK > PNa + PK =

(-) CH20

UNa + UK < PNa + PK =

(+) CH20 = low ECV state