NEPHROLOGY BOARD REVIEW. Palak Parikh June 19, 2009. TOPICS FOR TODAY. Acid-base disorders Treatment of HTN ARF/AKI Nephrotic syndrome Glomerulonephritis Vasculitis. COMPENSATION FOR ACID-BASE DISORDERS. Metabolic Acidosis Winter’s formula: Expected pCO2 = 1.5 (HCO3) + 8 +/- 2
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June 19, 2009
2 mmol/L decrease in HCO3
4 mmol/L decrease in HCO3
A 44-year-old woman w/ cirrhosis 2/2 autoimmune hepatitis is hospitalized for a progressively worsening 2-day hx of fever and abd pain. She is currently on the orthotopic liver transplant list and has been clinically stable for the past month. She ahs previously undergone TIPS placement and a cholecystectomy. Meds are oral spironolactone 100 mg BID, furosemide 80 mg BID, and oral lactulose 30 mL BID.
On PE, temp is 38.2 C, pulse is 72, RR is 24, and BP is 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.
Na 128, K 5.1, Cl 104, HCO3 12, BUN 20, Cr 1.3, Glu 84, Alb 1.4
ABG (on RA): pH 7.25, pCO2 28, pO2 78
Which of the following is the most likely diagnosis in the clinical scenario?
A 64-year-old man is admitted to the ICU w/ PNA and septic shock. Over the past 4 days, he has had increasing shortness of breath and fever. He has HTN. Surgical hx is significant for a previous cholecystectomy. Meds are amlodipine and HCTZ.
On PE, temp is 38.8 C, pulse is 110, RR is 22, and BP is 85/50. Cardiac exam reveals a grade 2/6 systolic murmur. On pulmonary exam, there are crackles over the entire right lung field. There is trace pedal edema.
Lab studies on admission:
Na 135, K 4.8, Cl 103, HCO3 10, BUN 22, Cr 1.4, Glu 115
ABG (on RA): pH 6.94, pCO2 48, pO2 51
Which of the following conditions is most likely present in this patient?
A 21-year-old man is evaluated in the ED for severely diminished mental status. He has a 3-day history of nausea and has been unable to eat well. This morning, he vomited several times.
On physical exam, temp is 37.4 C, pulse is 105/min, RR is 28, and BP is 122/57. He is thin and appears in moderate distress. Cardiac and pulmonary exams are normal. The abdomen is soft and nontender. A stool specimen is neg for occult blood.
During the exam, 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.
Lab studies 1 hr after initiation of mechanical ventilation:
Na 138, K 3.7, Cl 91, HCO3 16, BUN 11, Cr 1.7, Glu 980
ABG: pH 7.53, pCO2 19, pO2 67
Which of the following is the most likely acid-base disturbance present in this patient?
(A) Mixed AG metabolic acidosis, non-AG metabolic acidosis, respiratory acidosis
(B) Mixed AG metabolic acidosis, metabolic alkalosis, respiratory alkalosis
(C) Mixed AG metabolic acidosis w/ respiratory alkalosis
(D) Mixed metabolic alkalosis w/ respiratory acidosis
A 66-year-old man w/ type 2 DM and HTN is evaluated for an 8-day hx of severe diarrhea, abdominal pain, and decreased food intake. His intake of liquids has been adequate. He believes that he became sick after babysitting his grandson, who had similar symptoms. Three years ago, he underwent CABG surgery. Meds are enalapril 20 mg BID, ASA 81 mg qd, atenolol 25 mg qd, HCTZ 25 mg qd, and metformin 1000 mg BID. He drinks alcoholic beverages occasionally and does not smoke cigarettes or use illicit drugs.
On PE, temp is 37.1 C, pulse is 66 w/ no orthostatic changes, and RR is 26. A stool specimen is positive for occult blood.
Na 136, K 3.9, Cl 114, HCO3 13, BUN 21, Cr 1.2, Glu 128, Alb 4.0
UNa 32, UK 21, UCl 80
ABG (on RA): pH 7.27, pCO2 30, pO2 90
Which of the following is most likely responsible for this patient’s acid-base disorder?
A 44-year-old man diagnosed w/ cryptogenic cirrhosis 2 years ago is hospitalized for a fractured left hip sustained after a car accident. He is asymptomatic except for pain in his hip. He has felt well recently and is currently on the liver transplant list. He smokes 1 pack of cigarettes daily and does not drink alcoholic beverages or use illicit drugs. Meds are spironolactone 50 mg BID, lactulose 30 mL BID, propranolol 20 mg BID, and furosemide 20 mg BID.
On PE, temp is 36 C, pulse is 72, RR is 18, and BP is 98/55. He is cachectic. There is scleral icterus. He has normal mentation, and no asterixis is noted. Cardiac exam reveals no murmurs or rubs, and his lungs are clear to auscultation. The abdomen is distended but nontender. There is 2+ peripheral edema and palmar erythema.
Na 130, K 3.3, Cl 107, HCO3 18, BUN 14, Cr 0.9, Glu 88, Alb 2.6
ABG (on RA): pH 7.48, pCO2 25, pO2 92
Which of the following is the most likely cause of this patient’s acid-base disorder?
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, temp is 36.7 C, pulse is 96, and BP is 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.
Lab studies: Na 137, K 6.2, Cl 107, HCO3 18, BUN 63, Cr 3.6
U/A: Sp Grav 1.014, Trace protein, 2-3 leukocytes/hpf, 3-5 erythrocytes/hpf
Which of the following is most likely to establish a diagnosis?
A 45-year-old woman is evaluated for newly diagnosed HTN. She has a family history of essential HTN, and both her parents have type 2 DM.
On PE, BP is 150/95. BMI is 32. The remainder of the exam is normal.
Electrolytes, BUN, Cr Normal
Fasting Glucose 90
Total Cholesterol 220, HDL 35, LDL 140, TG 250
In addition to repeating blood pressure measurement to confirm the diagnosis of hypertension and counseling regarding lifestyle modification, therapy with which of the following agents is indicated for this patient?
A 45-year-old woman is referred evaluation for a BP 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 PE, her average BP is 148/98. 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?
An 80-year-old woman is evaluated for resistant HTN and fatigue. Home BP measurements are typically approximately 180/70. Meds are metoprolol 50 mg qd, lisinopril 20 mg qd, and HCTZ 12.5 mg qd.
On PE, pulse is 72 and BP is 180/70.
Na 132, K 3.3, Cl 99, HCO3 26, BUN 12, Cr 0.9
Plasma renin activity: 0.36 ng/mL per hour
Which of the following is the most appropriate next step in this patient’s management?
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 w/ a new med 1 week ago. She also has type 2 DM.
On PE, temp is 37 C, pulse is 68, RR is 12, and BP is 115/65. She is confused and unable to appropriately answer questions. Cardiac exam is normal. The lungs are clear to auscultation. There is no edema.
Na 107, K 2.9, Cl 76, HCO3 21, BUN 17, Cr 1.1, Glu 94
Therapy with which of the following agents was most likely recently started in this patient?
After discontinuing the offending agent, which of the following is the next best step in this patient’s management?
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 level is 7 (baseline Cr 1 month ago was 1). She has a history of HTN and Type 2 DM. Meds include aspirin, atenolol, glipizide, enalapril, and chlorthalidone.
On PE, pulse is 68 and BP is 85/60. She is not in distress. Skin turgor is decreased. Cardiac and pulmonary exams are normal. There is no peripheral edema. On neurological exam, she is alert and oriented.
Na 120, K 3.7, Cl 86, HCO3 26, BUN 85, Cr 8, Glu 56
U/A: Several hyaline casts/hpf
UCr 40, UNa 40
Which of the following is the next best step in this patient’s management?
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.
Total cholesterol 325
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?
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.
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?
A 38-year-old woman is evaluated in the ED for generalized itching, an erythematous skin rash, and joint pain. She initially tried over-the-counter diphenhydramine , but her itching and rash did not improve. She was diagnosed with a course of amoxicillin. Her sinus drainage and cough have improved. However, her joint pain remains, and her temperature has been between 37.5 C and 37.8 C. She states that she has otherwise been healthy and takes no additional meds.
On PE, temp is 37.3 C, pulse is 88, and BP is 122/68. There is a diffuse erythematous macular papular skin rash involving her trunk, arms, and upper thighs.
Hg 12.5, Leukocyte count 9800 (10% eosinophils), Platelet count 325,000
Na 138, K 4.4, HCO3 26, BUN 36, Cr 2.6
U/A: pH 5, sp grav 1.020, 2+ blood, trace protein, 4+ leukocyte esterase, 20-25 leukocytes and several leukocyte casts/hpf, 3-5 intact erythrocytes/hpf, Hansel stain shows eosinophils
Which of the following is the most likely diagnosis in this patient?
A 41-year-old woman is evaluated for increased fatigue and weakness. Her breathing is more labored when she walks to get her mail at the end of her driveway. She also has increased redness of her eyes and a skin rash over her nose and cheeks. She has a history of osteoarthritis and HTN. Meds are amlodipine and intermittent acetaminophen.
On PE, BP is 135/80. She has perilimbal injection (ciliary flush) and a scaly purplish rash across her nose and cheeks. Cardiac exam reveals a soft holosystolic ejection murmur at the lower left sternal border. There is no JVP or gallops. Pulmonary exam is unremarkable. There is no lower-extremity edema.
Na 137, K 5.1, Cl 105, HCO3 22, BUN 24, Cr 1.8, Glu 113
Ca 11.1, Phos 2.4
U/A: 1+ protein, 1+ blood, 10-15 leukocytes/hpf, 3-5 nondysmorphic erythrocytes/hpf
Results of SPEP are normal. CXR reveals hilar lymphadenopathy. Renal ultrasound reveals a right kidney 8.9 cm in diameter and a left kidney 9.5 cm in diameter with bilateral increased echogenicity.
Which of the following is the most likely cause of this patient’s kidney disease?
Use of thiazide diuretics
Use of vitamin D sterols
Normal saline IVF
Calcitonin, if needed
Nephrogenic diabetes insipidusHYPERCALCEMIA
An 18-year-old man with hepatitis C virus infection is evaluated in the ED for nausea, vomiting, anorexia, hiccups, hemoptysis, and itching. He felt well until 4 weeks ago, when he developed an upper respiratory tract infection.
On PE, pulse is 90 and BP is 170/100. The conjunctivae are pale. Cardiac exam reveals a grade 2/6 systolic murmur along the left sternal border. There are diffuse crackles in both lung bases. The abdomen is soft and nontender with no masses. There is 1+ edema in the extremities.
Hg 8.5, Leukocyte count 10,500, Platelet count 250,000
BUN 70, Cr 4.3
C3 140, C4 35
Antinuclear antibodies Negative
Urinalysis: 15-20 dysmorphic erythrocytes and 1 erythrocyte cast/hpf
CXR reveals bilateral fluffy pulmonary infiltrates.
Which of the following assays is most likely to be positive in this patient?
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
C3 86, C4 5
AST 57, ALT 5
Urinalysis: 3+ hematuria, 1+ protein, 7-10 dysmorphic erythrocytes/hpf
Which of the following is most likely causing this patient’s renal abnormalities?
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
Urinalysis: 1+ protein, 12 dysmorphic erythrocytes and 1 erythrocyte cast/hpf
Which of the following is the most likely diagnosis?