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Outline
Highlights of MKSAP Testable Points Multi-center Trials Questions throughout Questions please
Hypertension
Prevalence
20% adults 60% > 65
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
Question 1
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
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
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
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
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
Myeloma Kidney Light chains in urine toxic insult (LCDD), cast nephropathy, amyloid Lamda chains: amyloid Kappa chains: LCDD Dipstick NOT adequate
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
X linked AR AR
Collagen defect
X-linked AR
PCKD
Abx penetrating the cysts
TMP/SXT Chloramphenicol Ciprofloxacin
Question 14
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
Indinavir Crystals
Question 9
Question 12
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
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Question 18
Nephrolothiasis
Most patients: hypercalciuria
Tx: low salt, low protein, thiazides NO calcium restriction (increases oxalate)
Nephrolothiasis Images
Nephrolothiasis Images
Nephrolothiasis
Work-up Initial: chemistry, UA, stone analysis (if available), and imaging
Hydration!!! 50% recurrence at 10 years
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