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Renal Board Review

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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Renal Board Review

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  1. 1/18/10 Suneel M Udani MD MPH Renal Board Review

  2. Topics to Review • Approach to the patient with proteinuria • Approach to the patient with late stage CKD • Approach to the patient with metabolic acidosis

  3. 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

  4. Topics to Review • Interpretation of urine electrolytes (Fe Na, Fe Urea) • Approach to the patient with acute kidney injury • Electrolyte disorders

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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?)

  10. Approach to the patient with GN

  11. 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

  12. Question 2 • EGFR – 29 ml/min • Urinalysis • Trace protein • No RBC • No WBC

  13. 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

  14. 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

  15. Approach to the patient with CKD

  16. Renal replacement therapy

  17. Importance of hemodialysis access

  18. 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

  19. 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

  20. 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

  21. 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

  22. Approach to patient with metabolic acidosis • Anion Gap • Concomitant non-gap acidosis • Evaluation of renal acid excretion

  23. What is the anion gap?

  24. 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

  25. Renal maintenance of HCO3- • Proximal reclamation of HCO3- • Distal acidification • Titratable acidity • Ammonium excretion

  26. Renal maintenance of HCO3-

  27. Diagnosis of RTA • Urine pH • Concomitant electrolyte abnormalities • Urinary Anion Gap • (UNa + UK) - UCl • Estimation of Ammonium excretion • Limitations of UAG

  28. 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

  29. 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

  30. Question 4 Which of the following is the most appropriate management of this patient’s hypertension? • Begin captopril • Begin HCTZ • Begin labetalol • Discontinue ibuprofen

  31. Question 4 Which of the following is the most appropriate management of this patient’s hypertension? • Begin captopril • Begin HCTZ • Begin labetalol • Discontinue ibuprofen

  32. Renal effects of NSAIDS

  33. Renal effects of NSAIDS • Hypertension • Acute kidney injury • Interstitial nephritis • Hyperkalemia

  34. 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

  35. 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

  36. 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

  37. 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

  38. CKD and Bone Disease

  39. CKD and Bone Disease

  40. CKD and Bone Disease

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. Renal atherosclerotic disease

  47. Renal atherosclerotic disease

  48. 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.

  49. 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%

  50. 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

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