Nephrology

Question 1

Presentation of Goodpasture’s syndrome

Answer 1

Cough, hemoptysis, SOB

Glomerulonephritis

Question 2

What are best initial and most accurate test for Goodpasture’s syndrome?

Answer 2

Initial: anti-basement membrane Abs
Accurate: Renal bx showing “linear deposits”

Question 3

Tx Goodpasture’s

Answer 3

Plasmapharesis and steroids

Question 4

Presentation of Churg-Strauss Syndrome

Answer 4

Asthma, cough, eosinophilia with renal abnls

Question 5

Best initial and most accurate test for Churg-Strauss Syndrome

Answer 5

Initial: CBC for eosinophil count
Accurate: biopsy

Question 6

Best treatment of Churg-Strauss Syndrome

Answer 6

Prednisone

If not responding then cyclophosphamide

Question 7

Presentation Wegener’s granulomatosis

Answer 7

Upper respiratory problems (e.g. sinusitis/otitis)
Lung problems
Systemic vasculitis symptoms

Question 8

Best initial and most accurate test for dx of Wegener’S

Answer 8

Initial: cANCA (antineutrophil cytoplasmic antibodies)
Accurate: biopsy kidney

Question 9

Tx Wegener’s

Answer 9

Cyclophosphamide and steroids

Question 10

Presentation of polyarteritis nodosa

Answer 10

Systemic vasculitis affecting every organ system except the lung
Multiple motor and sensory neuropathies are key to dx

Question 11

Best initial and most accurate test of polyarteritis nodosa

Answer 11

Initial: ESR and markers inflammation
Accurate: Biopsy of sural nerve or kidney

Question 12

What disease are assd with PAN and should be tested for?

Answer 12

HBV and HCV

Question 13

Angiography showing “beading” may be positive for what disorder

Answer 13

Polyarteritis nodosa

Question 14

Tx PAN

Answer 14

Cyclophosphamide and steroids

Question 15

What is the essential test for IgA/Berger’s nephropathy?

Answer 15

Renal biopsy (no good initial tests)

Question 16

What is beneficial treatment for IgA/Berger’s nephropathy?

Answer 16

No good treatment really. Steroids and ACEi can be used to alleviate proteinuria; fish oil may delay progression

Question 17

What is the most accurate test and finding for HSP (even though it isn’t necessary for confirmation)?

Answer 17

Renal biopsy showing IgA deposits

Question 18

Best initial test and most accurate test for PSGN

Answer 18

Initial: Antistreptolysin O, anti-DNase, antihyaluronidase; also low complement levels
Accurate: biopsy showing subepithelial deposits of IgG and C3

Question 19

How is HTN managed in PSGN?

Answer 19

Diuretics

Question 20

A patient presents with joint pains, purpuric skin lesions, and has a hx of HCV. Dx?

Answer 20

Cryoglobulinemia

Question 21

Best initial test for cryoglobulinemia?

Accurate?

Answer 21

Initial: serum cryoglobulin component levels
Accurate: biopsy

Question 22

What are treatments of type I cryoglobulinemia? What are other options for other genotypes?

Answer 22

Type I: ledipsavir and sofosbuvir

Sofosbuvir and ribavirin are used for all other genotypes

Question 23

Unlike other renal diseases, why is the biopsy in lupus nephritis especially important?

Answer 23

Because the extent of disease guides therapy

Question 24

How is lupus nephritis treated based on the following levels of injury:
Sclerosis only
Mild disease
Severe disease

Answer 24

Sclerosis only: no treatment
Mild: steroids
Severe: mycophenolate mofetil and steroids

Question 25

What are treatment options in HUS or TTP?

Answer 25

Plasmapharesis DO NOT GIVE PLATELETS

Question 26

What amount of protein on spot testing or 24 hr urine is concerning for nephrotic disease?

Answer 26

Spot protein: creatinine >3.5:1 | 24 hr urine protein > 3.5g or protein

Question 27

Primary renal disorders such as MCD, FSGS, mesanigal, membranous, or membranoproliferative are all treated in the same manner, how?

Answer 27

Initial: steroids | If no response then add cyclophosphamide

Question 28

If a patient has isolated proteinuria what should you do first?

Answer 28

Recheck and inquire as to why they might have that (e.g. infection, exercise, CHF, fever) If still present it may be orthostatic proteinuria (e.g. in people that stand all day)

Question 29

You suspect a patient to have orthostatic proteinuria. What further testing do you do?

Answer 29

Split the urine testing into morning and afternoon. If only proteinuria in afternoon that confirms orthostatic proteinuria. If persistent then get a 24hr urine or spot protein:creatinine. If that remains elevated consider a renal biopsy

Question 30

How can you use urine volume in response to DDAVP to distinguish central from nephrogenic DI?

Answer 30

Prompt reduction in urinary volume with central DI but not in nephrogenic

Question 31

Causes of hypervolemic hyponatremia

Answer 31

CHF Nephrotic syndrome Cirrhosis

Question 32

Causes of hypovolemic hyponatremia

Answer 32

Diuretics GI loss Skin loss

Question 33

What meds may cause SIADH?

Answer 33

Sulfonylureas, SSRIs, carbamazepine

Question 34

What does urine look like (electrolyte wise) in SIADH?

Answer 34

High urine sodium and urine osmolality | Low serum osmolality

Question 35

Tx SIADH

Answer 35

Fluid restriction *In severe cases give saline infusion with loop diuretics, HTS, or consider ADH blockers like coinvaptan, tolvaptan

Question 36

What are causes of hyperkalemia?

Answer 36

``` Metabolic acidosis Beta-blockers Insulin deficiency Digoxin toxicity Aldosterone deficiency (e.g. spironolactone) ACEi/ARBs (inhibit aldosterone) Type IV RTA Renal failure Prolonged immobility, seizures, rhabdo, crush injury ```

Question 37

Why do beta blockers cause hyperkalemia?

Answer 37

They inhibit Na/K ATPase which normally brings K into cells

Question 38

Why does pseudohyperkalemia occur?

Answer 38

Hemolysis in RBC sample from prolonged waiting or excessive time of tourniquet placement during phlebotomy

Question 39

What ECG abnormalities arise in hyperkalemia and in what order?

Answer 39

1) Peaked T waves 2) Loss of P waves 3) Widened QRS

Question 40

A patient presents with severe hyperkalemia with ECG abnormalities. What therapies do you want to give and in what order?

Answer 40

Calcium gluconate Insulin and glucose Kayexylate

Question 41

If a patient has moderate hyperkalemia but no ECG abnormalities what therapies do you want to provide and in what order for correction?

Answer 41

Insulin and glucose IV Bicarbonate if d/t metabolic acidosis Kayexylate

Question 42

What acid-base disturbance causes hypokalemia?

Answer 42

Metabolic alkalosis

Question 43

What potent antifungal med causes hypokalemia?

Answer 43

Amphotericin

Question 44

How does hypokalemia develop in Bartter syndrome?

Answer 44

Failure to absorb Na and Cl leads to secondary hyperaldosteronism which causes hypokalemia

Question 45

What ECG abnl seen with hypokalemia?

Answer 45

U wvaes

Question 46

What are signs and symptoms of hypermagnesia?

Answer 46

Muscle weakness and loss of DTRs

Question 47

How do you treat hypermagnesia?

Answer 47

Restrict oral intake Saline to promote diuresis Occasionally dialysis if needed

Question 48

How does hypomagnesia present?

Answer 48

Hypocalcemia and cardiac arrhytymias

Question 49

How does Mg effect Ca levels?

Answer 49

Mg is required for PTH release which then leads to increased Ca. This is why Mg is given during torsades de pointes

Question 50

What are causes of normal AG metabolic acidosis?

Answer 50

Diarrhea and RTA

Question 51

Hyperchloremic normal AG metabolic acidosis caused by ...

Answer 51

Diarrhea

Question 52

Type I RTA (distal type) is due to .... Potassium and bicarb levels are .... Treatment is ....

Answer 52

Inability to excrete hydrogen ions in distal tubuke Low Bicarbonate (still absorbed at proximal tubule)

Question 53

Type II RTA (proximal type) is due to ... Urine pH is .... Treat with ...

Answer 53

Inability to absorb bicarbonate at proximal tubule Low Diuretic (contraction alkalosis increases serum bicarbonate)

Question 54

Type IV RTA caused by ... Potassium is ... Treat with ...

Answer 54

Lack of aldosterone production or effect High (only RTA to have increased) Aldosterone (i.e. Fludricortisone)

Question 55

What is the only RTA with a high urine pH?

Answer 55

``` Type I (d/t inability to excrete H+ at distal tubule) *as a result kidney stones form in this one ```

Question 56

What is the utility of the urine anion gap?

Answer 56

Helps distinguish between diarrhea and RTA as causes of normal AGMA. Urine Na - Urine Cl. If acid can be excreted from the kidney then urine Cl increases thus in diarrhea UAG is NEGATIVE. In RTA UAG will be POSITIVE

Question 57

Ingestion of too much antacid leads to what acid base disorder

Answer 57

Milk-Alkali syndrome (metabolic alkalosis)

Question 58

What acid base disturbance does volume contraction cause?

Answer 58

Activation of RAAS system leads to secondary hyperaldosteronism which increases Na, decreases K. This leads to increased urinary loss of acid and thus a metabolic alkalosis

Question 59

What is the most common cause of death in patients with cystic disease which develop cysts throughout body?

Answer 59

ESRD

Question 60

How do you test for urge incontinence and what is used for treatment?

Answer 60

Urodynamic pressure monitoring | Anticholinergic agents

Question 61

What therapies are used for stress incontinence?

Answer 61

Kegel exercises | Estrogen cream

Question 62

What medication is used for HTN control in pregnant woman?

Answer 62

Alpha-methyldopa