Transcript BOARD REVIEW

BOARD REVIEW
NEPHROLOGY 1
URINALYSIS
• Proteinuria
• 1) overflow of proteins- MM, MGUS
• 2) increased filtration of proteins: glomerular diseases:
nephrotic protein> 3g/day
• nephritic protein<2 g/day
• 3) decreased tubular reabsorbtion: tubulointerstitial
nephritis: protein< 2g/day
• 4) transient: fever, exercise, upright position, seizures
URINALYSIS
• Normally< 100 mg proteins excreted daily
• Normally < 30 mg albumin excreted daily
• Microalbuminuria 30-300 mg daily seen in early DM
nephropathy
• 1. patient with fever and UTI, urine + for protein wtd?
• 2. patient on NSAIDs for pain. UA + for protein wtd?
• 3. patient with proteinuria on dipstick after exercise wtd?
URINALYSIS
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Casts:
Nephrotic sdr hyaline casts, fatty casts, oval fat bodies
Nephritis RBC casts
Pre-renal azotemia hyaline casts
ATN muddy/ dirty brown, pigmented casts
Interstitial nephritis WBC casts, granular casts,
eosinophils
• Chronic renal failure chronic renal failure
Question
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1. Eosinophiluria can be seen in the following except:
A) interstitial nephritis
B) athero embolism
C) NSAIDs
D) rapidly proliferative glomerulonephritis
2. A 72 year old Asian female has anorexia, night sweats
and hematuria. There is no pain or other urinary symptoms.
Urine has no casts, 21 WBC. Urine culture is sterile. BUN
and creatinine are mildly elevated. X ray chest is negative.
What is your next step?
• a) dsDNA ab b) PPD c) CT scan chest d) renal bx
Match:
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1. hyaline casts
2. muddy brown casts
3. RBCs
4. RBC casts
5. Oval fat bodies
6. eosinophils
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A. ATN
B. prerenal azotemia
C. glomerulonephritis
D. nephrolithiasis
E. interstitial disease
F. nephrotic syndrome
hematuria
proteinuria other
APCKD
+
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Medullary
sponge
disease
+
Alports
syndrome
+
Renal
failure
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Flank pain
Stones
HTN
stones
+
deafness
+
-
crystals
• 1) calcium oxalate crystals: envelope appearance-acid
urine- ethylene glycol toxicity, intestinal hyperoxaluria( ex.
Chron)
• 2) cystine crystals( hexagonal shaped, positive urine
nitroprusside test), in cystinuria ( patient young, around
20)
• 3. uric acid crystals- in acid urine- tumor lysis sdr
• 4. calcium phosphate crystals (needle like prismatic)- in
alkaline urineeg distal RTA, idiopathic hypercalciuria,
primary hyperparathyroidism
• 5. struvite stones- staghorn, MgNH4Po4(coffin lids) in
alkaline urine- UTi with urease producing bacteria
Renal failure
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Pre-renal azotemia- decreased renal perfusion
volume depletion- bleeds, diarrhea, burns, etc
volume overload- CHF, cirrhosis
Decresed urine volume- increased urine osmol,
Decreased urine Na FeNa <1
Urine sediment neg
FeNa= Urine Na x plasma creatinine/ urine creatininex
plasma Na X100
Prerenal azotemia
ATN
Inciting factors
Low volume
Toxins
Ischemia
medication
BUN/creatinine
>20/1
<20/1
Urinary Na
<20mEq/l
>40
FeNa
<1
>2
Urine osmolality
>500
<350
Urine cells and casts
bland
Lots of cells, muddy
granular, dirty brown
casts
Intrinsic acute renal failure
• -Glomerular disease- urine: RBC casts
• -ATN- aminoglycosides, ampho B, rhabdo, tumor lysis,
athero embolism
• urine- muddy brown casts
• -tubulo interstitial disease
• Allergic- B lactam, sulfa, dilantin, quinolone
• NSAIDs- no eosinophils
• Urine- WBC- eosinophils
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Question
• 1. Elderly man with h/o HTN, DM, hyperlipidemia on beta blocker,
statin, HCTZ. Blood pressure still elevated at 170/110. Serum
creatinine 1.1. Patient is started on Ace inhib. One week later, BP
controlled. BUN/creat 19/1.5. UA – no sediment. The most likely
cause of ARD is:
• A) tubulointerstitial disease
• B) ATN
• C) rhabdo sec to statin
• D) ACE inhib
• 2. a young man with h/o drug abuse and recent seizures presents with
lab findings- BUN- 65, creatinine 5 hyperphosphatemia, hyperkalemia,
high uric acid, low calcium, high CP. Urine no RBC, positive for
heme. Muddy brown casts are seen. Dg?
Question
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1.ATN can be caused by any of the following except:
A) aminoglycosides
B) ampho B
C) cyclosporine
D) rhabdomyolysis
E) NSAIDs
2. Patient with post infarct angina scheduled for cardiac cath. H/o DMserum creatinine 1.6. Best way to prevent radiocontrast nephropathy is
• A) ½ NS 12 h pre and post procedure +/- acetylcysteine
• B) ½ NS 6 h pre and post procedure
C) 0.9 NS with diuresis at th end of procedure
Question
• 65 year old woman presents with abdominal pain and
fever. Patient is started on Ampicillin, Gentamycin, Flagyl.
CT scan abdominal with contrast is done. Next day patient
has decreased urine output to 300cc/24h. Serum BUN/
creat 40/2.2
• UA shows no sediment. FeNa <1.
• The most likely diagnosis?
• A) ampicillin induced interstitial nephritis
• B) gentamycin induced toxicity
• C) radiocontrast induced nephropathy
Renal effects of NSAIDs
• NSAID inhibit renal prostaglandin( PG causes vasodilation
and stimulates renin secretion)
• NSAIDs decrease renal blood flow and decrease renin
secretion:
• Prerenal azotemia
• Low renin low aldo high K( RTA type 4)
• Other types of renal disease with NSAID• 1. allergic interstitial nephritis: within 3-10 days
• 2. minimal change glomerulopathy- weeks after starting txpresents with nephrotic range proteinuria
Question
• 1. 65 year old with H/o HTN, ventricular arrythmias controlled on
Amiodarone, OA on NSAIds presents with puffiness on face on
waking up. Has bilateral pitting dema. UA 3+ prot, 3 RBC., 15-20
WBC
• 24 h prot – 4 g/day
• BUN/creat 80/5
• Serum albumin 2.8, TSH normal. The most likely diagnosis?
• A) amiodarone induced hypothyroidism
• B) RPGN
• C) NSAIDs induced nephrotic sdr and interstitial nephritis
Question
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NSAIDs can cause all the following except:
1) prerenal azotemia
2) acute interstitial nephritis
3) chronic interstitial nephritis
4) nephrotic sdr
5) ATN
6) type 4 RTA
Question
• 1. Pregnant lady 18 w gestation, hardly gains any weight.
C/o persistent nausea, vomiting for the past month.
Creatinine increases from 0.5 to 1.9 DG?
• 2. 60 year old patient presents with cellulitis of the leg. She
is started on Clindamycin and PCN and patient defervesces
in 24h. 5 days later, cellulitis is much improvd and patient
has sudden onset of fever and a maculopapular rash with
itching. You stop the drug. She has no dysuria or Foley’s
catheter. What will you do next?
• UA and Hansel Wright stain for eosinophils
• Change antibiotics to cephalosporin
Question
• The UA shows 10 WBC, 7 RBC, Eosinophils +, casts
negative. What is the most likely diagnosis?
• A) nosocomial UTI
• B) PCN induced interstitial nephritis
• C) clindamycin induced nephrotoxicity
• 2. All the following can cause interstitial nephritis except:
A)antibiotics- PCN, cephalosporins, rifampin, Cipro,
Sulfa
• B) NSAIDs
• C) diuretics( thiazide, furosemide)
• D) dilantin
• E) ACE inhibitors
Bactrim 4 renal effects
• 1. Sulfonamides induce renal failure by triggering allergic
interstitial nephritis
• 2. in high doses, Bactrim interferes with the renal secretion
of potassium, resulting in hyperkalemia as in patients with
PCP treated with Bactrim
• 3. Bactrim competes for tubular secretion with creatinine
and cause an increase in serum creatinine level
• 4. long acting sulfonamides cause renal insuff by the
crystals of the acetyl metabolite
Interstitial nephritis
• Acute allergic IN
• Chronic tubulointerstitial nephritis( analgesic nephropathy)
• Acute allergic IN- presents with fever, maculopapular rash,
eosinophilia with use of certain drugs or systemic inf
• UA_ microscopic hematuria, pyuria, non nephrotic
proteinuria, eosinophils+
• Usually resolves after d/c of offending drug and steroids