RENAL CASES

beyondprinting.com
  • No tags were found...

RENAL CASES

Ishir Bhan, M.D. M.P.H.PHDepartment of MedicineDivision of NephrologyMassachusetts General HospitalHarvard Medical SchoolRENAL CASESJune 9, 2012Dr. Bhan has no potential conflicts of interest to disclose.


CASE 1


Presentation• 34 year old white male who presents for anew PCP visit. Has not previously seen a PCPas an adult. He has no complaints.• PMH: Appendectomy @ 10y• FH: Father with hyperlipidemia. Mother hashigh blood pressure.• SH: Works in the computer industry• Meds: MVI


Exam• Hih Height 5’ ’ 8”• Weight 200 lbs• T 98.8 HR 82 BP 162/90• Fundi appear normal• JVP 7• Regular S1 S2, Clear lungs• No edema


Audience ResponseBased on JNC 7 Guidelines, whatstage of hypertension is this?*• A. Pre‐hypertension• B. Stage I hypertension• C. Stage II hypertension• D. Stage III hypertension• E. Malignant hypertension*assume stable readings on subsequent visits


Based on JNC 7 Guidelines, whatstage of hypertension is this?*• A. Pre‐hypertension• B. Stage I hypertension• C. Stage II hypertension• D. Stage III hypertension• E. Malignant hypertension*assume stable readings on subsequent visits


JNC 7 (2003)• Average 2+ readings over 2+ visits iiStage SBP DBPNormal


Audience ResponseIn general, what fraction of hypertensionis due to secondary caues?• A.


In general, what fraction of hypertensionis due to secondary caues?• A.


Audience ResponseWhich of the following is the most commonsecondary cause of hypertension?• A. Renovascular disease• B. Glomerulonephritis• C. Pheochromocytoma• D. Addison’s Disease• E. Primary hyperaldosteronism


Which of the following is the most commonsecondary cause of hypertension?• A. Renovascular disease• B. Glomerulonephritis• C. Pheochromocytoma• D. Addison’s Disease• E. Primary hyperaldosteronism


Secondary hypertension• Severe• Acute• Onset before puberty• Age < 30, particularly if Not obese Not black Negative family history


Renovascular hypertension screening(ACC/AHA) Onset < 30 New stage II HTN after 55 Acute rise End‐organ damage (retina, CHF, renal failure,neurologic changes) Cr rise after ACEI/ARB HTN + Diffuse atherosclerosis HTN + recurrent acute pulmonary edema Lateralizing systolic‐diastolic bruit


Potential screening tests• MRA – risk ik of NSF• CTA –risk of contrast nephropathy• Angiogram – risk of emboli, contrast• Duplex ultrasound – operator dependent


Presentation• 48 year old Asian female presents for visit iiafter being rejected for life insurance due tohematuria• Never noticed overt urinary blood• Occasionally notes dark urine in setting ofURI• PMH: Fibroids, s/p hysterectomy, seasonalallergies


Presentation• FH: Father had lung cancer, mother with ih CAD.• SH: Physics professor, never smoked, doesnot drink• Medications: Zyrtec (cetirizine) 10 mg POPRN• ROS: Negative in detail


Physical Exam• T 98.5 HR 88 BP 110/78 /8• Well appearing middle aged woman• HEENT benign• Chest clear• S1 S2, no murmurs• No edema• No rashes• Joints normal


Laboratory studies• Na 140 K 3.6 Cl 105 CO2 25 BUN 18 Cr 1.1• eGFR 56• WBC 9.0 Hct 36 Hgb 12 Plt 309 Normal differential• UA: Lg blood, leuk esterase neg, 3+ protein,SG 1.020


Audience ResponseWhat stage of chronic kidney disease doesthis patient have?• A. Stage I• B. Stage II• C. Stage III• D. Stage IV• E. Stage VAssume labs remain stable over subsequent visits.


What stage of chronic kidney disease doesthis patient have?• A. Stage I• B. Stage II• C. Stage III• D. Stage IV• E. Stage VAssume labs remain stable over subsequent visits.


Stages of CKDStage GFR (ml/min/1.73m 2 )1 (normal or incr GFR) ≥ 902 (mild decrease) 60‐893 (moderate decrease) 30‐594 (severe decrease) 15‐295 (kidney failure)


Audience ResponseWhich of the following is the mostappropriate initial management for thisstage of CKD?• A. Refer for transplant evaluation• B. Refer for AV fistula placement inpreparation for dialysis• C. Evaluate and treat complications such asanemia and hyperparathyroidism• D. Follow renal function annually• E. Routine care


Which of the following is the mostappropriate initial management for thisstage of CKD?• A. Refer for transplant evaluation• B. Refer for AV fistula placement inpreparation for dialysis• C. Evaluate and treat complications such asanemia and hyperparathyroidism• D. Follow renal function annually• E. Routine care


More laboratory studies• 24 hour urine: 800 mg protein, 0.9 gmcreatinine• C3 100 (86‐184) 8 • C4 30 (20‐58)


Audience ResponseWhich of the following is most consistentwith the data presented?• A. IgA nephropathyh• B. Post‐streptococcal glomerulonephritis• C. Lupus nephritis• D. Cryoglobulinemia• E. Minimal change disease


Which of the following is most consistentwith the data presented?• A. IgA nephropathyh• B. Post‐streptococcal glomerulonephritis• C. Lupus nephritis• D. Cryoglobulinemia• E. Minimal change disease


IgA Nephropathy• Most common cause of primary GN• Predominantly Asians and Caucasians• Flares may be associated with URI• May have benign course with asymptomatichematuria/proteinuria or may progress toESRD• Therapy may be minimal (e.g. ACEI/ARB) ifstable without rising Cr, HTN, heavyproteinuria


CASE 3


Presentation• 62 year old African American man presentswith progressive fatigue over the past 2weeks. Also recent non‐productive cough andsubjective fevers, myalgias.• PMH: Hypertension, Hyperlipidemia, id i Obesity,Type 2 DM• SH: Accountant. t 10 pk yr smoking history,stopped at 42. Rare EtOH.• FH: He was adopted, d unknown.


Presentation• Mdi Medications: i ASA 325 mg PO daily Metformin 500 mg po bid Lisinopril 10 mg po daily HCTZ 25 mg po daily Atorvastatin 10 mg daily


Laboratory studies• Na 142 K 4.4 Cl 115 CO2 25 BUN 42 Cr 2.1• Albumin 3.9 g/dl• BUN/Cr 15/1.1 two months ago


Audience ResponseBased on the data provided, which of thefollowing tests is most appropriate?• A. Urine and serum ketones• B. Arterial blood gas• C. Lactate level• D. Serum protein electrophoresis withimmunofixation• E. Kidney biopsy py


Based on the data provided, which of thefollowing tests is most appropriate?• A. Urine and serum ketones• B. Arterial blood gas• C. Lactate level• D. Serum protein electrophoresis withimmunofixation• E. Kidney biopsy py


Anion Gap• Some acidoses result in increased unmeasuredanions: bicarbonate level drops while anion gapincreases• Examples: Intoxications: Methanol, ethanol, ethylene glycol ketones lactate salicylate phosphates, sulfates 5‐oxoproline


Anion Gap• Some acidoses result in increased unmeasuredanions: bicarbonate level drops while anion gapincreases• Examples: Intoxications: Methanol, ethanol, ethylene glycol ketones lactate salicylate phosphates, sulfates 5‐oxoproline


Non‐anion gap acidoses• Bicarbonate falls while Cl rises• Examples: Diarrhea Ureteral diversions Renal tubular acidosis Saline Post‐hypercapnia


Anion Gap ‐ simplified


Anion gap


Laboratory studies• Na 142 K 4.4 Cl 115 CO2 25 BUN 42 Cr 2.1• Albumin 3.9 g/dl• AG = 142 – (115+25) = 2• Expected AG = 3.9 x 2.5 ~ 10• Reduced unmeasured anions or increasedReduced unmeasured anions or increasedunmeasured cations


Anion gap


Anion gap


Anion gap


Additional studies• C3 110 C4 32 (normal)• WBC 5.8 HCT 31 Plt 330• SPEP – 2 gm/dl monoclonal spike• Large amount free light chains• UA dip: SG 1.030, pH 5, blood neg, leuk neg,glu trace, protein neg


Audience ResponseThe pattern of this patient’s renaldysfunction is most consistent with whichof the following?• A. Cast nephropathyh• B. Light chain deposition disease• C. Amyloidosis• D. Renal tubular acidosis


The pattern of this patient’s renaldysfunction is most consistent with whichof the following?• A. Cast nephropathyh• B. Light chain deposition disease• C. Amyloidosis• D. Renal tubular acidosis


CASE 4


Presentation• 55 year old white male presents after anabnormal CT scan performed for abdominaldiscomfort• PMH: Hypertension, hyperlipidemia, HCV• SH: English teacher. Never smoked. Drinks 1glass of wine per night. Married.• FH: Father died in MVA at 45. Mother hadcolon cancer, alive at 82. One daughter, 26,healthy.h


Presentation• Mdi Medications: i Rosuvastatin 10 mg daily Ib Irbesartan 150 mg daily MVI Cli Calcium carbonate Ergocalciferol 400 IU/day


Exam• T 98.4 HR 83 BP 150/83• No distress, appears comfortable• Lungs clear, heart regular without murmurs• Abdomen slightly distended, nontender• No edema


Audience ResponseHCV is most closely linkedto which of the following?• A. Minimal i change disease• B. Medullary sponge kidney• C. Membranoproliferative GN• D. Focal and segmental GN• E. Pauci‐immune GN


HCV is most closely linkedto which of the following?• A. Minimal i change disease• B. Medullary sponge kidney• C. Membranoproliferative GN• D. Focal and segmental GN• E. Pauci‐immune GN


CT ScanFred HL, Siddique I. New Engl J Med 1995; 333: 31


Which of the following statements aboutthis patient’s disease is true?• A. It has a frequency of 1:1000 in the generalpopulation• B. It is most lk likely l to have autosomalrecessive inheritance• C. While the kidneys are structurallyabnormal, there is minimal chance ofsignificant ifi renal dysfunction• D. Early medical intervention could haveprevented its development


Which of the following statements aboutthis patient’s disease is true?• A. It has a frequency of 1:1000 in the generalpopulation• B. It is most lk likely l to have autosomalrecessive inheritance• C. While the kidneys are structurallyabnormal, there is minimal chance ofsignificant ifi renal dysfunction• D. Early medical intervention could haveprevented its development


Autosomal Dominant Polycystic KidneyDisease• Frequency 1:1000• Affects all racial and ethnic groups• Typically presents between 30 and 50 years ofage• 50% develop renal insufficiency• Multiple bilateral renal cysts


Audience ResponseWhich of the following is NOT associatedwith ADPKD?• A. Hypertension• B. Hematuria• C. Hepatic cysts• D. Colonic polyps• E. Mitral valve prolapse


Which of the following is NOT associatedwith ADPKD?• A. Hypertension• B. Hematuria• C. Hepatic cysts• D. Colonic polyps• E. Mitral valve prolapse


The case continues…• The patient calls you to inform you that hehas developed a severe bilateral headache,but is not sure what to take for it given hiscondition. There is associated nausea. He hasno visual or neurologic changes, is afebrile,and has felt fine an earlier in the evening. Heasks your advice.


Audience ResponseWhat is the appropriate recommendation?• A. No treatment: analgesic therapy mayexacerbate kidney disease and iscontraindicated• B. Take ibuprofen 400‐800 mg po• C. Take acetaminophen 650 mg po• D. Take sumatriptan 25 mg po, repeatingafter 2 hours if needed• E. Proceed to the emergency department forurgent evaluation and treatment


What is the appropriate recommendation?• A. No treatment: analgesic therapy mayexacerbate kidney disease and iscontraindicated• B. Take ibuprofen 400 mg po• C. Take acetaminophen 650 mg po• D. Take sumatriptan 25 mg po, repeatingafter 2 hours if needed• E. Proceed to the emergency department forurgent evaluation and treatment


ADPKD and Cerebral Aneurysms• Present in up to 10% of all ADPKD patients• Higher risk with positive family history (~20%if positive, ~5% if negative)• 50% have normal renal function• Ruptured aneurysms carry high morbidityand mortality


CASE 5


Presentation• 82 year old nursing home resident p/w alteredmental status.• PMH: Hypertension, dementia, GERD• FH: Unknown• SH: Dependent on staff. No tobacco, EtOH• ROS: Unable


PresentationMd M l l bid A l di i• Meds: Metoprolol 25 mg po bid, Amlodipine 5mg daily, ASA 81 mg daily, MVI


Exam• T 99 HR 92 BP 139/70• Wt 60 kg (per records)• Non‐verbal, OP slightly dry• JVP 7• Scattered wheezes• Regular rhythm• Soft abdomen• No edema


Data• Lb Labs: Na 160, K 3.9, Cl 120, CO2 29 BUN 20 Cr1.0• CXR: Possible RML infiltrate fl c/w earlypneumonia• UA: SG 1.030, WBC neg, bld neg, nitrite neg


Audience ResponseWhat IV fluids would best correct this patient’ssodium safely and rapidly (~48 hours)?• A. 3% hypertonic saline 30 cc/hr• B. NS 75 cc/hr• C. NS 500 cc bolus, then 75 cc/hr• D. ½ NS 75 cc/hr• E. D5W 100 cc/hr


What IV fluids would best correct this patient’ssodium safely and rapidly (~48 hours)?• A. 3% hypertonic saline 30 cc/hr• B. NS 75 cc/hr• C. NS 500 cc bolus, then 75 cc/hr• D. ½ NS 75 cc/hr• E. D5W 100 cc/hr


Free water deficitGroupWater deficit = TBW * (1‐140/Na)140/Na)TBW = correction factor * weightMen 0.6Women 0.5Elderly men 0.5Elderly women 0.45Correction factorTBW = 0.5 * 60 = 30Water deficit = 30 * (1‐140/160) = 3.75 L


Sodium correctionExpected ΔNa = (Na IVF – Na serum )/(TBW+1))Expected ΔNa D5W = (0‐160)/31 = ‐5.2Expected ΔNa 1/2NS = (77‐160)/31 = ‐2.7Expected ΔNa NS = (154‐160)/31 = ‐0.2These equations ignore the ability of the kidney toproduce concentrated urine.


BONUS CASE 1


Presentation• 56 year old woman p/w weakness andlightheadedness to the ER• Abdominal cramping and diarrhea for severaldays• Poor oral intake• Just returned from trip to Mexico• PMH: Type 2 DM, diet controlled


Presentation• SH: Runs a café. 20 pk yr smoking history.Occasional alcohol.• FH: Mother had hdbreast cancer.• Medications: Trimethoprim‐Sulfamethoxazle(Bactrim DS) twice daily


Exam• T 98 HR 104 BP 90/50• Appears weak• Dry mucous membranes• Neck veins not distended• Lungs clear• Tachycardic but regular S1 S2• Diffusely tender abdomen• No edema


Audience ResponseInitial labs show Na 128 K 3.0 Cl 100 CO2 14BUN 38 Cr 1.2 Glu 200; Albumin 4These findings best support which statement ofher acid‐base status?• A. Anion gap metabolic acidosis• B. Non‐anion gap metabolic tbli acidosisi• C. Anion gap and non‐anion gap metabolicacidosisi• D. Anion gap metabolic acidosis andmetabolic alkalosisl• E. Combined metabolic acidosis andmetabolic alkalosis


Initial labs show Na 128 K 3.0 Cl 100 CO2 14BUN 38 Cr 1.2 Glu 200; Albumin 4These findings best support which statement ofher acid‐base status?• A. Anion gap metabolic acidosis• B. Non‐anion gap metabolic tbli acidosisi• C. Anion gap and non‐anion gap metabolicacidosisi• D. Anion gap metabolic acidosis andmetabolic alkalosisl• E. Combined metabolic acidosis andmetabolic alkalosis


Na 128 K 3.0 Cl 100 CO2 14 BUN 38 Cr 1.2 Glu200Albumin 4• Anion gap: 128 – (100+14) = 14• Expected AG: 10• Delta AG: 4• Expected CO2 = 24• Delta CO2 10• Delta CO2 is more than expected from AG: suggestsconcomitant non‐AG acidosis• Delta CO2 less than expected: concomitant metabolicalkalosisC t di i lt AG id i d• Cannot diagnose simultaneous non‐AG acidosis andmetabolic alkalosis


Audience ResponseNa 128 K 3.0 Cl 100 CO2 14 BUN 38 Cr 1.2 Glu200Osm 280 Uosm 560• A. The patient likely l has SIADH• B. The patient likely has hyponatremia due tohyperglycemia, though hcannot excludeSIADH• C. The patient likely has hyponatremia due tovolume depletion, though cannot excludeSIADH• D. The patient likely has pseudohyponatrmeia


Na 128 K 3.0 Cl 100 CO2 14 BUN 38 Cr 1.2 Glu200Osm 280 Uosm 560• A. The patient likely l has SIADH• B. The patient likely has hyponatremia due tohyperglycemia, though hcannot excludeSIADH• C. The patient likely has hyponatremia due tovolume depletion, though cannot excludeSIADH• D. The patient likely has pseudohyponatrmeia


The case continues• The patient is given IV normal saline with ihsome symptomatic improvement• Repeat lb laboratory studies are sent


Audience ResponseNa 140 K 3 Cl 110 CO2 10 BUN 10 Cr 0.9 Glu 100Osm 290 Uosm 290 UNa 30 UK 6• A. The patient has hypokalemia from a renaltubular disorder• B. The patient has hypokalemia from extrarenallosses• C. The patient has hypokalemia due tonormal saline administration• D. The patient has hypokalemia due toBactrim (TMP‐SMX) use• E. Not enough information


Na 140 K 3 Cl 110 CO2 10 BUN 10 Cr 0.9 Glu 100Osm 290 Uosm 290 UNa 30 UK 6• A. The patient has hypokalemia from a renaltubular disorder• B. The patient has hypokalemia from extrarenallosses• C. The patient has hypokalemia due tonormal saline administration• D. The patient has hypokalemia due toBactrim (TMP‐SMX) use• E. Not enough information


Potassium handling• Transtubular potassium gradient (TTKG)• (U K /U osm )/(S K /S osm )• Low TTKG (< 3) suggests no renal potassium wastingIn hypokalemia, suggests extrarenal lossIn hyperkalemia, suggests hypoaldosteronism• High TTKG (>7) suggests renal potassium wastingIn hypokalemia, suggests renal lossIn hyperkalemia, suggests low output (e.g. renal failure)

More magazines by this user
Similar magazines