7/1/2013

ABIM Certification Exam: Nephrology

Division of Nephrology Department of Medicine July 2013 UCSF CME Kathleen D. Liu, MD, PhD Associate Professor

NEPHROLOGY

Roadmap for today Department of Medicine

Division of . AKI (beyond ATN) Nephrology . Glomerulonephritis . A few odds and ends… . Common abnormalities . Acid-base

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NEPHROLOGY

Case Department of Medicine A 57-yr-old man is admitted after a motor Division of Nephrology vehicle accident. He has sustained multiple fractures and blunt chest and abdominal trauma. A left hemothorax is treated with a chest tube, an abdominal lavage reveals only minimal blood, and a noncontrast computed tomography (CT) scan of the abdomen is negative. He is volume-resuscitated with approximately 15 L of crystalloid. Twenty-four hours after admission, he is noted to have marked abdominal distension and low output.

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NEPHROLOGY

Case Department of Medicine Physical Exam: Division of Nephrology Tm 37.2 BP 135/86 HR 86 RR 16 UOP 100 cc/12h CVP 18 Bladder pressure 28 Intubated, sedated Decreased breath sounds at bases Regular heart sounds, no m/r/g Abdomen distended and firm, hypoactive BS

NEPHROLOGY

Case Department of Medicine Labs: Division of Nephrology . Na 135 . K 5.8 . Cl 103 . HCO3 24 . BUN 46 . Cr 2.3 . Imaging: Small retroperitoneal hematoma,normal sized kidneys without hydronephrosis, marked ascites.

NEPHROLOGY

Case Question Department of Medicine

Division of Which of the following would be the most Nephrology appropriate next step? A. Abdominal decompression B. Fluid resuscitation C. Placement of bilateral ureteral stents D. Initiation of renal replacement therapy

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NEPHROLOGY

Acute Renal Failure/ Injury Department of Medicine

Division of . Pre-Renal = Decreased kidney perfusion Nephrology . Intra-Renal = Intrinsic kidney disease . Post-Renal = Obstructive nephropathy

NEPHROLOGY Pre-Renal ARF:

Department Kidney Hypoperfusion of Medicine

Division of . Dehydration, overdiuresis, hypovolemia Nephrology – Abdominal compartment syndrome: Typically occurs after massive volume resuscitation . Hemorrhage . Hemodynamic effect: ACE/ARB and NSAIDs . Heart failure – Cardiorenal syndrome . Cirrhosis/End-stage liver disease –

NEPHROLOGY Pre-Renal ARF:

Department Kidney Hypoperfusion of Medicine

Division of . Diagnosis Nephrology – +/- Oliguria – High BUN: ratio > 20 – Bland urine sediment, normal kidney US – Low FENa < 1% and low urine Na <10 mEq/L – High specific gravity, high urine osmolality – Rapid renal recovery with resuscitation . Therapy: Restore renal perfusion . Prognosis: Good, often rapid renal recovery – Exceptions: Cardiorenal and hepatorenal syndromes

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NEPHROLOGY Fractional Excretion of

Department (FeNa) of Medicine

Division of . FeNa = (UNa * PCr)/(PNa * Ucr) * 100 Nephrology . <1% consistent with pre-renal state . Only useful when patient is oliguric (< 400 cc urine output/24 hours) . Confounded by use of diuretics

NEPHROLOGY

Case Department of Medicine

Division of A 40-yr-old man with end-stage liver disease Nephrology secondary to alcohol abuse is admitted to the hospital with altered mental status. Home meds: Propranalol/rifaximin/lactulose/lasix/spironola ctone Physical exam: T 37.4 BP 90/50 HR 80 RR 16 O2 sat 95% RA No JVD appreciated Bibasilar rales + abdominal distension + fluid wave 1-2+ LE edema

NEPHROLOGY

Case Department of Medicine

Division of Labs: Nephrology . Na 135 . K 5.1 . Cl 103 . HCO3 24 . BUN 46 . Cr 2.3 . U/A: 1.025/7/neg heme/gluc/nit/LE/prot . Imaging: Normal sized kidneys without hydronephrosis, marked ascites.

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NEPHROLOGY

Case Question Department of Medicine

Division of Which of the following would be the most Nephrology appropriate next step? A. Abdominal decompression B. Fluid resuscitation C. Placement of bilateral ureteral stents D. Initiation of renal replacement therapy

NEPHROLOGY Pre-renal ARF:

Department Hepatorenal Syndrome of Medicine

Division of . Severe end-stage liver disease patients Nephrology . Intense renal vasoconstriction . Diagnosis of exclusion – Oliguria – Low urine sodium < 10 mEq/L, low FENa < 1% – Hyponatremia – Bland urine sediment – Normal US (no hydronephrosis) – No other identifiable cause – Lack of response to volume expansion

NEPHROLOGY Pre-renal ARF:

Department Hepatorenal Syndrome of Medicine

Division of . Treatment Nephrology – Splanchnic vasoconstrictors (terlipressin, ornipressin), midodrine, octreotide – TIPS (transjugular intrahepatic portosystemic shunt) – Dialysis as bridge to liver transplant – Liver transplant

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NEPHROLOGY

Case Department of Medicine A 39-yr-old woman with stage 4 ovarian Division of Nephrology carcinoma with bulky pelvic and retroperitoneal disease is admitted with complaints of shortness of breath and decreasing urine output. Physical exam: T 37.4, BP 130/90, HR 76, RR 16, UOP 35cc/6h + jugular venous distention Bibasilar rales + abdominal distension 1-2+ LE edema

NEPHROLOGY

Case Department of Medicine Labs Division of Nephrology . Na 135 . K 5.7 . Cl 107 . HCO3 16 . BUN 60 . Cr 3.1 . PO4 6.9 . Uric acid 12.4

NEPHROLOGY

Case Department of Medicine Imaging Division of Nephrology . Abdominal ultrasound (outpatient study, 2 weeks ago): moderate right-sided hydronephrosis, normal left kidney . Repeat ultrasound demonstrates moderate calyceal dilation on the left, with no dilation on the right but persistent hydronephrosis. Kidney size is normal bilaterally.

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NEPHROLOGY

Case Question Department of Medicine

Division of Which of the following would be the most Nephrology appropriate next step? A. CT scan with contrast B. Allopurinol and urinary alkalinization C. Emergent hemodialysis D. Percutaneous nephrostomy

NEPHROLOGY

Post-Renal ARF: Obstruction Department of Medicine . Urinary tract obstruction Division of Nephrology – Renal pelvis, ureters, bladder, prostate, urethra – Congenital and acquired lesions, BPH – Neurogenic bladder, medication effects . Nephrolithiasis . Malignancy – GI cancers – Prostate cancers – Uterine, cervical, ovarian cancers . Lymphadenopathy . Retroperitoneal fibrosis

NEPHROLOGY

Post-Renal ARF: Obstruction Department of Medicine

Division of . Clinical Nephrology – Oliguric or non-oliguric – Can have type 4 RTA, – Foley does not definitively rule out obstructive nephropathy – Hydronephrosis on US, although negative US does not rule out obstructive nephropathy . Therapy – Correct obstruction – Urology consultation – Interventional radiology consultation: nephrostomy tubes

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NEPHROLOGY

Post-Renal ARF: Obstruction Department of Medicine

Division of . Prognosis Nephrology – More rapid recovery with rapid correction of obstruction – Can recover kidney function after prolonged obstruction – Post-obstructive diuresis from urinary concentrating defect

NEPHROLOGY

Case Department of Medicine

Division of A 65 year-old woman is admitted to the Nephrology hospital with newly diagnosed diffuse B cell lymphoma for induction chemotherapy. 24 hours after induction chemotherapy, she is noted to be oliguric. Physical exam T 38.4, BP 95/60, HR 94, RR 24 Heart is normal. Lungs are clear, though she is mildly tachypneic Trace-1+ pitting edema

NEPHROLOGY

Case Department of Medicine Labs Division of Nephrology . Na 138 . K6.0 . Cl 95 . HCO3 19 . BUN 43 mg/dL . Creatinine 3.4