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ABIM Certification Exam: Nephrology

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ABIM Certification Exam: Nephrology 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 electrolyte abnormalities . Acid-base 2 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 urine output. 1 7/1/2013 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 2 7/1/2013 NEPHROLOGY Acute Renal Failure/Kidney 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 – Hepatorenal syndrome NEPHROLOGY Pre-Renal ARF: Department Kidney Hypoperfusion of Medicine Division of . Diagnosis Nephrology – +/- Oliguria – High BUN:Creatinine 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 3 7/1/2013 NEPHROLOGY Fractional Excretion of Sodium 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. 4 7/1/2013 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 5 7/1/2013 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. 6 7/1/2013 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, metabolic acidosis – 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 7 7/1/2013 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 mg/dL . Ionized Ca 0.79 mmol/L . PO4 9.9 mg/dL . Uric acid 11.1 mg/dL 8 7/1/2013 NEPHROLOGY Case Question Department of Medicine Division of What is the most likely diagnosis? Nephrology A. Rhabdomyolysis B. Tumor lysis syndrome C. Cisplatin nephrotoxicity D. Sepsis associated ATN NEPHROLOGY Intra-Renal ARF: Department Acute Tubular Necrosis (ATN) of Medicine Division of . Etiology Nephrology – Ischemic = hypotension, sepsis, shock, hemorrhage –Toxic • Exogenous: intravascular radiocontrast, aminoglycosides, amphotericin, cisplatin, oxalate (ethylene glycol/anti-freeze ingestion) • Endogenous: rhabdomyolysis (myoglobin), hemolysis (hemoglobin), tumor lysis (urate) . Diagnosis – Muddy brown/pigmented casts in urine sediment – Elevated FENa > 1-2% – High urine Na > 20 mEq/L NEPHROLOGY Intra-Renal ARF: Department Acute Tubular Necrosis (ATN) of Medicine . Prognosis Division of Nephrology – Mortality: 40-70% in ICU ARF requiring dialysis – Slower recovery . Therapy – Supportive care – Dialysis as needed – Fluid and electrolyte management – Medication dosing adjustment for GFR – No proven therapies – No benefit: mannitol, furosemide, dopamine, ANP, thyroxine 9 7/1/2013 NEPHROLOGY Intra-Renal ARF: Department Radiocontrast Nephropathy of Medicine . Etiology Division of Nephrology – Iodine-based radiocontrast – Intravenous or intraarterial injection – CT, angiography, cardiac catheterization . Risk factors – Pre-existing chronic kidney disease – Proteinuria –Age – Diabetes mellitus – Multiple myeloma – Dehydration NEPHROLOGY Intra-Renal ARF: Department Radiocontrast Nephropathy of Medicine Division of . Presentation Nephrology – Rise in creatinine 24-48 hours post-exposure – Patient with risk factors – Low FENa < 1% – Bland sediment (mild forms with vasoconstriction) or muddy brown casts of ATN (severe forms with toxic injury) . Prognosis – Mild cases resolve within 2-5 days, likely vasoconstriction mediated ARF – Severe cases resolve slowly over days to weeks, require dialysis, and may be irreversible due to toxin- induced ATN NEPHROLOGY Intra-Renal ARF: Department Radiocontrast Nephropathy of Medicine . Prevention Division of Nephrology – Avoid radiocontrast (US, nuclear medicine) – Minimize
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