Nephrology 2

Question 1

Common complications (2) of ESRD patients despite EPO therapy that leads to fatigue and tiredness?

Answer 1

1. Iron Deficiency Anemia due to blood loss (multiple blood draws.)
   EPO therapy (causes high mobilization to build more RBCs)
2. Anemia of Chronic Disease (elevated hepcidin levels)

Question 2

1. Management of a patient with Hx of Cigarette Smoking, Older age, White Ethnicity with Microscopic Hematuria (>3 RBC/hpf)
2. What to do if the microscopy shows RBC cast, Proteinuria, CKD ?
3. What to do if the microscopy is Normal?

Answer 2

1 . Repeat Analysis again, if positive cystoscopy and urine cytology for Bladder Cancer.

2. Evaluate for Renal causes
3. Repeat in 6 months if normal then routine follow up

Question 3

Pt with Nephrogenic DI due to Lithium can be treated with what medication to augment symptoms if lithium cant be stopped?

Answer 3

Amiloride

Question 4

Pt presets with Confusion, Excessive Urination, N/V and Fatigue. She takes OTC medications for Heartburn. PTH normal and Vit D normal. CA 14.8. There is a metabolic acidosis.

Answer 4

PTH-Indepedent hypercalcemia - Milk Alkali Syndrome from ingestion of Calcium Carbonate.

Question 5

Difference between Anti-GM (Goodpasture Syndrome) and Granulomatosis with Polyangiitis (Wegners)?

Answer 5

Anti-Gm does not have Constitutional vasculitis Symptoms.

Question 6

Pt presents with Hematuria, Red Blood Cell Cast, Proteinuria, Hypertension and Hemoptysis. DENIES any fever, chills, weight-loss and arthralgias.

Dx?

What is the positive antibody?

What is shown on renal biopsy?

Answer 6

Anti-GM disease.

Anti-GM Antibody.

Linear immunofluorescence of IgG in glomerular capillaries.

Question 7

In a patient with edema and CKD on a Thiazide. What would be the best course of management to improve the Persistent Edema?

Answer 7

Switch the thiazide to a loop diuretic.

Question 8

80 y old woman presents with Fatigue, Dizzy spells, and Nausea. Pt was recently started on Thiazide Diuretic for Hypertension. Dx? Rx?

Answer 8

Thiazide Induced Hyponatremia
-Causes Increase Na+ Excretion and Increase ADH ( Leads to Water retention unlike Loop Diuretics that Do Not Cause Water Retention)

Check Na+ Level, Stop Thiazide and Give Normal Saline.

Question 9

Rx for Renal Artery Stenosis?

Answer 9

ACE.

Question 10

Rx for Salicylic Acid intoxication (Respiratory Alkalosis with Metabolic Acidosis )?

Answer 10

Alkalization of urine with IV Sodium Bicarb.

Question 11

Pt present for 10 month follow up after Cadaveric Renal Transplantation. Creatinine is 2.7. UA shows WBC, RBCs, Cellular Cast and Atypical Cells with Intranuclear Inclusions?

Answer 11

BK Polyomavirus-Induced Nephropathy ( Develop Tublointerstial nephritis)

Question 12

Management of a patient developing Possible Abdominal Compartment syndrome from massive fluid resuscitation from Sepsis or Trauma.

Answer 12

Measure Bladder Pressure.

Question 13

Young women reports recurrent UTIs and decreased GFR. Urine pH is 8. Dx? Rx?

Answer 13

Stone Removal for Struvite Stone + Abx ( only way to eradicate the bacteria and restore kidney function). The struvite stone can lead to staghorn calculi caused by E. Coli and Proteus.

Question 14

1. Management of PSA < 3?
2. Management of PSA > 7?

Answer 14

Follow routinely.

Referral to Urology for biopsy.

Question 15

43 y M presents with Weakness, Joint Pains and Erythematous Macules on exam. AST and ALT are elevated, Hematuria and Proteinuria present in urine. Pt has LOW Complement Levels with Positive RF. Dx?

Answer 15

Hep C causing Mixed cryoglobulinemia causing Hep C glomerulonephritis.

Question 16

1. What is the Serum Anion Gap?
2. What is the Urine Anion Gap?
3. What is the osmolar gap>

2. What is the Urine Anion Gap?

Answer 16

1.) Na - ( CL + HCO3 )
2.) Na + K- CL ( Urine Anion- Urine Cation)
Inability of the Kidney to excrete Acid because the kidney cannot Generate enough ammonium to excrete Acid = Renal Tubular Acidosis ( the Urine Anion Gap is Positive)
Negative Urine Anion Gap = A lot of Ammonium is Generated by a normal Kidney to help excrete Acid ( after eating Animal Protein) Also present in GI loss. Lose HC03.

3. 2 (Na) + Bun/2.8 + Glucose/18

Question 17

42 yo W presents with Recurring Red Spots on her legs for 2-3 years. Also reports Occasional Abdominal pain, Arthralgias. She has 2+ Protein, RBC 10-120 and Occasional red blood cell cast. Dx? Test? Rx?

Answer 17

Henoch Schonlein Purpura.

IgA immune complex deposits in small vessels on skin biopsy. It is a leukoclastic vasculitis.

Question 18

Man presents with Abdominal pain, progressive Fatigue, LE edema and chronic cough. CXR shows Cardiomegaly with Small effusions. UA protein is 1+ but Spot Urine Total Protein/Creatinine ratio is 2.5. Dx?

Answer 18

Multiple Myeloma.

There will be discrepancy on the dipstick (only picks up Albumin and not light chains) vs the qualitative analysis.

Question 19

Name The Effects of Calcium stone prevention:

1. Decrease Sodium Intake?
2. Increase Calcium Intake?
3. Increase Fluid Intake
4. Increase Fruit and Vegetable Intake?
5. Decrease Animal Protein?

Answer 19

1. Decreases Calcium Excretion and increases Sodium and Calcium Proximal Tubule Reabsorption
2. Calcium Binds to Oxalate in Gut which Decreases Urinary Calcium and Oxalate Excretion. Oxalate wont be reasorb in the blood stream going to the kidney to form calcium oxalate stones.
3. Increase Urine flow and Decreases Solute Concentration
4. Increase Citrate Excretion, Citrate binds to Urinary Calcium to inhibit Stone formation (Lemon Juice)
5. Decreases Acid load and Urinary Calcium Excretion, Decrease Uric Acid Excretion.

Question 20

22 yo M (Young Patient) presents with 7mm Kidney stone. UA shows occasional hexagonal crystals with benzene ring morphology. Dx? Rx?

Answer 20

1. Cystine Stone.

Increase fluid and .2 Alkalinize Urine. (potassium citrate or bicarbonate.)

Question 21

Name the Stone:
Risk Factors:
1. Hyperparathyrodism (hypercalciuria), Malabsorption (hyperoxaluria), Distal RTA (hypocitraturia).

2. What will the UA show?

Answer 21

1. Calcium oxalate.
2. Enveloped shape crystals

Question 22

Name the Stone:

1. Risk Factors: Gout, Myeloproliferative disorders
2. What will the UA show?

Answer 22

1. Uric Acid Stones

2. Rhomboid Crystals, Radiolucent stones

Question 23

Name the Stone:

1. Risk Factors: Decrease reabsorption of cystine in Kidney?
2. What will the UA show?

Answer 23

1. Cystine Stone.

Hexagonal green/yellow crystals, Large branched calculi