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ABIM Nep CKD & HTN

QuestionAnswer
Results of ACCORD study? aggressive BP target (sys <120 vs <140) was not beneficial (except possibly for stroke) in patients with diabetes.
KDOQI recommends keep HCO3 at ___ mEq/L? >22 mEq/L appear to slow progression of CKD. No increase in BP, edema, diuretic use, or need for more BP med noted despite more Na. Am Soc Nephrol. 2009(Sep);20(9):2075-84
Safe diabetes meds in CKD? glipizide and glimepiride (sulfonylureas), pioglitazone, and linagliptin (a DPP-4 inhibitor). AVOID: glyburide (lonegr T1/2 in CKD); metformin (higher risk of adverse effects); canagliflozin (a SGLT2 inhibitor); and exenatide (a GLP-1 receptor agonist).
Results of BEACON? 2185 patients with DM + CKD4, randomized to bardoxolone or placebo. Stopped early d/t more CV events in bardoxolone arm and no clear benefit of primary endpoints (ESRD or death from CVD).
For CV risk, when should BP meds be taken? taking at least 1 BP med at bedtime substantially reduced the risk of a cardiovascular event
in cases of unilateral renovascular disease, he decision about further evaluation depends on ______. response to drug therapy, specifically ACE inhibition. If BP controlled & renal fcn stable stable, current data indicate that little is to be gained by further maneuvers.
T/F The actual level of creatinine does not reliably predict the outcome for a specific patient in RAS. TRUE
What RIs carry better prognosis in RAS? LOW RIs associated with improved functional outcomes more commonly than hi levels, which suggest poor microvascular blood flow during diastole.
Page kidney is _____. what effects does it cause? Renal trauma assoc w/ perinephric hematoma compressing renal parenchyma—> renal ischemia and RAAS activation. It commonly induces activation of RAS (usu unilateral) that responds to blockade of that system.
Renal artery stenosis is associated with _____ PRA? Elevated PRA (hi rennin & aldo)
T/F: captopril renal scan useful for RAS? FALSE. Sensitivity and specificity low with AKI & CKD
Classic US findings for RAS? elevated peak systolic velocity, increased acceleration time, increased renal artery/aortic ratio
Best imaging study for primary hyperaldosteronism? CT scan of adrenal glands but only order after salt loading test done and results consistent with diagnosis
MIBG Scan is used for? Pheochromocytoma
Flank pain, stones, parenchymal calcifications are suspicious for? Nephrocalcinosis. Diagnosis made on CT urogram.
T/F Megestrol is helpful and dialysis/CKD patients with Anorexia and malnutrition. falls. Associated with increased death, fluid gains, diarrhea
What is most common cause of death in CKD patients GFR > 60? cancer
SPRINT trial results? BP control improves survival but not progression to ESRD. BP control beneficial and Non-diabetics
IDEAL study results early start of dialysis does not survival
___ may help improve AV graft patency. Fish oil
Tolvaptan therapy for PKD has shown (TEMPLE study)? moderate improvement of change in decline of GFR slope but not onset of ESRD. antHTN rx also not effective to slow down progression.
T/F high phosphorus is associated with increased mortality, and lowering phosphorus improves outcomes. FALSE. hi Phos is associated with higher mortality, but treatment has not been shown to improve survival.
T/F high creatinine is associated with better prognosis. True
T/F correction of metabolic acidosis enhances protein metabolism true
T/F albumin is a marker of nutrition and inflammation True
T/F intradialytic TPN is associated with improved survival false
CREATE study results there is no difference in outcomes with hemoglobin of 10.5 - 11.5 versus 13 – 15
CHOIR Study results higher hematocrit associated with more CV events, Increased death, and no improvements in quality of life
Answer the faction of iron versus ESA? iron starts working in days, ESA takes weeks
Goal for hemoglobin in anemia of CKD 10 – 11. Adverse events seen with > 11.5, harm seen >13.
Contra indications to ESA therapy? malignancy, Recent stroke, RBC aplasia
What is Hepcidin? molecule produced in the liver (d/t inflammation) that binds to ferroportin, which then induces internalization and degradation. It controls iron levels by regulating iron GI absorption, release from RES and hepatocytes, placental transfer.
DRIVE trial 47% of pts responded to IV ferric gluconate iron by inc Hgb > 2g/dl; po iron less effective.
Ferritin level of ________ indicates true iron deficiency in CKD 3/4. <100 with TSAT <20
Ferritin level of ________ indicates true iron deficiency in dialysis patients. ferritin < 200 and TSAT < 20
Therapy with sodium bicarbonate is most likely to _____ . slow progression of CKD. Target > 23. It reduces tubulo-intestitial damage by limiting infl biomarkers like ET and TGFbeta.
ACCORD study results: Glu < 140 vs 120 no difference except poss fatal CVA…. but more risks and hypoglycemia.
What drugs worsen RLS? dopamine antagonists (SSRI and TCAs)
In PKD patients with new or known aneurysms, RESCREENING is recommended how often? every 2-3 years until 40.
Renal malacoplakia findings? rare granulomatous inflammatory dz assoc with E. coli. Usu affects the bladder; but kidney primary site in 15%. CT shows enlarged kidney w hypovascular masses.
Renal findings of Xanthogranulomatous pyelonephritis? massive destruction of kidney d/t granulomatous tissue containing lipid-rich macrophages
Which GNs have fibrils on EM? Amyloid and fibrillary GN have fibrils on EM. Immunotactoid has microtubules on EM.
Histology & presentation of renal amyloid Lambda light chains, nephrotic proteinuria, nodular glomerulus, and fibrillar deposition in the nodule on EM are diagnostic of renal amyloidosis
Histology of & presentation of LCCD Kappa light chains, nephrotic proteinuria, nodular glomerulus, and granular deposition along basement membranes & nodules on EM are diagnostic of LCDD.
Fibrillary GN has what type of deposits? randomly arranged micro fibers 15–30 nm. positive for IgG, C3, and both kappa and lambda (ie, polyclonal) light chains
Immunotactoid GN has what type of deposits? parallel arrays of microtubules >30 nm. Have either kappa or lambda. Also larger organized deposits on EM Monoclonal IgG
Fibronectin nephropathy has what type of deposits? 10–15 nm fibrils
Rx idiopathic minimal change disease (iMCD) high-dose pred QD or QOD… slower response time. (effective >90%). cyclophosphamide, CsA, or MMF also beneficial in iMCD as steroid-sparing agents. also used in iMCD w freq relapse or steroid-dependent NS
In GPA (Wegeners), what is most common serologic finding? 80 to 90% have PR3-ANCA. absence of ANCA does not exclude the diagnosis of GPA
microscopic polyangiitis (MPA) are ANCA positive — of time 70 percent
What serologies are useful in distinguishing MPA from classic PAN? 75% of pts with MPA are ANCA positive, classic PAN is NOT associated with antibodies to either PR3 or MPO.
APOL1 gene variants are strongly associated with what kidney disease? FSGS, collapsing variant (HIV & SLE), sickle cell nephropathy, and focal global glomerulosclerosis with low-level proteinuria (previously attributed to hypertension). Not assoc w diabetic kidney disease.
Since minimal change dz may remit spont, why not watch? Conservative rx alone not rec’d d/t complications from NS.
Rx FSGS High dose GC initially. If no resp after 2 mos or relapse, add CNI & taper steroid. NO rx if have severe scarring or not nephrotic. Cyclophosphamide & MMF useful in freq relapsers, BUT not useful in steroid resistant cases.
Rx Membranous GN Spontaneous complete remission of NS in 5-30% @ 5 yrs. mod risk pts: rx’d conservatively for 6 mos.RTx started in hi or mod risk pts who fail to respond: Cytotoxic rx usu cyclophosphamide +steroid (or CNI+/- steroid). Ritux used for resistant cases.
Plasma Aldosterone to Renin ratio < 25 means? primary hyperaldo unlikely. Levels 25-50 need confirmatory testing; >ARR > 50 + aldo >10 is diagnostic. Image w CT adrenals if surgical candidate.
Preferred diagnostic test for Glucocorticoid-remediable aldosteronism (esp w +FMH) genetic testing approach because of improved sensitivity and specificity over measurement of corticosteroid metabolites or dex suppression testing
What medicines affect the RAS and interfere w testing? diuretics, β-blockers, ACE inhibitors, and ARBs. However don’t need to stop for PRA measurement
_______ was shown to control serum phosphorus and also to increase iron stores and decrease requirements for IV iron & ESAs. Ferric citrate
T/F Patients undergoing surveillance had a higher rate of prophylactic angioplasty, but the frequency of graft thrombosis was not decreased. TRUE. graft surveillance has not been proven to be effective in improving graft outcomes.
How does inflammation worsen anemia? Anemia, hypoxia, and infl (IL6) inc hepatic production of hepcidin, which causes ferroportin removal from cell membranes and limits iron release from RE cells for RBC production—>ESA-hyporesponsive.
Renal artery stenosis is associated with _____ PRA? Elevated PRA (and hi aldo)
T/F: captopril renal scan useful for RAS? FALSE. Sensitivity and specificity low with AKI & CKD
Classic US findings for RAS? elevated peak systolic velocity, increased acceleration time, increased renal artery/aortic ratio
Best imaging study for primary hyperaldosteronism? CT scan of adrenal glands but only order after salt loading test done and results consistent with diagnosis
MIBG Scan is used for? Pheochromocytoma
Renal microaneurysms are found in? Polyarteritis nodosa
Polyarteritis nodosa affects which vessels? small and medium sized arteries, especially Reno and visceral, nerves and coronaries… Causes aneurysms that look like tiny beads
Flank pain, stones, parenchymal calcifications are suspicious for? Nephrocalcinosis. Diagnosis made on CT urogram.
Imaging of medullary sponge kidney shows what findings? Dilated collecting ducts on retrograde urography with parenchymal calcifications. Contrast tends to pool and give brush like appearance.
Medullary sponge kidney is associated with? Ectasia of collecting ducts, urine stasis, lo Ucitrate, distal RTA. Asymptomatic hematuria common, some develop flank pain. RX citrate.
Papillary necrosis presentation? Asymptomatic or gross hematuria, pain, obstruction.
AVP mechanism of action increases the synthesis and provokes the insertion of aquaporin 2 water channels into the luminal membrane, thereby allowing water to be reabsorbed down the favorable osmotic gradient
Created by: ka1usg