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ABIM Nep CKD & HTN
| Question | Answer |
|---|---|
| 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
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