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Nephrotoxicity And Acid Base Balance

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  • 1. TOP 10 NEPHRO SLIDES IN EACH BOARD EXAM EVERY YEAR
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  • 11. BOARD EXAM SLIDES
  • 12. WHAT IS THIS ?
  • 13. WHAT IS THIS ?
  • 14. WHAT IS THIS ?
  • 15. WHAT IS THIS ?
  • 16. WHAT IS THIS ?
  • 17. WHAT IS THIS ?
  • 18. WHAT IS THIS ?
  • 19. COMMONEST NEPHRO CASES IN BOARD EXAM – TRICKS AND CLUES
    • MOST OF THE CASES CONTAIN ONE SINGLE OUTSTANDING CLUE THAT CAN GIVE YOU THE DIAGNOSIS ---
    • LOOK FOR THAT CLUE
    • THIS IS THE M-KASAP TYPE OF QUESTIONS
  • 20. CASE-1
    • 72 OLD MALE DIABETIC ON INSULINE HAD CHEST PAIN AND WENT FOR CARDIAC CATH .AFTER SECOND DAY HIS CREATININE WENT UP TO 300 FROM BASE LINE BEFORE CATH 90.
    • HIS LABS SHOW;
    • CBC; WBC 4500,HB 11.5,PLAT 200 THOUSANDS
  • 21. BUN 23, CR 300,NA 138,K 5.8 LDH 400,AST 60,ALT 40 UA +BLOOD,+PROTIEN,TOTAL 24 HRS COLLECTION 1GM C 3 LOW,C 4 LOW,ESR 90
  • 22. THE MOST LIKELY DX IS :
    • A. CHOLESTEROL EMBOLISATION
    • B. CONTRAST NEPHROPATHY
    • C. SLE-DIFFUSE PROLIF GN
    • D. SLE-FOCAL PROLIF GN
    • E. RENAL ARTERY STENOSIS WITH ISHEMIA INDUSED BY ANGIOGRAM
  • 23. CORRECT ANSWER IS A
    • CHOLESTEROL EMBOLISATATION
    • ONE OF THE MOST AND TOP QUESTIONS IN ARAB-SAUDI-AMERICAN BOARD EXAMS
    • SIMPLY EXAMINERS THEY LOVE IT !!!
  • 24. I TOLD U LOOK FOR THE CLUE!! WHERE IS THE CLUE HERE ?
    • THE CLUE IS THE TIME OF INCREASE IN CR WHICH IS AFTER 48 HRS
    • CONTRAST GIVE U INCREASE CR WITHIN FIRST 24 HRS OF THE ANGIO BUT CE THE RISE IS AFTER 48 HRS
    • OTHER CLUES LOW COMPLEMENTS,AND HIGH ESR
  • 25. CE-CASE
    • ESINOPHILLIA
    • DIGITAL INFARCTS
    • LIVEDO RETICULARIS
    • RETINAL EMBOLI AND HEMORRHAGES
    • RISK INCREASED BY HEPARINE
    • AS CTD
    • PROGNOSIS GRAVE ( NO SINGLE CASE HAS BEEN RECOVERED
  • 26. Cr timing
    • Cr increase in contrast within first 24 hrs
    • Cr increase in embolisation after 24-72 hrs
    • Cr increase in gentamycine after 7-10 dys
  • 27.  
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  • 30. CASE-2
    • 65 OLD MALE DIABETIC FOR 15 YRS ON INSULINE PRESENTED WITH INCREASE CR FOR THE LAST 6 MONTHS ,HAS HX OF IHD 1 YEAR AGO,PRESENTED WITH PULMONARY EDEMA,HIS DRUG HX INCLUDE AMLOR 10 MG,ISORDIL,CLONIDINE,AND ZESTRIL 20 MG,AND RECENTLTY START TAKING NSAID . HIS V/S IN ER;
  • 31. HR 110 REGULAR,BP 185/95,T 37 CBC; WBC 5000,HB11,PLAT 180,000 CR 300 AND 2 MONTHS AGO WAS 150,BUN 27,NA 136,K 2.8,HCO3 20 LFT NORMAL UA ++ PROTIEN,RBS 5-10 ECHO ; EF 55 %
  • 32. THE MOST LIKELY CAUSE OF HIS RENAL DETORIATION IS;
    • A. HYPERTENSIVE GLOMERULOSCELEROSIS
    • B.NSAID NEPHROPATHY
    • C.RAS
    • D.ACE INHIBITOR
    • E. B AND D
  • 33. RAS-VERY COMMON QUESTION IN BOARD EXAMS-THE CLUE
    • PATIENT ON 3 DRUGS ( RESISTANT HYPERTENTION )
    • DIABETIC AND IHD(ATHEROSCELEROSIS
    • ACE CAN CAUSE RENAL DETORIATION
    • FLASH PUL EDEMA IN A PATIENT WITH NORMAL HEART (NORMAL EF ) AND HYPERTENSIVE IS ALMOST ALWAYS DIAGNOSTIC OF RAS
    • MOST IMPORTANT IS HYPOKALEMIA
  • 34. NSAID CAUSE HYPERKALEMIA REMEMBER THAT !!!!!!! ACE INHIBITOR CAUSE HYPERKALEMIA-ALSO REMEMBER THAT.
  • 35. RAS-GOLDEN POINTS IN BOARD EXAMS-IF U KNOW IT U WILL NOT MISS THE ANSWER:
    • FIRST RULE IS THE CLASSIC SETTING;
    • ELDERLY,ATHEROSCELEROTIC,IHD,PVD,ON THREE OR MORE ANTIHYPERTENSIVES
    • ACE CAUSE DETORIA OF RENAL FUNCTIO
    • HYPOKALEMIA,HIGH BP,ABD BRUITE
    • IN YOUNG FEMALES ABOVE SIGNS ARE ABSENT EXCEPT BRUITE AND HIGH BP AND THE CAUSE IS FMD
  • 36.  
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  • 44. All the follwing are true of preclampcia EXCEPT :
    • A. high uric acid
    • B. high Cr
    • C. no urine RBC casts
    • D. high urine calcium
    • E. high urine protien
  • 45.  
  • 46.  
  • 47. 36 yrs female known case of SLE want to become pregnant, what would u advice her ?
    • A. the single most important is Cr level at the time of conception
    • B.the single most important is disease activity level at conception
    • C.the single most imprtant is protienurea
    • D.A AND B
    • E.B AND C
  • 48.  
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  • 50.  
  • 51. What is the single most important labs finding to diffrenciate between preeclamcia and SLE during pregnancy?
  • 52.  
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  • 58. 25 OLD MALE COCCAINE ABUSER PRESENTED TO ER WITH :
    • VOMITING,HYPERTENTION,AND FEVER WITH DECREASE URINE OUTPUT
    • O/E BP 170 / 98 T 38
    • CVS S1,S2 NORMAL WITH ESM
    • LUNGS CLEAR,ABD NO ORGANOMEGALY
    • HX OF CHANGE OF URINE COLOUR
  • 59. LABS
    • CBC WBC 7,PLAT 230,Hb 10.6
    • LFT NORMAL
    • Cr 600 AND ONE MONTH AGO WAS 78
    • Na 137, K 6.8,Ca 1.2,Ph 1.9
    • Uric Acid 600
    • UA POSITIVE FOR BLOOD +++ ON DIPSTICK,PROT +,RBC 1-5
  • 60. THE MOST LIKELY DX:
    • A. RHABDOMYOLYSIS
    • B. SBE
    • C.TUMOR LYSIS SYNDROME
    • D.POST INF GN
    • E.POLYARTERITIS NODOSA
  • 61. RHABDOMYOLYSIS-THINS IN EXAM TO REMEMBER
    • THE COMMONEST CAUSE IS TRUMA-SOLDIER SYNDROME
    • THE COMMONEST DRUG IS COCCAINE
    • OTHER DRUGS HMG-COENZ-RED-INHIBITORS AS STATINS
    • THE SINGLE MOST IMPORTANT STEP IN MANAG IS IVF AND IVF AND IVF
  • 62. COMMONEST MCQ IN EXAMS-GN
    • 54 YRS MALE PRESENTED WITH WEAKNESS,DIAZINESS, FOR 4 MONTHS
    • CBS HB 8GM,WBC 5,PLAT 230
    • LFT Na 137,K 6,Ca 2.6,
    • U/A DIPSTICK PROTIEN +,BLOOD –
    • MICROSCOPY NO RBC CASTS
    • TOTAL 24 HRS PROTIEN 8 GM
  • 63. RENAL BX;
  • 64.  
  • 65.  
  • 66. THE MOST LIKELY DX IS ;
    • A.AMYLOIDOSIS
    • B.MYELOMA KIDNEY
    • C.MEMRANOUS GN
    • D.FSGS
    • E.MINIMAL CHANGE DISEASE
  • 67. MYELOMA KIDNEY-EXAM FAVOURITE
    • THE MOST IMPORTANT CLUE IN EXAM IS DIPSTICK URINE NEGATIVE FOR PROTIEN OR MILD + POSITIVE BUT THE 24 HRS URINE COLLECTION FOR PROTIEN IS MORE THAN 3 GM. WHY ?
    • LARGE KIDNEY. WHAT OTHER CAUSES OF LARGE KIDNEY ????
  • 68. TWO TYPES OF MYELOMA KIDNEY
    • A. TUBULAR WITH LIGHT CHAIN DEPOSITION AND GIVE U FRACTURED CAST DIAGNOSTIC OF MM.THIS TYPE HAS GOOD PROGNOSIS
    • B.LDD-CHARACTERISED BY NODULAR SCELEROSIS AND POOR PROGNOSIS
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  • 82. MEMBRANOUS GN-EXAM POINTS
    • THE COMMONEST CAUSE OF RENAL VIEN THROMBOSIS
    • THE COMMONEST CAUSE OF NEPHROTIC SYNDROME IN ADULTS
    • COMPLEMENTS NORMAL,NO RBC CASTS
    • ASSOCCIATED WITH MALIGNANCY COLON
  • 83. MGN
    • IDIOPATHIC
    • SECONDARY TO DRUGS ( ACE,GOLD,PENCILLAMINE )
    • INFECTIONS(MALARIA,HEP B)
    • TREATMENT( ACE,PONTICELLI PROTOCOL=CHLORAMPUCIL ALTERNATING WITH STEROIDS OR IMMURAN
  • 84. PROGNOSIS-THE 25 % DISEASE
    • 25 % COMPLETE RECOVERY
    • 25 % PARTIAL RECOVERY
    • 25 % ESRD
    • 25 % RELAPSE ON AND OFF
  • 85.  
  • 86.  
  • 87.  
  • 88.  
  • 89. FSGS-EXAM QUESTIONS
    • THE COMMONEST QUESTIONS IS CAUSES
    • OR A CASE WHICH TELL U THE CAUSE
    • OBESE PATIENT WITH PROTIENUREA IS FSGS
    • A PATIENT WITH HIV THE COOMNEST RENAL BX FINDING IS COOLAPSING FSGS
    • A PATIENT ON HEROINE OR DRUG ABUSER IS FSGS
  • 90. FSGS
    • A PATIENT WITH SINGLE KIDNEY AND PROTIENUREA IS FSGS
    • A PATIENT WITH REFLUX HAS FSGS
    • STEROIDS CAN INDUSE REMISSION IN 40 % OF CASES
    • IT IS THE HIGHEST AND FASTEST RECURRENCE OF RENAL TX WITH MPGN
  • 91.  
  • 92. MCD-EXAM QUESTIOS
    • NSAID IS THE ONLY DRUG KNOWN TO CAUSE MCD
    • ALL MALIGNANCY ASSOCIATED WITH MEMBRANOUS GN EXCEPT ONE MLIGNANCY ASSOCIATED WITH MCD DO U KNOW WHAT IT IS ????????????
  • 93. MCD-EXAM POINTS
    • IN A PATIENT WITH MCD WHO IS NOT RESPONDING TO ADEQUATE COURSE OF STEROIDS THE MOST LIKELY CAUSE IS FSGS SO DO RENAL BX
    • THE MOST IMPORTANT POINTS ABOUT MCD IS THIS
    • IN CHILDREN A COURSE OF 8 WEEKS STEROIDS IS ADEQUATE TO INDUSE REMISSION
  • 94. BUT IN ADULTS THE STORY IS DIFFERENT
    • IN ADULTS DO NOT LABEL THE PATIENT AS STEROIDS RESISTANT UNLESS U GIVE 12 WEEKS OF STEROIDS
    • REMEMBER AT LEAST 12 WEEKS
    • DO U KNOW THE DIFFERENCE BETWEEN STEROIDS DEPENDENT AND STEROIDS RESISTANT AND STEROIDS RELAPSER
  • 95.  
  • 96. MPGN-EXAM POINTS
    • THE HIGHEST RECURRENCE OF DISEASE IN TX ( 80 % )
    • THE COMMONEST CAUSE OF MPGN IN THE WORLD NOW IS …………………………
    • CRYOGLOBULINEMIA IS IMPORTANT CAUSE
  • 97. FREQUENT AND COMMON BOARD EXAM QUESTION IS THIS ONE
    • 54 YRS MALE PRESENTED WITH HEAVY PROTIENUREA OF 7GM
    • HIS LFT IS ABNORMALA
    • THE RENAL BIOBSY WILL SHOW…………………………….
  • 98.  
  • 99.  
  • 100.  
  • 101.  
  • 102. RPGN-THE MOST FREQUNT QUESTION COMES IN EXAMS
    • IT IS A MEDICAL EMERGENCY
    • IN FACT IT IS THE ONLY GN THAT IS EMERGENCY
    • IT CAN KILL THE KIDNEY IN 72 HRS IF U DID NOT ACT
    • U START RX EVEN BEFORE THE BX RESULT
  • 103.  
  • 104. CAUSES;
    • WEGNERS
    • PAN
    • CHURG-STRAUSS
    • ANTI-GBM
  • 105. THE MOST IMPORTANT AND MOST THAT COMES IN THE EXAM IS THIS QUESTION:
    • 36 OLD MALE PRESENTED WITH HX OF URTI AND SUDDEN DECREASE IN URINE OUTPUT AND RISING Cr .HIS Cr 2WEEKS AGO WAS 80 NOW IT IS 490
    • CXR SHOWED LUNG INFILTRATE
    • U/A SHOWED RBC 10-20,RBC CASTS
    • THE BEST FIRST STEP OF TREATMENT IN THIS PATIENT IS :
  • 106. RPGN CASE;
    • A. START PULSE STEROIDS,DO BX IF RPGN ADD CYCLOPHOSPHAMIDE
    • B. DO BX THEN START CYCLOPHOSPHAMIDE
    • C. START PULSE STEROIDS AND CYCLOPHOSPHAMIDE
    • D. START PLASMAPHRESIS AND STEROIDS
    • E. START PLASMAPHRESIS AND CYCLOPHOSPHAMIDE
  • 107. P-ANCA
    • WEGNERS
    • MICROSCOPIC POLYANGIOPATHY
    • CHURG-STRAUSS
    • IDIOPATHIC RPGN IN THE ELDERLY
  • 108.  
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  • 114. REVERSAL OF RENAL FUNCTION IN ANTI-GBM DISEASE(GODPASTUER)
    • IF Cr LESS THAN 550
    • IF PATIENT NOT YET STARTED ON DIALYSIS
    • IF PLASMAPHRESIS STARTED EARLY
  • 115. BEST RX FOR GODPASTURE
    • PLASMAPHRESIS
    • PULSE IV STEROIDS
  • 116. BEST RX FOR WEGNERS
    • PULSE IV STEROIDS
    • CYCLOPHOS
    • PLASMAPHRESIS
  • 117. C-ANCA-ONLY WEGNERS
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  • 127. THE MOST IMPORTANT SLIDE IN GLOMERULONEPHRITIS
    • ANY CASE IN THE EXAM MENTION UA CONTAIN RBC-CAST
    • THERE ARE ONLY 5 DDX IN MEDICINE
    • DO U KNOW WHAT ARE THEY ??????? ??
  • 128.  
  • 129. CAUSES OF RBC-CAST THIS IS CALLED ACTIVE URINE SEDIMENT
    • 1. MPGN
    • 2.IGA NEPHROPATHY
    • 3.POST-INFECTIOUS GN AS POST-STREPTOCOCCAL GN
    • 4.SLE
    • 5.RPGN
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  • 139. WHAT IS THE SINGLE MOST IMPORTANT TEST TO DIFFRENTIATE BETWEEN PRERENAL AND POSTRENAL AZOTEMIA ( ATN ) ??
  • 140. IT IS FENA
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  • 160. 22 yrs male found comatose and his friends mention that he had problems with his wife and attempted suicide and his labs; Na 140,k 5,cl 95,CO2 10,GLUCOSE 7,PLASMA OSMOL 325,BUN 13
  • 161. PH 7.1,PCO2 24,PO2 85
    • WHAT ACID BASE DISTURBANCE ?
    • IS IT SIMPLE OR MIXED ?
    • WHAT IS THE DX ?
  • 162. Expected PCO2 = 1.5 X HCO3 + 8 ( + OR – 2 )
    • MA WITH HIGH AG
    • EXP PCO2 IS 21 – 25
    • MA POISONING
  • 163. 5-DAYS LATER HIS ABG :
    • PH 7.2
    • HCO3 16
    • PCO2 45
    • WHAT ACID BASE IS THIS ?
  • 164. EXP PCO2=1.5 X 16 + 8=32
    • BUT PCO2 IS 45 SO THIS IS MIXED MA + RESP ACIDOSIS
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