Nephrotoxicity And Acid Base Balance

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Nephrotoxicity And Acid Base Balance

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

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