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  • Absolute Nephrology Review

    Alluru S. Reddi

    An Essential Q & A Study Guide

    123

  • Absolute Nephrology Review

  • Alluru S. Reddi

    Absolute Nephrology Review

    An Essential Q & A Study Guide

  • Alluru S. Reddi Professor of Medicine Chief, Division of Nephrology and Hypertension Rutgers New Jersey Medical School Newark, NJ, USA

    ISBN 978-3-319-22947-8 ISBN 978-3-319-22948-5 (eBook) DOI 10.1007/978-3-319-22948-5

    Library of Congress Control Number: 2015959706

    Springer Cham Heidelberg New York Dordrecht London # Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.

    Printed on acid-free paper

    Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)

  • Preface

    The purpose of writing this book is to allow the nephrology fellow and the practicing nephrologist to learn nephrology as a

    whole, in the form of questions and answers. This avoids having these clinicians read a lengthy nephrology textbook. The

    questions are based on a review of recent information obtained from several journals and standard textbooks and also from

    the author’s clinical experience. The questions in each chapter are geared to cover the basics of physiology, pathogenesis,

    and treatment strategies of a clinical problem.

    Writing a pertinent question is more difficult than writing a book chapter. Each question took a lengthy time to write and

    even more time to provide a satisfactory answer. I strongly believe that this review book would help each graduating

    nephrology fellow and practicing nephrologist to pass their board examination.

    This book would not have been completed without the help of many students, house staff, and colleagues, who made me

    learn nephrology and manage patients appropriately. They have been the powerful source of my knowledge, and I am

    grateful to all of them. I am extremely thankful and grateful to my family for their immense support and patience. My special

    thanks go to Surya V. Seshan, MD, who provided all the photomicrographs included in Chapter 2. Her contribution to our

    Nephrology Fellowship Program and to this review book is gratefully acknowledged and recognized. Finally, I extend my

    thanks to the staff at Springer, particularly Gregory Sutorius and Michael Koy, for their constant support, help, and advice.

    Constructive criticism for improvement of the book is gratefully acknowledged.

    Newark, NJ Alluru S. Reddi

    v

  • Contents

    1 Fluids, Electrolytes, and Acid–Base Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

    2 Glomerular, Tubulointerstitial, and Vascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

    3 Acute Kidney Injury and Critical Care Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

    4 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

    5 Disorders of Mineral Metabolism and Nephrolithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

    6 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

    7 Renal Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

    8 Genetic Diseases and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

    9 Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

    10 Peritoneal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

    11 Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

    Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

    vii

  • Chapter 1

    Fluids, Electrolytes, and Acid–Base Disorders

    1. A 36-year-old woman is admitted for dizziness, weakness, poor appetite, fatigue, and salt-craving for 4 weeks. She has

    history of asthma, and not on any medications. She has a family history of type 1 diabetes and hypothyroidism. On

    admission, her blood pressure (BP) is 100/60 mmHg with a pulse rate of 100 (sitting), and 80/48 mmHg with a pulse rate

    of 120 beats/min (standing). Her temperature is 99.6 �F. Laboratory values are as follows:

    Naþ ¼ 124mEq=L Creatinine ¼ 1:8mg=dL Kþ ¼ 6:1mEq=L Glucose ¼ 50mg=dL Cl� ¼ 114mEq=L Hemoglobin ¼ 13g=dL HCO3

    � ¼ 20mEq=L Hematocrit ¼ 40% BUN ¼ 42mg=dL Urinary Naþ ¼ 60mEq=L

    Based on the above history and laboratory values, which one of the following fluids is APPROPRIATE in addition

    to pertinent hormone administration?

    A. 5 % Dextrose in water (D5W)

    B. 5 % Albumin

    C. Ringer’s lactate (lactated Ringer solution)

    D. Normal (0.9 %) saline

    E. 0.45 % (Half-normal) saline

    The answer is D

    The orthostatic BP and pulse changes suggest volume depletion. Hyponatremia, hyperkalemia, elevated BUN and

    creatinine, hypoglycemia, and high urinary Na+ excretion suggest adrenal insufficiency (Addison’s disease), which

    is due to glucocorticoid and mineralocorticoid deficiency. Her signs and symptoms are related to volume depletion and electrolyte abnormalities. Hypotension is related to loss of both Na+ and water caused by deficiency of the

    above hormones.

    In addition to administration of hydrocortisone and fludrocortisones, the patient needs normal saline adminis-

    tration to improve total body volume (D is correct). Both volume repletion and hormone treatment improve BP

    and electrolytes.

    D5W may improve hyperkalemia and glucose, but not adequate to improve volume (A is incorrect). 5 %

    albumin may expand volume, but is not indicated in this patient (B is incorrect). Ringer’s lactate may exacerbate

    hyperkalemia and hypercalcemia (about 10 % of patients with Addison’s disease have hypercalcemia) with little effect on hyponatremia. Thus, C is incorrect. Half-normal saline is not adequate to replete the entire fluid in this

    patient (E is incorrect).

    Suggested Reading

    Ten S, New M, Maclaren N. Addison’s disease 2001. J Clin Endocrinol Metab 86:2909–2922, 2001.

    Sarkar SB, Sarkar S, Ghosh S, et al. Addison’s disease. Contemp Clin Dent 3:484–486, 2012.

    # Springer International Publishing Switzerland 2016 A.S. Reddi, Absolute Nephrology Review, DOI 10.1007/978-3-319-22948-5_1

    1

  • 2. It is always important to know how much infused crystalloid or colloid will remain in the intravascular compartment to

    improve volume status and hemodynamic status. Which one of the following fluids contributes MOST to the

    intravascular compartment?

    A. D5W

    B. Half-normal saline

    C. Normal saline

    D. Ringer’s lactate

    E. C and D

    The answer is E

    In order to answer the question, it is important to remember the percentage of total body water and its distribution

    in various fluid compartments. In a 70 kg man with lean body mass, the total body water accounts for 60% of body

    weight (42 L), and two-thirds of this water (i.e., 28 L) is in the intracellular fluid (ICF) and one-third (i.e., 14 L) is in

    the extracellular fluid (ECF) compartment (Fig. 1.1). Of these 14 L of ECF water, 3.5 L (25 %) is present in the

    intravascular and 11.5 L (75 %) in the interstitial compartments. Accordingly, if 1 L of D5W is infused, approximately 664 mL will move into the ICF and 336 mL will remain in the ECF compartment. Of these

    336 mL, only 84 mL (25 %) will remain in the intravascular compartment (Fig. 1.2).

    The retention of hypotonic solutions such as 0.45 % NaCl (half-normal) is different. 0.45 % NaCl is considered to

    be a 50:50 mixture of normal saline and free water.