Absolute Nephrology Review: An Essential Q & A Study Guide

623 Pages·2022·13.788 MB·English

by  Alluru S. Reddi

Alluru S. Reddi
Absolute
Nephrology Review
An Essential Q & A Study Guide
Second Edition
123
Absolute Nephrology Review
Alluru S. Reddi
Absolute Nephrology Review
An Essential Q & A Study Guide
Second Edition
Alluru S. Reddi
Division of Nephrology and Hypertension
Rutgers New Jersey Medical School
Newark, NJ, USA
ISBN 978-3-030-85957-2 ISBN 978-3-030-85958-9 (eBook)
https://doi.org/10.1007/978-3-030-85958-9
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2016, 2022
This work is subject to copyright. All rights are solely and exclusively licensed 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, expressed or implied, with respect to the material contained herein or for
any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional
affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Rajendra Kapila MD, a friend and colleague, knew everything about the
bacterium, parasite, virus, fungus, and every organ system in the body. As a
great clinician and teacher, we will all miss him. It is an honor for me to
dedicate this book to him.
New Nomenclature for Kidney Function and Disease1
In June 2019, Kidney Disease: Improving Global Outcomes (KDIGO) convened a Consensus Conference with the goal of
revising and refining the nomenclature to describe kidney function and disease. For example, common terms such as renal
or nephro- and end-stage renal (kidney) disease have been replaced by kidney and kidney failure, respectively. The following
table summarizes some important changes proposed by KDIGO. The reader is referred to the Suggested Reading for expla-
nation of the preferred terms.
Preferred term Term (s) to avoid
Kidney function and disease Renal and the prefix “nephro-” (except in the setting of specific functions, diseases, or
syndromes
Kidney disease (acute kidney disease and Renal disease, nephropathy (except in the setting of specific diseases such as membranous
chronic kidney disease) nephropathy)
Kidney function Renal function with exception of describing specific functions such as renal acidification, renal
concentrating mechanism
Residual kidney function (RKF) Residual renal function (RRF)
Kidney structure Renal structure with the exception of describing specific structures within the kidney, such as
artery, vein, capsule, parenchyma, cortex, medulla, glomeruli, tubules, interstitium, cysts,
tumors
Kidney failure Renal failure (RF); end-stage renal disease (ESRD); end-stage kidney disease (ESKD), renal
disease; nephropathy; renal/kidney impairment, insufficiency, dysfunction; azotemia
Duration of kidney failure
AKI stage 3 (disease duration ≤3 months) Acute renal failure; renal disease; nephropathy; renal/kidney impairment, insufficiency,
Kidney failure (disease duration >3 months) dysfunction; azotemia; uremia
Chronic renal failure; chronic renal disease; chronic nephropathy; chronic renal/kidney
impairment, insufficiency, dysfunction; azotemia; uremia; irreversible kidney failure
Kidney replacement therapy (KRT) Renal replacement therapy (RRT)
Dialysis
AKI stage 3D AKI-D, dialysis-dependent AKI
CKD G5 ESKD, ESKF, ESRD, ESRF, dialysis-dependent CKD
Kidney transplantation ESKD, ESKF, ESRD, ESRF
Acute kidney disease (AKD) Acute renal failure (ARF); acute renal insufficiency (ARI)
AKI ARF, ARI
CKD Chronic renal failure (CRF); ESRD; renal/ kidney impairment, insufficiency, dysfunction
CKD classification [KDIGO CGA Mild, moderate, severe, early, advanced CKD; CKD stage 1–5 (complete description preferred
classification by cause, GFR category (G1– rather than G category alone). Patient with CKD could not be classified as “CKD G2, A1”
G5), and albuminuria category (A1–A3)]
GFR (units must be specified as mL/
min/1.73 m2 or mL/min)
Suggested Reading
Levey AS, Eckardt K-U, Dorman NM, et al. Nomenclature for kidney function and disease: report of a Kidney Disease:
Improving Global Outcomes (KDIGO) Consensus Conference. Kidney Int 97:1117–1129, 2020.
1 Note that old terminology was used in this book because the chapters were written prior to publication of the paper in Kidney International.
vii
Preface
The purpose of the second edition of Absolute Nephrology Review is to have the nephrology fellows and the practicing
nephrologists to learn kidney disease as a whole in the form of questions and answers. It is the intention of the author to
familiarize the reader with board-like questions to provide nephrological information in thought-provoking fashion. The
questions are based on a review of recent information obtained from several journals and standard textbooks and also from
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 choice of education-enhancing answers. I strongly believe that this review book would help each
graduating nephrology fellow and practicing nephrologist to learn the subject and pass their board and other examinations.
The author emphasizes that this review book is not a substitute for the existing textbooks and all other available board-type
question books.
This book would not have been completed without the help of many students, house staff, and colleagues, who encour-
aged and supported me learn kidney disease 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, particularly to my two grand-
children, for their immense support and patience. Finally, I extend my thanks to the staff at Springer, particularly Hannah
Campeanu, Associate Editor, for her constant support, help, and advice. Constructive criticism for improvement of the book
is gratefully acknowledged.
Newark, NJ, USA Alluru S. Reddi
ix
Contents
1 Fluids, Electrolytes, and Acid–Base Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Sodium and Water Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Potassium and Acid-Base Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2 Glomerular, Tubulointerstitial, and Vascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3 Calcium, Phosphorus, and Magnesium Disorders and Kidney Stones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
4 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
5 Acute Kidney Injury and Critical Care Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
6 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
7 Renal Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
8 Genetic Diseases and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
9 Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
10 Peritoneal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
11 Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
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Chapter 1
Fluids, Electrolytes, and Acid–Base Disorders
Sodium and Water Abnormalities
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 admis-
sion, her blood pressure (BP) is 100/60 mm Hg with a pulse rate of 100 beats/min (sitting), and 80/48 mm Hg with a pulse
rate of 120 beats/min (standing). Her temperature is 99.6 °F. Laboratory values are as follows:
Na+ = 124 mEq/L Creatinine = 1.8 mg/dL
K+ = 6.1 mEq/L Glucose = 50 mg/dL
Cl− = 114 mEq/L Hemoglobin = 13 g/dL
HCO3− = 20 mEq/L Hematocrit = 40%
BUN = 42 mg/dL Urinary Na+ = 60 mEq/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
Based on the orthostatic BP and pulse changes, hyponatremia, hyperkalemia, acute kidney injury, hypoglycemia,
and high urine Na+ excretion, the most likely diagnosis is Addison’s disease, which is due to glucocorticoid and
mineralocorticoid deficiency. Her signs and symptoms are related to volume depletion and electrolyte abnormali-
ties. 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 admin-
istration to improve total body volume (D is correct). Both volume repletion and hormone treatment improve BP
and electrolytes.
D5W may improve hyperkalemia and glucose; however, it is not adequate to improve volume as much as nor-
mal saline (A is incorrect). Five percent 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
Griffing GT. Addison disease treatment and management. MedScape. 2018.
Sarkar SB, Sarkar S, Ghosh S, et al. Addison’s disease. Contemp Clin Dent. 2012;3:484–6.
Ten S, New M, Maclaren N. Addison’s disease 2001. J Clin Endocrinol Metab. 2001;86:2909–22.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1
A. S. Reddi, Absolute Nephrology Review, https://doi.org/10.1007/978-3-030-85958-9_1
2 1 Fluids, Electrolytes, and Acid–Base Disorders
2. It is always important to know how much infused crystalloid and colloid will remain in the intravascular compartment
to improve volume status and hemodynamic status. Which one of the following fluids contributes MOST to the intra-
vascular compartment?
A. 5% dextrose in water (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 distribu-
tion 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 pres-
ent in the intravascular and 11.5 L (75%) in the interstitial compartments. Accordingly, if 1 L of D5W is infused,
approximately 667 mL will move into the ICF and 333 mL will remain in the ECF compartment. Of these 336 mL,
only 83 mL (25%) will remain in the intravascular compartment (Fig. 1.2).
Fig. 1.1 Distribution of total
Total body water (60%)
body water (TBW) in a 70-kg 70 kg
man. ECF extracellular fluid
volume, ICF intracellular fluid TBW= 42 L
volume 1/3 ECF 2/3 ICF ICF= 28 L
ECF= 14 L
Intravascular= 3.5 L
Intravascular Interstitial Interstitium= 11.5 L
(25%) (75%)
Fig. 1.2 Distribution of 5%
dextrose in water (D5W) in the D5W (1L or 1,000 mL)
body. ECF extracellular fluid
volume, ICF intracellular fluid
volume
ECF= 333 mL ICF= 667 mL
Intravascular= 83 mL Interstitium= 250 mL
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. If 1 L of 0.45% NaCl is infused, the free water (500 mL) is
distributed between ICF (333 mL) and ECF (167 mL) compartments. Of 167 mL, only 42 mL (25%) will remain
in the intravascular compartment. Considering the other 500 mL, which behaves like 0.9% saline, 375 mL (75%)
will move into the interstitial space and 125 mL stays in the intravascular compartment (Fig. 1.3). Thus, the total
volume remaining intravascularly after 1 L of infusion would be only 167 mL (42 + 125 = 167 mL).
On the other hand, more fluid is retained in the intravascular space with isotonic fluids. If 1 L of normal saline
is infused, all of the fluid will remain in the intravascular compartment, and then approximately 750 mL will
move into the interstitial compartment, leaving 250 mL in the intravascular compartment (Fig. 1.4). The move-
ment of saline into the interstitial compartment occurs approximately 30 min after infusion. During this period
of intravascular stay of saline, volume status and BP improve. Urine output may or may not improve until addi-
tional volume is infused. Similar volume changes occur with Ringer’s lactate. Thus, E is correct.