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米国にて内科修行中。何ができるか模索している過程を記録していく

Nephrology (memo from NEJM knowledge plus and MKSAP)

・statin for CKD 

no benefit for dialysis patient, but reduce all-cause of mortality in patient with CKD not on dialysis

 

・management of patient with acute myeloid leukemia on chemotherapy, on normal saline IV at 200ml/hr and rasburicase for tumor lysis syndrome prophylaxis, urine output of 50cc/hr, Cre 1.0, K 5.2, phos 5.7, uric acid 7.1

increase IV hydration to help promote excretion of K, phos, uric acid (250cc/hr)

 

・estimate of GFR

modification of diet in renal disease (MDRD) equation underestimate GFR
chronic kidney disease epidemiology collaboration (CKD-EPI) equation more accurate

 

・diagnostic test for former battery factory worker with CKD, glycosuria, proteinuria

chelation mobilization testing

(for lead nephrotoxicity, lead blood level would be normal due to former exposure)

 

・management of blood access for patient with stage 4 CKD who develop osteomyelitis requiring 4 weeks IV ABX 

through peripheral line,  not PICC line for potential hemodialysis in future

 

・management of recurrent nephrolithiasis with calcium-containing kidney stone and hypercalciuria

thiazide diuretic

 

・management of IV fluid for patient on HCTZ who present with altered mental status secondary to hyponatremia of 110, that came up to 121, 10 hours after initiation of 3% saline

discontinue 3% saline and start 5% dextrose to adjust Na around 114 to 116 in the first 24 hours

 

・evaluation of hypokalemic metabolic alkalosis

urine chloride (↑: diuretic, Gitelman, Batter, ↓: vomiting, volume depletion)

 

・acanthocyte in urine

glomerular hematuria, suggesting glomerulonephritis

 

・DDx of effacement of podocyte foot process in electron microscopy

minimal change glomerulopathy:  normal light and immunofluorescence microscopy

menbranous glomerulopathy:  glomerular membrane thickening, IgG, C3 deposit

 

・management of patient with bipolar disorder who develops lithium-associated nephrotoxicity, but still requires to continue lithium

amiloride

 

・diagnosis of patient with h/o psoriasis using certain cream who develop confusion, slight AG metabolic acidosis, respiratory alkalosis

salicylate toxicity

 

・Tx of salicylate toxicity

sodium bicarbonate infusion

(HD indicated for level>80, AMS, pulmonary edema, advanced kidney disease)

 

 ・Tx of low risk of membranous glomerulopathy with nephrotic syndrome

ACEI (no glucocorticoid)

untreated 2/3 of MG undergo spontaneous complete or partial remission 

high risk of progression to CKD: male, > 50 yo, HTN, elevated Cre, secondary glomerulosclerosis, tubulointerstitial change on biopsy

 

・Dx of patient from Romania who has CKD, no proteinuria, no obvious cause of CKD

Balkan nephropathy

 

・initial managment of polyoma BK virus associated nephropathy in kidney transplant recipient

decrease immunosuppression 

 

・DDx of patient with AKI following partial colectomy for perforated diverticulitis, requiring 15L of IV hydration to maintain BP

abdominal compartment syndrome

 

・management of pregnant patient with h/o borderline HTN and family history of preeclampsia

low-dose aspirin (reduce risk of preeclampsia for patient with risk factor)

 

・management of severe ANCA positive vasculitis presenting as rapidly progressive glomerulonephritis

plasmapheresis, cyclophosphamide, glucocorticoid

 

・management of patient with CKD who develop dyspnea on exertion, no chest pain, no JVD, trace leg edema

refer to ED, for possible ACS, ACS in CKD patient may have atypical Sx 

 

・management of CKD wiht low calcium, high normal phosphorus, elevated parathyroid hormone, low 25-hydroxyvitamin D

try inactive form of vitamin D (cholecalciferol (vit D3), ergocalciferol (vit D2)) before beginning active form of vitmain D (calcitriol, alfacalcidol, doxercalciferol) that are expensive

 

・Dx of 17 weeks pregnant female with BP 140/90, Cre 1.7, 1+ protein in urinalysis

CKD and HTN (not preeclampsia)

blood pressure typically decreases early in the first trimester, creatinine typically falls during pregnancy due to expansion of plasma volume

 

・negative eosinophil in urine in the setting of acute interstitial nephritis

not uncommon (eosinophil in urine: low sensitivity and specificity)