| Normal: < 120/80,
Stage 1: < 120-140/ 80-90
Stage 2: > 140/90
Rx: > 130/80.
HTN Urgency: > 180/110 Asymptomatic
HTN Emergency > 180/110 Symptomatic | Stages of HTN, threshold for treatment |
| < 149/90 Most pts, ASCD < 10%
< 130/80 CVD, CKD, DM or ASCD > 10%
< 150/90 if over 60 | HTN Goals |
| None: Thiazide, ACE/ARB, CCB
AA: Thiazide, CCB
CKD: ACE/ARB
CVD: BB, CCB
CHF: BB, ACE/ARB, Thiazide/Loop
Nephrotic proteinuria: < 125/75
Post stroke : CCB
ISH/elderly: CCB, PVD: CCB | Treatment based of comorbidities |
| BP > 20/10 above goal, > 160/100
Usually ACE/CCB combo | When do you start with two medications? |
| Poor control despite 3 meds ( can try spironolactone 25 m/d)
Suspect secondary causes. | When do you refer out for HTN? |
| Resistant HTN
Young
Spontaneous low K | Secondary HTN , when to work up? |
| Metabolic Syndrome, renovascular ( FMD and AS), polycystic kidney, renal disease, OSA, Pheo, Cushing, hyperthyroid, hyperaldosterone, Scleroderma, | What are the secondary causes of HTN? |
| Renal MRA or angiography- String of beads
Presents in young pt, with HTN urgency or Resistant HTN
May have unilateral abdominal bruit. | How do you dx Fibromuscular dysplasia? |
| NSAIDS, OCP, Etoh, sympathomimetics, steroids, cocaine, MJ, SSRI, erythopoietin. | Which drugs can elevate BP? |
| Check for end organ damage: Eyes, Heart and kidney
Chem 7, Ca, Lipid, UA and EKG | What is the evaluation for HTN? |
| Don't work with Crcl < 20, Use loop dosed bid
Supplement K when < 3.5 or if on Dig or DM, CAD
Avoid: Gout, hyperlipidemia, orthostatic, Lithium, Sulfa allergy
Lytes: Increase Ca, glucose, uric acid, lower Mg and K. | Thiazide Diuretics in renal disease, what to look for ? |
| Pregnancy contraindicated
Caution with smokers/ AA, hyperkalemia, Bilaeral renal a. obstructions, CHF or low renin state, DM: OK for Cr to increase up to 35%.
Cough : Switch to ARB | ACE/ARB caution/contraindication |
| Asthma or RAD, Severe PVD,
Cocaine: may precipitate MI | BB for HTN: When to use caution? |
| Goal DBP < 105 in 2-6 hours. or < 25% of original BP
Can use oral if asymptomatic.
Rx: Loop diuretics, BB, CAB or alpha 2 antagonist
Avoid Nifedipine. | How do you treat a HTN crisis? |
| Renal US, PRA ( stimulated Plasma renin Acitvity) and plasma aldosterone.
See low renin, low K in Hyperaldosteronism.
5% of all resistant HTN. | How do you screen for secondary HTN? |
| Adrenal adenoma
Dx with CT | Cause of hyperaldosterone? |
| 24 urine for metanephrine, VMA and catecholamine.
If positive do a CT of adrenals. | How do you screen for Pheo? |
| W/U if present 3x
UA and cx. and renal function
Repeat UA 6 wk, if positive referral | Microscopic hematuria W/U |
| Age > 35, analgesic abuse, exposure to chemicals, smoking, chronic UTI or irritating voiding sx, irradiation.
W/U will need CT urography and cystoscopy. | Risk factors for urologic malignancy |
| Prerenal: Volume depletion, Decrease CO, peripheral vasodilataiton, meds: ACE, NSAID,
Renal vasoconstriction: Contrast.
Post renal: Obstruction usually prostate or stone
Intrarenal ATN, vascular, Drugs causing interstitial nephritis. | Acute renal failure Causes: |
| High BUN/ Cr ratio
FENA: < 1% | Prerenal w/u: |
| Renal us | Post renal w/u |
| FENA > 1%
UA ; Large muddy granular cast
Referral out | Intrarenal ATN w/u |
| AMG, NSAIDS, ACE/ARB, Amphotericin, Cisplatin, Contrast, PPI, Tenofovir (Prep) | Which meds are associated with ATN? |
| GFR < 60 / 3 mo | Definition of CKD |
| Stage 1: GFR >90
Stage 2: GFR 60-80
Stage 3a GFR 45-60
Stage 3b GFR 30-45
Stage 4 GFR 15-30
Stage 5 GFT < 15 Dialysis | What are the stages of CKD? |
| Stop offending meds : NSAIDS, AMG, B lactam, TMP
Treat UTI, HTN, hpercacemia, hyperphosphatemia
Referr to nephrology whten GFR < 30 or rapid decline in kidney function | Work up of CKD |
| Phosphate binders to keep Ca x P < 55
Use Ca carbonate, Sevelaamer ( Renagel) | How do you treat hyperparathyroid in CKD? |
| Labs: CMP, Lipids, A1c, microalbumin and UA, PTH, Vit D
Renal US
Hep B,C, HIV
SPEP and UPEP rot r/o MM or light chain disease
C3 and C4 to r/o Lupus, | W/U of CKD |
| ACE/ARB, CCB, STATINS, BP control, smoking cessation, decrease protein, treat malnutrition, treat metabolic acidosis with bicarb, control osteodystrophy with Vit D, Ca, erythropoietin if anemic, treat hyperphosphatemia, | How do you slow the progression of CKD? |
| Cr< 15, pericarditis, progressive uremic encephalopathy, | When do you start dialysis? |
| UA with C&S
Spiral CT,
Ca level to r/o hyperparathyroid. | Kidney stone w/u |
| Stone < 4 mm, may take up to 4 wks. | Which stone pass on own? |
| Strain urine
Indomethacin 100mg did,
Tamsulosin 4 mg/d x 4 wk. | Treatment of kidney stone |
| Persistent pain > 4 wks
Stone > 10 mm Need stereoscopy first then lithotripsy.
Monitor: renal function, periodic image for stone location and hydronephrosis. | When do you refer for kidney stone? |
| Primary hyperparathyroid ( Ca < 11), Malignancy (Ca>13), Vit D box, Renal failure, Meds: Thiazide, Lithium, Theophylline | Hypercalcemia causes |
| Repeat test with ionized Ca level
Corrected Ca= Serum Ca + .8 ( nl albumin x 4 - pt's albumin)
Causes: Increase protein or dehydration | Cause and w/u of pseudohypercalcemia |
| Ca < 12 Asymptomatic
Constipation, fatigue, depression, polyuria, polydypsia, kidney stone | Hypercalcemia Sx |
| Ca < 12 : Find and remove underlying cause and hydrate 8 glasses water/d
Ca 12-14: Usually symptomatic. IVF and biophosphante
Ca > 14 : Usually comatose Hemodyalysis | Hypercalcemia Treatment |
| Repeat ionized Ca, PTH,Vit D, BMP
Second line: Alk Phos, SPEP,CXR ( look for granuloma) | W/U of hypercalcemia |
| Ca level < 8.5 | Define Hypocalcemia |
| Low PTH ( surgery, autoimmune, radiation)
Low Vit D/Ca ( malnutrition, ETOH)
Low albumin
Low Mg
Loop diuretics
Pancreatitis | Causes of hypocalcemia |
| Mild: Perioral numbness, paresthesia in hand and feet, cramps
fatigue
Severe: Neuromuscular irritability/ Tetany/Seizure | What are the sx of hypocalcemia |
| Trousseau sign: metacarphophalangeal spasm with cuff inflated above SBP for 3 min
Chvostek sign: contraction of ipsilateral face muscle with tapping facial n.
EKG: Prolongation of QT | What are the signs of hypocalcemia? |
| Repeat level with ionized Ca
Check corrected Ca: Add 0.8 to Ca level for each 1 g/dL that albumin is below 4
Check PTH, Cr, Vit D, Mg, and Alk Phos ( elevated in Vit D def and hyperparathyroid from osteomalacia) | W/U of hypocalcemia? |
| First correct low Mg and low Vit D
Ca > 7.5: Oral replacement
Ca < 7.5 IV replacement | Treatment of hypocalcemia? |
| K > 5.5 | Definition of Hyperkalemia |
| Pseudokyperkalemia: most common; Repeat
Release from cell: hyperglycemia, acidosis, BB, Exercise
Decrease urine excretion: Low aldosterone ( ACE, NSAIDS, Spironolactone, Heparin), dehydration, Renal insufficiency
Obstruction. | Causes of hyperkalemia |
| K > 7 : Progressive muscle weakness to paralysis | What are the sx of hyperkalemia? |
| Peaked T wave, Short QT initially then prolonged QT
Leads to arrhythmias | What is the EKG sign of hyperkalemia? |
| R/O reversible causes ( drugs, diet, urine obstruction)
K < 6.5 or chronic : Diuretics ( thiazide or loop) Laxatives or Kayexalate
** Kayexalate: Has been associated with intestinal necrosis ( rare)
K > 6.5 : Calcium gluconate IV, Insulin and glucose IV, Albuterol
Low K diet | What is the treatment of hyperkalemia? |
| K < 3.5 | Definition of Hypokalemia |
| Vomiting, Diarrhea, Diuretics | What are some of the causes of hypokalemia? |
| Progressive muscle weakness to paralysis
N/V/Anorexia/ Ileus | What are the symptoms of hypokalemia? |
| Uwaves, St depression and QT prolongation. | What is the EKG sign of hypokalemia? |
| Repeat and check Mg level
Check for Sx
EKG | Hypokalemia evaluation |
| Remove cause if known
K 3-4: Oral KCL 10-20 bid
K < 3 : IV KCL or oral 40 mEq tid-qid
Treat until level > 3.5 | Treatment of hypokalemia |
| Hyperglycemia, diuretics, High TG and protein, Volume overload or depletion, SIADH ( CNS and malignancy) | Hyponatremia causes |
| r/o pseudohyponatremia: Glucose: for each100 increase, Na decrease 1.6
Assess extracellular volume: Edema, Dehydrated?
Check Osmo: 2(Na) + glucose/18 + BUN/2.8 ( Nl 285-295) | Hyponatremia workup |
| Osmo > 300
Cause: Glucose | Hypertonic hyponatremia |
| UNa < 10
Cause: diuretics, GI loses
Treat with IV NS | Cause and treat low volume hyponatremia |
| CHF, Cirrhosis
Treat with water restriction and liberal Na intake | Cause and treat high volume hyponatremia |
| Always represents a water deficit. Always hyperosmolar
Dementia, no access to water, ADH abnormality or CNS disease ( Diabetes Insipidus. | What is the cause of hypernatremia? |
| Drugs: Laxative/antacids containing Mg
Renal failure | What is the cause of hypermagnasemia? |
| Muscle weakness progressive to paralysis, sedation, loss of reflex and nausea. | Syptoms of hypermagnesemia |
| Remove underlying cause
Hydrate
Calcium | Treatment of hypermagnasemia |
| Diuretics, ETOH , Insulin, Gentamycin and Cisplatin | What causes hypomangasemia? |
| Low Ca and Low K | What other electrolyte abnormalities do you see with hypo Mg? |
| Cramps and arrythmias | What are sx of low Mg? |
