Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the annual Kidney Week meeting of the American Society of Nephrology. During the 2015 meeting the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, end-stage renal disease and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single-best-answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cell-phone app containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for theClinical Journal of the American Society of Nephrologyreaders. Enjoy the clinical cases and expert discussions.
Highlights
Other studies have reported an incidence of Calcineurin inhibitors (CNIs)-associated hyperkalemia and hypertension that ranges between 10% and 33% [2,3,4], and which appears to be higher with tacrolimus
The mechanisms involved in CNI-associated hypertension and hyperkalemia were initially thought to be caused by the effects of drugs on the renin-angiotensin-aldosterone system, as observations showed that CsA was associated with the suppression of plasma renin levels, which was likely to be secondary to CsA-induced sodium retention and resulting volume expansion [5,6]
Despite this decrease in mineralocorticoid receptor expression, patients with hyperkalemia treated with fludrocortisone had improvement in both serum potassium levels and their metabolic acidosis
Summary
Case Discussion In order to address this question it is important to review the facts of the case: [1] this patient has long-standing hyponatremia (.4 years) and has a malignancy, as the etiology is otherwise highly unlikely ( a colonoscopy or CT scan of the chest is unlikely to show the underlying pathology), [2] the urine osmolality values provided are all inappropriate; the normal response to a hypo-osmolar state is to excrete a dilute urine (osmolality ,100 mOsm/kg) and this indicates some vasopressin effect on urine-concentrating capacity, [3] the patient has a normal physical examination as well as normal renal, adrenal and thyroid function ( brain magnetic resonance imaging and chest CT scan are unlikely to show the underlying pathology), and [4] all of the findings appear to be consistent with the syndrome of inappropriate antidiuretic hormone release (SIADH) [38]. Identification of the specific mutation in these cases is of critical importance in determining treatment options
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