UPDATES IN HARRISON 18TH EDITION

UPDATES IN NEPHROLOGY
Table 277-1 Inherited Disorders Affecting Renal Tubular Ion and Solute Transport Disease or Syndrome Disorders Involving the Proximal Tubule Proximal renal tubular acidosis Sodium bicarbonate cotransporter (SLC4A4, 4q21) Fanconi-Bickel syndrome Glucose transporter, GLUT2 (SLC2A2, 3q26.2) Isolated renal glycosuria Sodium glucose cotransporter (SLC5A2, 16p11.2) Cystinuria Type I Cystine, dibasic and neutral amino acid transporter (SLC3A1, 2p16.3) Nontype I Amino acid transporter, light subunit (SLC7A9, 19q13.1) Lysinuric protein intolerance Hartnup disorder Amino acid transporter (SLC7A7, 222700 4q11.2) Neutral amino acid transporter (SLC6A19, 5p15.33) Hereditary hypophosphatemic rickets with hypercalcemia Renal hypouricemia Type 1 Urate-anion exchanger (SLC22A12, 11q13) Type 2 Urate transporter, GLUT9 (SLC2A9, 4p16.1) 612076 220150 Sodium phosphate cotransporter 241530 (SLC34A3, 9q34) 34500 600918 220100 233100 227810 604278 Gene OMIM*

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Disease or Syndrome Dent's disease

Gene Chloride channel, ClC-5 (CLCN5, Xp11.22)

OMIM* 300009

X-linked recessive nephrolithiasis with renal failure X-linked recessive hypophosphatemic rickets

Chloride channel, ClC-5 (CLCN5, Xp11.22) Chloride channel, ClC-5 (CLCN5, Xp11.22)

310468

307800

Disorders Involving the Loop of Henle Bartter's syndrome Type 1 Sodium, potassium chloride cotransporter (SLC12A1, 15q21.1) Type 2 Potassium channel, ROMK (KCNJ1, 11q24) Type 3 Chloride channel, ClC-Kb (CLCNKB, 1p36) with sensorineural deafness Chloride channel accessory subunit, Barttin (BSND, 1p31) Autosomal dominant hypocalcemia with Bartter- Calcium-sensing receptor like syndrome (CASR, 3q13.33)) Familial hypocalciuric hypercalcemia Calcium-sensing receptor (CASR, 3q13.33) Primary hypomagnesemia Claudin-16 or paracellin-1 (CLDN16 or PCLN1, 3q27) Isolated renal magnesium loss Sodium potassium ATPase, 1subunit (ATP1G1, 11q23) Disorders Involving the Distal Tubule and Collecting Duct Gitelman's syndrome Sodium chloride cotransporter (SLC12A3, 16q13) Primary hypomagnesemia with secondary Melastatin-related transient 602014 263800 154020 248250 601199 602522 602023 601678 241200

145980

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Disease or Syndrome hypocalcemia

Gene receptor potential cation channel 6 (TRPM6, 9q22)

OMIM*

Pseudoaldosteronism (Liddle's syndrome)

Epithelial sodium channel and subunits (SCNN1B, SCNN1G, 16p12.1)

177200

Recessive pseudohypoaldosteronism Type 1

Epithelial sodium channel, , , and 264350 subunits (SCNN1A, 12p13; SCNN1B, SCNN1G, 16pp12.1)

Pseudohypoaldosteronism Type 2 (Gordon's hyperkalemia-hypertension syndrome)

Kinases WNK-1, WNK-4 (WNK1, 12p13; WNK4, 17q21.31)

145260

X-linked nephrogenic diabetes insipidus Nephrogenic diabetes insipidus (autosomal)

Vasopressin V2 receptor (AVPR2, Xq28) Water channel, aquaporin-2 (AQP2, 12q13)

304800 125800

Distal renal tubular acidosis autosomal dominant Anion exchanger-1 (SLC4A1, 17q21.31) autosomal recessive Anion exchanger-1 (SLC4A1, 17q21.31) with neural deafness Proton ATPase, 1 subunit (ATP6V1B1, 2p13.3) with normal hearing Proton ATPase, 116-kD subunit 602722 192132 602722 179800

(ATP6V0A4, 7q34) Online Mendelian Inheritance in Man database (http://www.ncbi.nlm.nih.gov/Omim).

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Table 279-2 Biomarkers of Acute Kidney Injury Biomarker Alanine aminopeptidase (AAP) Comments 1. Proximal tubule brush border enzyme 2. Instability may limit clinical utility Alkaline phosphatase (AP) 1. Proximal tubule brush border Colorimetry enzyme. Human intestinal alkaline phosphatase is specific for proximal tubular S3 segment; human tissue nonspecific alkaline phosphatase is specific for S1 and S2 segments 2. Levels may not correlate with extent of functional injury 3. Instability may limit clinical utility Alpha -Glutathione- 1. Proximal tubule cytosolic ELISA S-transferase (alpha- enzyme GST) 2. Requires stabilization buffer for specimen storage and processing 3. Upregulated in AKI and renal cell carcinoma Gamma -Glutamyl transpeptidase ( gamma GT) 1. Proximal tubule brush border enzyme 2. Instability requires samples to be analyzed quickly after collection, limiting clinical utility N-Acetyl-beta -(D) glucosaminidase (NAG) 1. Proximal tubule lysosomal enzyme 2. More stable than other urinary enzymes 3. Extensive preclinical and clinical data in a variety of conditions (nephrotoxicant exposure, cardiopulmonary bypass, delayed renal allograft function, Colorimetry Mouse, rat, human Colorimetry Rat, human Mouse, rat, human Rat, human Detection Colorimetry Species Rat, dog, human

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Biomarker

Comments etc.) 4. Endogenous urea may inhibit activity

Detection

Species

Beta 2Microglobulin

1. Light chain of the MHC I molecule expressed on the cell surface of all nucleated cells 2. Monomeric form is filtered by the glomerulus and reabsorbed by the proximal tubule cells 3. Early marker of tubular dysfunction in a variety of conditions 4. Instability in acidic urine limits clinical utility

ELISA Nephelometry

Mouse, rat, human

Alpha 1Microglobulin

1. Synthesized by the liver 2. Filtered by the glomerulus and reabsorbed by proximal tubule cells 3. Early marker of tubular dysfunction; high levels may predict poorer outcome 4. Stable across physiologic urinary pH

ELISA Nephelometry

Mouse, rat, human

Retinol-binding protein

1. Synthesized by liver, involved in ELISA vitamin A transport Nephelometry 2. Filtered by glomerulus and reabsorbed by proximal tubule cells 3. Early marker of tubular dysfunction 4. Increased stability in acidic urine when compared to microglobulin
2

Mouse, rat, human

Mouse, rat, human

Cystatin C

1. Important extracellular inhibitor ELISA of cysteineproteases

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Comments 2. Filtered by the glomerulus and reabsorbed by proximal tubule cells 3. Elevated urinary levels reflect tubular dysfunction; high levels may predict poorer outcome

Detection Nephelometry

Species

Microalbumin

1. Established marker for ELISA Mouse, rat, monitoring progression of chronic dog, kidney disease Immunoturbidimetry monkey, human 2. Elevated urinary levels may be indicative of proximal tubular damage 3. Lack of specificity for AKI may limit its utility

Kidney injury 1. Type-1 cell membrane molecule-1 (KIM-1) glycoprotein upregulated in dedifferentiated proximal tubule epithelial cells 2. Ectodomain is shed and can be quantitated in urine following AKI in preclinical and clinical studies 3. Elevated urinary levels are highly sensitive and specific for AKI 4. Upregulated following various models of preclinical and clinical AKI, fibrosis, renal cell carcinoma, and polycystic kidney disease Clusterin 1. Expressed on dedifferentiated proximal tubular epithelial cells 2. Elevated kidney and urinary levels are very sensitive for AKI in preclinical models 3. Upregulated in various rodent models of AKI, fibrosis, renal cell carcinoma, and polycystic kidney disease

ELISA, Luminexbased assay

Zebrafish, mouse, rat, dog, monkey, human

ELISA

Mouse, rat, dog, monkey, human

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Biomarker

Comments 4. No clinical study demonstrating its use

Detection

Species

Neutrophil 1. Initially identified bound to gelatinase associated gelatinase in specific granules of lipocalin (NGAL) the neutrophils, but also may be induced in epithelial cells in the setting of inflammation or malignancy 2. Expression upregulated in kidney proximal tubule cells and urine following ischemic or cisplatin induced renal injury 3. Found to be an early indicator of AKI following cardiopulmonary bypass 4. Specificity for AKI in setting of sepsis and pyuria need to be further established Interleukin-18 (IL18) 1. Cytokine with broad immunomodulatory properties, particularly in setting of ischemic injury 2. Constitutively expressed in distal tubules; strong immunoreactivity in proximal tubules with transplant rejection 3. Elevated urinary levels found to be early marker of AKI and independent predictor of mortality in critically ill patients Cysteine-rich protein (CYR-61) 1. Induced in proximal straight tubules of kidney and secreted in the urine within 36 h following ischemic kidney injury 2. Urinary levels decrease rapidly in spite of progression of injury indicating stability issue 3. No clinical study demonstrating

ELISA Luminex-based assay

Mouse, rat, human

ELISA Luminex-based assay

Mouse, rat, human

Western blot

Mouse, rat, human

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Comments its use 4. No quantitative method established

Detection

Species

Osteopontin

1. Upregulated in various rodent models of AKI 2. The induction correlates with inflammation and tubulointerstitial fibrosis 3. No clinical study demonstrating its use

ELISA

Mouse, rat, monkey, human

Liver fatty acid binding protein (LFABP)

1. Expressed in proximal tubule epithelial cells 2. Current evidence suggests clinical utility as a biomarker in CKD and diabetic nephropathy 3. Additional studies necessary to determine utility in setting of preclinical and clinical AKI

ELISA

Mouse, rat, human

Sodium/hydrogen exchanger isoform (NHE3)

1. Most abundant sodium transporter in the renal tubule 2. Urinary levels found to discriminate between prerenal azotemia and AKI in ICU patients 3. Samples require considerable processing, limiting assay throughput

Immunoblotting

Mouse, rat, human

Exosomal fetuin-A

1. Acute phase protein synthesized Immunoblotting in the liver and secreted into the circulation 2. Levels in proximal tubule cell cytoplasm correspond to degree of injury 3. Urinary levels found to be much higher in ICU patients with AKI compared to ICU patients without AKI and healthy volunteers 4. Samples require considerable processing, limiting assay throughput

Rat, human

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Comments

Detection

Species

5. Additional studies necessary to determine utility in setting of preclinical and clinical AKI Abbreviations: AKI, acute kidney injury; ELISA, enzyme-linked immunosorbent assay; ICU, intensive care unit; RCC, renal cell carcinoma.
3.ALSO KNOW THE EXPANDED DONOR CRITERIA UPDATED IN 18TH EDITION HARRISON

Table 282-1 Definition of an Expanded Criteria Donor (ECD) and a Non-Heart-Beating Donor [Donation after Cardiac Death (DCD)] Expanded Criteria Donor (ECD) Deceased donor >60 years Deceased donor >50 years and hypertension and creatinine >1.5 mg/dL Deceased donor >50 years and hypertension and death caused by cerebrovascular accident (CVA) Deceased donor >50 years and death caused by CVA and creatinine >1.5 mg/dL Donation after Cardiac Deatha (DCD) I Brought in dead II Unsuccessful resuscitation III Awaiting cardiac arrest IV Cardiac arrest after brainstem death V Cardiac arrest in a hospital patient Kidneys can be used for transplantation from categories IIV but are commonly only used from categories III and IV. The survival of these kidneys has not been shown to be inferior to that of deceased-donor kidneys.
a

Note: Kidneys can be bought ECD and DCD. ECD kidneys have been shown to have a poorer survival, and there is a separate shorter waiting list for ECD kidneys. They are generally utilized for patients for whom the benefits of being transplanted earlier outweigh the associated risks of using an ECD kidney.
4. ALSO KNOW THE INFECTIONS IN RENAL TRANSPLANT RECIEPIENTS

Table 282-5 The Most Common Opportunistic Infections in Renal Transplant Recipients Peritransplant (<1 month) Late (>6 months)

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Wound infections Herpesvirus Oral candidiasis Urinary tract infection Early (16 months) Pneumocystis carinii Cytomegalovirus Legionella Listeria Hepatitis B Hepatitis C

Aspergillus Nocardia BK virus (polyoma) Herpes zoster Hepatitis B Hepatitis C

5. INDICATIONS FOR IMMUNOSUPRESSIVES HAVE BEEN ADDED IN THE 18TH EDITION.JUST GO THROUGH IT QUICKLY.

Table 285-2 Indications for Corticosteroids and Immunosuppressives in Interstitial Nephritis Absolute Indications Sjgren's syndrome Sarcoidosis SLE interstitial nephritis Adults with TINU Idiopathic and other granulomatous interstitial nephritis Relative Indications Drug-induced or idiopathic AIN with: Rapid progression of renal failure emsp; Diffuse infiltrates on biopsy emsp; Impending need for dialysis emsp; Delayed recovery Children with TINU Postinfectious AIN with delayed recovery (?) Abbreviations: AIN, acute interstitial nephritis; SLE, systemic lupus erythematosus; TINU,

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tubulointerstitial nephritis with uveitis. Source: Modified from S Reddy, DJ Salant: Ren Fail 20:829, 1998.

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6.RENAL ARTERY STENOSIS EVALUATION

Table 286-1 Summary of Imaging Modalities for Evaluating the Kidney Vasculature Perfusion Studies to Assess Differential Renal Blood Flow Captopril renography with technetium 99mTc mertiatide (99mTc MAG3) Captopril-mediated fall in filtration pressure amplifies differences in renal perfusion Normal study excludes Multiple limitations renovascularhypertension in patients with advanced atherosclerosis or creatinine >;2.0 mg/dL (177 mol/L) Nuclear imaging Estimates fractional with technetium flow to each kidney mertiatide or technetium-labeled pentetic acid (DTPA) to estimate fractional flow to each kidney Duplex ultrasonography Allows calculation of single-kidney glomerular filtration rate Results may be influenced by other conditions, e.g., obstructive uropathy

Vascular Studies to Evaluate the Renal Arteries Shows the Inexpensive; widely available renal arteries and measures flow velocity as a means of assessing the severity of stenosis Not nephrotoxic, but concerns for gadolinium toxicity exclude use in GFR <30 mL/min/1.73 m2; provides excellent images Heavily dependent on operator's experience; less useful than invasive angiography for the diagnosis of fibromuscular dysplasia and abnormalities in accessory renal arteries Expensive; gadolinium excluded in renal failure, unable to visualize stented vessels Expensive, moderate volume of contrast required, potentially nephrotoxic Expensive, associated hazard of atheroemboli, contrast toxicity, procedure-related

Magnetic resonance Shows the angiography renal arteries and perirenal aorta Computed tomographic angiography

Shows the Provides excellent images; stents do renal not cause artifacts arteries and perirenal aorta Shows location and severity of vascular Considered "gold standard" for diagnosis of large vessel disease, usually performed simultaneous with planned intervention

Intra-arterial angiography

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complications, e.g., dissection Abbrevations: DTPA, diethylenetriamine pentaacetic acid (pentetic acid); GFR, glomerular filtration rate. Table 286-2 Clinical Factors Favoring Medical Therapy and Revascularization or Surveillance for Renal Artery Stenosis Factors Favoring Medical Therapy and Revascularization for Renal Artery Stenosis Progressive decline in GFR during treatment of systemic hypertension Failure to achieve adequate blood pressure control with optimal medical therapy (medical failure) Rapid or recurrent decline in the GFR in association with a reduction in systemic pressure Decline in the GFR during therapy with ACE inhibitors or ARBs Recurrent congestive heart failure in a patient in whom the adequacy of left ventricular function does not explain a cause Factors Favoring Medical Therapy and Surveillance of Renal Artery Disease Controlled blood pressure with stable renal function (e.g., stable renal insufficiency) Stable renal artery stenosis without progression on surveillance studies (e.g., serial duplex ultrasound) Very advanced age and/or limited life expectancy Extensive comorbidity that make revascularization too risky High risk for or previous experience with atheroembolic disease Other concomitant renal parenchymal diseases that cause progressive renal dysfunction (e.g., interstitial nephritis, diabetic nephropathy) Abbreviations: ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers; GFR, glomerular filtration rate.

lesion

7. TRANSPLANTATION-ASSOCIATED

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THROMBOTIC MICROANGIOPATHY (TA-TMA). TA-TMA can develop after hematopoietic stem cell transplantation (HSCT) with an incidence of 8.2%. Etiologic factors include conditioning regimens, immunosuppression, infections, and graft-versus-host disease. Other risk factors include female sex, age, and human leukocyte antigen (HLA)-mismatched donor grafts. TA-TMA usually occurs within the first 100 days after HSCT. A firm diagnosis may be difficult because thrombocytopenia, anemia, and renal insufficiency are common in the posttransplant period. TA-TMA carries a high mortality rate (75% within 3 months). Plasma exchange is beneficial in less than 50% of patients, most of whom have more than 5% ADAMTS13 activity. Calciuria inhibitors should be discontinued, and substitution with daclizumab [antibody to the interleukin 2 (IL-2) receptor] is recommended. Treatment with rituximab and defibrotide may also be helpful.

Microangiopathic Kidney Injury Can Be Associated With Hematopoietic Stem Cell Transplantation. IF POSSIBLE KNOW THE CRITERIA FOR IT.

Table 286-3 Criteria for Establishing Microangiopathic Kidney Injury Associated with Hematopoietic Stem Cell Transplantation International Working Group >;4% schistocytes in the blood De novo, prolonged, or progressive thrombocytopenia A sudden and persistent increase in LDH Decrease in hemoglobin or increased RBC transfusion requirement Blood and Marrow Transplant Clinical Trials Network Toxicity Committee RBC fragmentation and at least 2 schistocytes per high-power field Concurrent increase in LDH above baseline Negative direct and indirect Coombs test Concurrent renal and/or neurologic dysfunction without other explanations

Decrease in haptoglobin concentration Note: These features underscore the need to identify pathways of hemolysis and thrombocytopenia that accompany deterioration of kidney function. Abbreviations: LDH, lactate dehydrogenase; RBC, red blood cell. HIV-RELATED TMA TMA is mainly a complication encountered before widespread use of highly active retroviral therapy for HIV. It is seen in patients with advanced AIDS and low CD4 count, although it occasionally can be the first manifestation of HIV infection. The presence of MAHA thrombocytopenia and renal failure are suggestive, but renal biopsy is required to establish the diagnosis since HIV is associated with several other renal diseases.

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The median platelet count is 77,000/L with a range of 10,000 to 160,000/L, which may prohibit a renal biopsy in some patients. Cytomegalovirus (CMV) coinfection may also be a risk factor. The mechanism of injury is unclear, but HIV may induce apoptosis in endothelial cells. Plasma exchange is effective and is recommended in conjunction with antiviral therapy.

UPDATES IN RHEUMATOLOGY 1.BELIMUMAB IN SLE: Recent trials of anti-BLyS (belimumab, directed against the ligand of the BLyS/BAFF receptor on B cells that promotes B cell survival and differentiation to plasmablasts) showed a small, but statistically significant, better suppression of disease activity in comparison to placebo, when added to standard combhnation therapies. The US FDA has approved belimumab for treatment of SLE: it has not been studied in active nephritis or central nervous system lupus.

2.CLINICAL FEATURES OF ANTIPHOSPHOLIPID ANTIBODY SYNDROME Table 320-2 Clinical Features of Antiphospholipid Antibody Syndrome Manifestation Venous Thrombosis and Related Consequences Deep vein thrombosis Livedo reticularis Pulmonary embolism Superficial thrombophlebitis Thrombosis in various other sites Arterial Thrombosis and Related Consequences Stroke Cardiac valve thickening/dysfunction and/or Libman-Sacks vegetations Transient ischemic attack Myocardial ischemia (infarction or angina) and coronary bypass thrombosis Leg ulcers and/or digital gangrene Arterial thrombosis in the extremities Retinal artery thrombosis/amaurosis fugax Ischemia of visceral organs or avascular necrosis of bone Multi-infarct dementia Neurologic Manifestations of Uncertain Etiology Migraine Epilepsy 20 7 20 14 11 10 9 7 7 6 3 39 24 14 12 11 %

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Manifestation Chorea Cerebellar ataxia Transverse myelopathy

% 1 1 0.5

Renal Manifestations Due to Various Reasons (Renal Artery/Renal Vein/Glomerular 3 Thrombosis, Fibrous Intima Hyperplasia) Osteoarticular Manifestations Arthralgia Arthritis Obstetric Manifestations (Referred to the Number of Pregnancies) Preeclampsia Eclampsia Fetal Manifestations (Referred to the Number of Pregnancies) Early fetal loss (<10 weeks) Late fetal loss (10 weeks) Premature birth among the live births Hematologic Manifestations Thrombocytopenia Autoimmune hemolytic anemia Source: Adapted from R Cervera et al. 30 10 35 17 11 10 4 39 27

3. KNOW THE LATEST CRITERIA FOR RHEUMATOID ARTHRITIS NEW 2010 ACR-EULAR CRITERIA Table 321-1 Classification Criteria for Rheumatoid Arthritis Score Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 210 large joints 13 small joints (MCP, PIP, Thumb IP, MTP, wrists) 410 small joints >10 joints (at least 1 small joint) Serology Negative RF and negative ACPA Low-positive RF or low-positive anti-CCP antibodies ( times ULN) 3 0 1 2 3 5 0 2

High-positive RF or high-positive anti-CCP antibodies (>3 times 3 ULN) Acute-phase Normal CRP and normal ESR 0

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Score reactants Abnormal CRP or abnormal ESR Duration of symptoms <6 weeks 1 0

1 6 weeks Note: These criteria are aimed at classification of newly presenting patients who have at least 1 joint with definite clinical synovitis that is not better explained by another disease. Abbreviations: CCP, cyclic citrullinated peptides; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IP, interphalangeal joint; MCP, metacarpophalangeal joint; MTP, metatarsophalangeal joint; PIP, proximal interphalangeal joint; RF, rheumatoid factor; ULN, upper limit of normal. Source: Neogi et al: Arthritis Rheum 62:2569, 2010.

LATEST TNF ALPHA INHIBITORS: Drug Dosage Serious Toxicities Other Common Side Effects Initial Evaluation Monitoring

Adalimumab: 40 mg SQ every other week

Risk of bacterial, fungal PPD skin test infections Reactivation of latent TB Lymphoma risk (controversial)

Monitor for injection site reactions

Golimumab: 50 mg SQ monthly Drug-induced lupus Neurologic deficits

PPD skin test

Monitor for injection site reactions

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TOCILIZUMAB Tocilizumab is a humanized monoclonal antibody directed against the membrane and soluble forms of the IL-6 receptor. IL-6 is a proinflammatory cytokine implicated in the pathogenesis of RA, with detrimental effects on both joint inflammation and damage. IL-6 binding to its receptor activates intracellular signaling pathways that affect the acute-phase response, cytokine production, and osteoclast activation. Clinical trials have attested to the clinical efficacy of tocilizumab therapy for RA, both as monotherapy and in combination with methotrexate and other DMARDs. Tocilizumab has been associated with an increased risk of infection, neutropenia, and thrombocytopenia; however, the hematologic abnormalities appear to be reversible upon stopping the drug. In addition, this agent has been shown to increase LDL cholesterol; however, it is not known as yet if this effect on lipid levels increases the risk for development of atherosclerotic disease.

Also know the criteria for remission

Table 321-3 Acr/Eular Provisional Definition of Remission in Rheumatoid Arthritis

At any time point, patient must satisfy all of the following: Tender joint count Swollen joint count C-reactive protein 1 1 1 mg/dL

Patient global assessment 1 (on a 010 scale) OR At any time point, patient must have a Simplified Disease Activity Index score of less than 3.3 Source: Adapted from Felson et al. SPONDYLOARTHROPATHIES ASAS CRITERIA FOR CLASSIFICATION OF AXIAL SPONDYLOARTHRITIS. New York criteria is no longer used at present. Table 325-1 Asas Criteria for Classification of Axial Spondyloarthritis (to Be Applied for Patients with Back Pain 3 Months and Age of Onset <45 Years)a or HLA-B27 plus >2 other SpA features SpA features Inflammatory back paind

Sacroiliitis on imaging plus > 1 SpA feature Sacroiliitis on imaging --Active (acute) inflammation on MRI highly suggestive of SpA-associated sacroiliitisb

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Sacroiliitis on imaging plus > 1 SpA feature and/or --Definite radiographic sacroiliitis according to modified New York criteriac

or HLA-B27 plus >2 other SpA features Arthritise Enthesitis (heel)f Anterior uveitisg Dactylitise Psoriasise Crohn's disease or ulcerative colitise Good response to NSAIDsh Family history of SpAi HLA-B27

Elevated CRPj a Sensitivity 83%, specificity 84%. The imaging arm (sacroiliitis) alone has a sensitivity of 66% and a specificity of 97%.
b

Bone marrow edema and/or osteitis on short tau inversion recovery (STIR) or gadoliniumenhanced T1 image.
c

Bilateral grade =2 or unilateral grade 3 or 4. See text for criteria.

Past or present, diagnosed by a physician.

Past or present pain or tenderness on examination at calcaneus insertion of Achilles tendon or plantar fascia.
g

Past or present, confirmed by an ophthalmologist. Substantial relief of back pain at 2448 h after a full dose of NSAID.

First- or second-degree relatives with ankylosing spondylitis (AS), psoriasis, uveitis, reactive arthritis (ReA), or inflammatory bowel disease (IBD).
j

After exclusion of other causes of elevated CRP.

Abbreviations: ASAS, Assessment of Spondyloarthritis International Society; CRP, C-reactive

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protein; NSAIDs, nonsteroidal anti-inflammatorydrugs; SpA, spondyloarthritis. Source: From M Rudwaleit et al: Ann Rheum Dis 68:777, 2009. Copyright 2009, with permission from BMJ Publishing Group Ltd. Also know the caspar criteria for psoriatic arthritis. Table 325-2 The Caspar (C Lassification Criteria for Psoriatic Arthritis) Criteriaa To meet the CASPAR criteria, a patient must have inflammatory articular disease (joint, spine, or entheseal) with 3 points from any of the following five categories:

1. Evidence of current psoriasis,b, c a personal history of psoriasis, or a family history of

psoriasisd 2. Typical psoriatic nail dystrophye observed on current physical examination 3. A negative test result for rheumatoid factor 4. Either current dactylitisf or a history of dactylitis recorded by a rheumatologist
5. Radiographic evidence of juxtaarticular new bone formationg in the hand or foot
a

Specificity of 99% and sensitivity of 91%. Current psoriasis is assigned 2 points; all other features are assigned 1 point.

Psoriatic skin or scalp disease present at the time of examination, as judged by a rheumatologist or dermatologist.
d

History of psoriasis in a first- or second-degree relative. Onycholysis, pitting, or hyperkeratosis. Swelling of an entire digit. Ill-defined ossification near joint margins, excluding osteophyte formation.

Source: From W Taylor et al.

GRANULOMATOSIS WITH POLYANGIITIS IS THE NEWER NAME FOR WEGENERS GRANULOMATOSIS.

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ENDOCRINOLOGY
1. CRITERIA FOR DIAGNOSIS OF DIABETES MELLITUS
Table 344-2 Criteria for the Diagnosis of Diabetes Mellitus Symptoms of diabetes plus random blood glucose concentration 11.1 mmol/L (200 mg/dL)aor Fasting plasma glucose 7.0 mmol/L (126 mg/dL)bor A1C > 6.5%cor Two-hour plasma glucose 11.1 mmol/L (200 mg/dL) during an oral glucose tolerance testd
a

Random is defined as without regard to time since the last meal. bFasting is defined as no caloric intake for at least 8 h. cThe test should be performed in laboratory certified according to A1C standards of the Diabetes Control and Complications Trial. dThe test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water, not recommended for routine clinical use. Note: In the absence of unequivocal hyperglycemia and acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. Source: American Diabetes Association, 2011.
2. New therapies under development for type 2 diabetes include

Inhibitor of the sodium-glucose co- transporter in the kidney, Activators of glucokinase, An inhibitor of 11 -hydroxysteroid dehydrogenase-1 Salsalate. Liraglutide GLP-1 AGONIST Saxagliptin, Vildagliptin -- Dipeptidyl Peptidase-4 Inhibitors PANCREATIC ISLET TRANSPLANTATION: Pancreatic islet transplantation has been plagued by limitations in pancreatic islet supply and graft survival. Other Therapies for Type 2 Diabetes: BILE ACIDBINDING RESINS. Bile acid metabolism is abnormal type 2 diabetes. The bile acidbinding resin colesevelam has been approved for the treatment of type 2 diabetes (already approved for treatment of hypercholesterolemia).

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Emerging evidence indicates that bile acids, by signaling through nuclear receptors, may have a role in metabolism. COLESEVELAM Colesevelam (available as a powder for oral solution and as 625-mg tablets) is prescribed as 36 tablets prior to meals. The most common side effects are gastrointestinal (constipation, abdominal pain, and nausea). Bile acidbinding resins can increase plasma triglycerides and should be used cautiously in patients with a tendency to hypertriglyceridemia. Bromocriptine. A formulation of the dopamine receptor agonist bromocriptine (Cycloset), has been approved by the FDA for the treatment of type 2 diabetes (approved in 2009).

CARDIOLOGY
KNOW THE CARDIOMYOPATHIES ASSOCIATED WITH VARIOUS METABOLIC PATHWAY ABNORMALITIES.
Table 238-4 Examples of Inherited Defects in Metabolic Pathways Associated With Cardiomyopathy, Usually Restrictive or Pseudohypertrophic Phenotype Glycogen Storage Diseases IIPompe's (alpha 1,4 glucosidase) IIIForbes: de-branching enzyme (amylo 1,6 glucosidase) Glucose Metabolism (Defective PRKAG2a) Fatty acid metabolism Carnitine transport defect Medium chain Acyl-CoA dehydrogenase Long chain Acyl-CoA dehydrogenase Sphingolipidoses Fabry's disease (alpha galactosidase A) Gaucher disease (beta-glucocerebroside) Disorders of lysosomal function Danon's disease(lysosome-associated membrane protein, LAMP2) Miscellaneous HemochromatosisFe metabolism Familial amyloidosisabnormal transthyretin Barth syndrometafazzin defect affecting cardiolipin Friedreich's ataxiafrataxin a Gamma-2 regulatory subunit of the AMP-activated protein kinase important for glucose metabolism.

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Drug Class Examples Usual Total Daily Dose* (Dosing Frequency/Day)

Other Indications

Contraindications/Cautions

Renin inhibitors

Aliskiren 150300 mg (1)

Diabetic nephropathy

Pregnancy

ENDOTHELIN RECEPTOR ANTAGONISTS The endothelin receptor antagonists bosentan and ambrisentan are approved treatments of PAH. In randomized clinical trials, both improved exercise tolerance as measured by an increase in 6-min walking distance. Therapy with bosentan is initiated at 62.5 mg bid for the first month and increased to 125 mg bid thereafter. Ambrisentan is initiated as 5 mg once daily and can be increased to 10 mg daily. Because of the high frequency of abnormal hepatic function tests associated with these drugs, primarily an increase in transaminases, it is recommended that liver function be monitored monthly throughout the duration of use. Bosentan is contraindicated in patients who are on cyclosporine or glyburide concurrently.

UPDATES: Respiratory system

FUTURE THERAPIES IN ASTHMA There is a need for the development of new therapies for patients with refractory asthma who have side effects with systemic corticosteroids. Antagonists of specific mediators have little or no benefit in asthma, apart from antileukotrienes, which have rather weak effects, presumably reflecting the fact that multiple mediators are involved. Blocking antibodies against IL-5 mepolizumab, reslizumab may reduce exacerbations in highly selected patients who have sputum eosinophils despite high doses of corticosteroids. anti-TNF-alpha antibodies are not effective in severe asthma. Novel anti-inflammatory treatments that are in clinical development include inhibitors of phosphodiesterase-4, NF-kappa B and p38 MAP kinase. However, these drugs, which act on signal transduction pathways common to many cells, are likely to have troublesome side effects, necessitating their delivery by inhalation. Safer and

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more effective immunotherapy using T-cell peptide fragments of allergens or DNA vaccination are also being investigated. Bacterial products, such as CpG oligonucleotides that stimulate TH1 immunity or regulatory T cells, are also currently under evaluation.

DEEP VEIN THROMBOSIS:

Table 262-1 Clinical Decision Rules Low Clinical Likelihood of DVT if Point Score Is Zero or Less; Moderate-Likelihood Score Is 1 to 2; High-Likelihood Score Is 3 or Greater Clinical Variable Active cancer Paralysis, paresis, or recent cast Bedridden for >3 days; major surgery <12 weeks Tenderness along distribution of deep veins Entire leg swelling Unilateral calf swelling >3 cm Pitting edema Collateral superficial nonvaricose veins Alternative diagnosis at least as likely as DVT High Clinical Likelihood of PE if Point Score Exceeds 4 Clinical Variable Signs and symptoms of DVT Alternative diagnosis less likely than PE Heart rate >100/min Immobilization >3 days; surgery within 4 weeks Prior PE or DVT Hemoptysis Cancer Score 3.0 3.0 1.5 1.5 1.5 1.0 1.0 Score 1 1 1 1 1 1 1 1 2

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- POINT SCORE METHOD FOR D.V.T. USG of deep leg veins:

Table 262-3 Ultrasonography of the Deep Leg Veins Criteria for Establishing the Diagnosis of Acute DVT Lack of vein compressibility (principal criterion) Vein does not "wink" when gently compressed in cross-section Failure to appose walls of vein due to passive distention Direct Visualization of Thrombus Homogeneous Low echogenicity Abnormal Doppler Flow Dynamics Normal response: calf compression augments Doppler flow signal and confirms vein patency proximal and distal to Doppler Abnormal response: flow blunted rather than augmented with calf compression Warfarin dosing in pulmonary embolism:
CYP2C9 variant alleles impair the hydroxylation of S-warfarin, thereby lowering the dose requirement. Variants in the gene encoding the vitamin K epoxide reductase complex 1 (VKORC1) can predict whether patients require low, moderate, or high warfarin doses.

NOVEL ANTICOAGULANTS:
Rivaroxaban, a factor Xa inhibitor, and dabigatran, a direct thrombin inhibitor, are approved in Canada and Europe for prevention of VTE after total hip and total knee replacement. In a large-scale trial of acute VTE treatment, dabigatran was as effective as warfarin and had less nonmajor bleeding. Because of these drugs' rapid onset of action and relatively short half-life compared with warfarin, "bridging" with a parenteral anticoagulant is not required.

DISEASE-SPECIFIC GUIDELINES FOR REFERRAL AND TRANSPLANTATIONTable 266-1 Disease-Specific Guidelines for Referral and Transplantation Chronic Obstructive Pulmonary Disease Referral

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BODE index >5 Transplantation BODE index 710 or any of the following criteria: Hospitalization for exacerbation, with PaCO2 >50 mmHg Pulmonary hypertension or cor pulmonale despite oxygen therapy FEV1<20% with either DLCO <20% or diffuse emphysema Cystic Fibrosis/Bronchiectasis Referral FEV1<30% or rapidly declining FEV1 Hospitalization in ICU for exacerbation Increasing frequency of exacerbations Refractory or recurrent pneumothorax Recurrent hemoptysis not controlled by bronchial artery embolization Transplantation Oxygen-dependent respiratory failure Hypercapnia Pulmonary hypertension Idiopathic Pulmonary Fibrosis Referral Pathologic or radiographic evidence of UIP regardless of vital capacity Transplantation Pathologic or radiographic evidence of UIP and any of the following criteria DLCO <39% Decrement in FVC 10% during 6 months of follow-up Decrease in SpO2 below 88% during a 6-min walk test Honeycombing on HRCT (fibrosis score >2) Idiopathic Pulmonary Arterial Hypertension Referral NYHA functional class III or IV regardless of therapy Rapidly progressive disease Transplantation Failing therapy with intravenous epoprostenol (or equivalent drug) Persistent NYHA functional class III or IV on maximal medical therapy Low (<350 m) or declining 6-min walk test Cardiac index <2 L/min/m2 Right atrial pressure >15 mmHg Abbreviations: BODE, body-mass index (B), airflow obstruction (O), dyspnea (D), exercise capacity (E); FVC, forced vital capacity; FEV1, forced expiratory volume in 1 s; DLCO, diffusing capacity for carbon monoxide; PaCO2, partial pressure of carbon dioxide in arterial

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blood; SpO2, arterial oxygen saturation by pulse oximetry; ICU, intensive care unit; UIP, usual interstitial pneumonitis; HRCT, high-resolution computed tomography; NYHA, New York Heart Association. Source: Summarized from Orens et al. For BODE index, BR Celli et al: N Engl J Med 350:1005, 2004.

Dear students, Since it is already December, keep revising the same material again & again. Go via the updates quickly. Dont take very long time for going via the updates. ALL THE BEST WISHES.

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