BOARD REVIEW

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BOARD REVIEW

• NEPHROLOGY 1

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URINALYSIS

• Proteinuria
• 1) overflow of proteins- MM, MGUS
• 2) increased filtration of proteins glomerular
  diseases nephrotic proteingt 3g/day
• nephritic proteinlt2 g/day
• 3) decreased tubular reabsorbtion
  tubulointerstitial nephritis proteinlt 2g/day
• 4) transient fever, exercise, upright position,
  seizures

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URINALYSIS

• Normallylt 100 mg proteins excreted daily
• Normally lt 30 mg albumin excreted daily
• Microalbuminuria? 30-300 mg daily seen in early
  DM nephropathy
• 1. patient with fever and UTI, urine for
  protein wtd?
• 2. patient on NSAIDs for pain. UA for protein
  wtd?
• 3. patient with proteinuria on dipstick after
  exercise wtd?

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URINALYSIS

• Casts
• Nephrotic sdr? hyaline casts, fatty casts, oval
  fat bodies
• Nephritis? RBC casts
• Pre-renal azotemia? hyaline casts
• ATN? muddy/ dirty brown, pigmented casts
• Interstitial nephritis? WBC casts, granular
  casts, eosinophils
• Chronic renal failure? chronic renal failure

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Question

• 1. Eosinophiluria can be seen in the following
  except
• A) interstitial nephritis
• B) athero embolism
• C) NSAIDs
• D) rapidly proliferative glomerulonephritis
• 2. A 72 year old Asian female has anorexia, night
  sweats and hematuria. There is no pain or other
  urinary symptoms. Urine has no casts, 21 WBC.
  Urine culture is sterile. BUN and creatinine are
  mildly elevated. X ray chest is negative. What is
  your next step?
• a) dsDNA ab b) PPD c) CT scan chest d) renal
  bx

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Match

• 1. hyaline casts
• 2. muddy brown casts
• 3. RBCs
• 4. RBC casts
• 5. Oval fat bodies
• 6. eosinophils

• A. ATN
• B. prerenal azotemia
• C. glomerulonephritis
• D. nephrolithiasis
• E. interstitial disease
• F. nephrotic syndrome

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hematuria proteinuria other Renal failure
APCKD - Flank pain Stones HTN
Medullary sponge disease - stones -
Alports syndrome deafness
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crystals

• 1) calcium oxalate crystals envelope
  appearance-acid urine- ethylene glycol toxicity,
  intestinal hyperoxaluria( ex. Chron)
• 2) cystine crystals( hexagonal shaped, positive
  urine nitroprusside test), in cystinuria (
  patient young, around 20)
• 3. uric acid crystals- in acid urine- tumor lysis
  sdr
• 4. calcium phosphate crystals (needle like
  prismatic)- in alkaline urineeg distal RTA,
  idiopathic hypercalciuria, primary
  hyperparathyroidism
• 5. struvite stones- staghorn, MgNH4Po4(coffin
  lids) in alkaline urine- UTi with urease
  producing bacteria

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Renal failure

• Pre-renal azotemia- decreased renal perfusion
• volume depletion- bleeds, diarrhea, burns, etc
• volume overload- CHF, cirrhosis
• Decresed urine volume- increased urine osmol,
• Decreased urine Na? FeNa lt1
• Urine sediment neg
• FeNa Urine Na x plasma creatinine/ urine
  creatininex plasma Na X100

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Prerenal azotemia ATN
Inciting factors Low volume Toxins Ischemia medication
BUN/creatinine gt20/1 lt20/1
Urinary Na lt20mEq/l gt40
FeNa lt1 gt2
Urine osmolality gt500 lt350
Urine cells and casts bland Lots of cells, muddy granular, dirty brown casts
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Intrinsic acute renal failure

• -Glomerular disease- urine RBC casts
• -ATN- aminoglycosides, ampho B, rhabdo, tumor
  lysis, athero embolism
• urine- muddy brown casts
• -tubulo interstitial disease
• Allergic- B lactam, sulfa, dilantin, quinolone
• NSAIDs- no eosinophils
• Urine- WBC- eosinophils

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Question

• 1. Elderly man with h/o HTN, DM, hyperlipidemia
  on beta blocker, statin, HCTZ. Blood pressure
  still elevated at 170/110. Serum creatinine 1.1.
  Patient is started on Ace inhib. One week later,
  BP controlled. BUN/creat 19/1.5. UA no
  sediment. The most likely cause of ARD is
• A) tubulointerstitial disease
• B) ATN
• C) rhabdo sec to statin
• D) ACE inhib
• 2. a young man with h/o drug abuse and recent
  seizures presents with lab findings- BUN- 65,
  creatinine 5 hyperphosphatemia, hyperkalemia,
  high uric acid, low calcium, high CP. Urine no
  RBC, positive for heme. Muddy brown casts are
  seen. Dg?

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Question

• 1.ATN can be caused by any of the following
  except
• A) aminoglycosides
• B) ampho B
• C) cyclosporine
• D) rhabdomyolysis
• E) NSAIDs
• 2. Patient with post infarct angina scheduled for
  cardiac cath. H/o DM- serum creatinine 1.6. Best
  way to prevent radiocontrast nephropathy is
• A) ½ NS 12 h pre and post procedure /-
  acetylcysteine
• B) ½ NS 6 h pre and post procedure
• C) 0.9 NS with diuresis at th end of
  procedure

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Question

• 65 year old woman presents with abdominal pain
  and fever. Patient is started on Ampicillin,
  Gentamycin, Flagyl. CT scan abdominal with
  contrast is done. Next day patient has decreased
  urine output to 300cc/24h. Serum BUN/ creat
  40/2.2
• UA shows no sediment. FeNa lt1.
• The most likely diagnosis?
• A) ampicillin induced interstitial nephritis
• B) gentamycin induced toxicity
• C) radiocontrast induced nephropathy

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Renal effects of NSAIDs

• NSAID inhibit renal prostaglandin( PG causes
  vasodilation and stimulates renin secretion)
• NSAIDs decrease renal blood flow and decrease
  renin secretion
• Prerenal azotemia
• Low renin? low aldo? high K( RTA type 4)
• Other types of renal disease with NSAID-
• 1. allergic interstitial nephritis within 3-10
  days
• 2. minimal change glomerulopathy- weeks after
  starting tx- presents with nephrotic range
  proteinuria

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Question

• 1. 65 year old with H/o HTN, ventricular
  arrythmias controlled on Amiodarone, OA on NSAIds
  presents with puffiness on face on waking up. Has
  bilateral pitting dema. UA 3 prot, 3 RBC., 15-20
  WBC
• 24 h prot 4 g/day
• BUN/creat 80/5
• Serum albumin 2.8, TSH normal. The most likely
  diagnosis?
• A) amiodarone induced hypothyroidism
• B) RPGN
• C) NSAIDs induced nephrotic sdr and interstitial
  nephritis

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Question

• NSAIDs can cause all the following except
• 1) prerenal azotemia
• 2) acute interstitial nephritis
• 3) chronic interstitial nephritis
• 4) nephrotic sdr
• 5) ATN
• 6) type 4 RTA

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Question

• 1. Pregnant lady 18 w gestation, hardly gains any
  weight. C/o persistent nausea, vomiting for the
  past month. Creatinine increases from 0.5 to 1.9
  DG?
• 2. 60 year old patient presents with cellulitis
  of the leg. She is started on Clindamycin and PCN
  and patient defervesces in 24h. 5 days later,
  cellulitis is much improvd and patient has sudden
  onset of fever and a maculopapular rash with
  itching. You stop the drug. She has no dysuria or
  Foleys catheter. What will you do next?
• UA and Hansel Wright stain for eosinophils
• Change antibiotics to cephalosporin

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Question

• The UA shows 10 WBC, 7 RBC, Eosinophils , casts
  negative. What is the most likely diagnosis?
• A) nosocomial UTI
• B) PCN induced interstitial nephritis
• C) clindamycin induced nephrotoxicity
• 2. All the following can cause interstitial
  nephritis except A)antibiotics- PCN,
  cephalosporins, rifampin, Cipro, Sulfa
• B) NSAIDs
• C) diuretics( thiazide, furosemide)
• D) dilantin
• E) ACE inhibitors

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Bactrim 4 renal effects

• 1. Sulfonamides induce renal failure by
  triggering allergic interstitial nephritis
• 2. in high doses, Bactrim interferes with the
  renal secretion of potassium, resulting in
  hyperkalemia as in patients with PCP treated with
  Bactrim
• 3. Bactrim competes for tubular secretion with
  creatinine and cause an increase in serum
  creatinine level
• 4. long acting sulfonamides cause renal insuff by
  the crystals of the acetyl metabolite

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Interstitial nephritis

• Acute allergic IN
• Chronic tubulointerstitial nephritis( analgesic
  nephropathy)
• Acute allergic IN- presents with fever,
  maculopapular rash, eosinophilia with use of
  certain drugs or systemic inf
• UA_ microscopic hematuria, pyuria, non nephrotic
  proteinuria, eosinophils
• Usually resolves after d/c of offending drug and
  steroids