Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Nephrology (Review) Year 5 – Internal Medicine Presented by: Dr. Dr.Amgad El-Agroudy Prepared by: Ali JassimAlhashli

2. Acute Renal Failure • When a patient presents to the hospital with acute renal injury, your initial diagnosis will be with ultrasound and urinalysis: • (3+) RBCs, (3+) proteins → you will suspect glomerulonephritis or vasculitis → therefore, your next step is doing renal biopsy to differentiate between the two conditions. • (1+) RBCs, (1+) proteins) → you will suspect interstitial nephritis: • If eosinophils are increased → it is allergic. • If there is pus and WBCs → this is pyelonephritis which will be confirmed by the presence of bacteria on urine culture.

3. Acute Renal Failure • How to differentiate between Acute Tubular Necrosis and Pre-Renal Uremia:

4. Questions • Which of the following factors would suggest that a patient has established acute tubular necrosis rather than pre-renal uremia? • Urine sodium = 10 mmol/L • Fractional urea excretion = 20% • Increase in urine output following fluid challenge • Specific gravity = 1025 • Fractional sodium excretion = 1.5% • Which of the following features would be expected in acute tubular necrosis? • Proteinuria on urinalysis • Red cell casts on urinalysis • Urine plasma osmolality ratio is >1:1 • Urinary sodium concentration >40 mmol/l • Creatinine clearance would be expected to be normal 1 year after the initial insult.

5. Questions • A 45 years old female is admitted with cellulitus requiring IV antibiotics. She is commenced on IV flucloxacillin. She is commenced on aspirin for pain. After 3 days, she developed pyrexia, arthralgia, maculopapular rash, hematuria and oliguria. Bloods reveal acute renal failure and eosinophilia. What is the most likely diagnosis? • Penicillin induced acute tubulointerstitial nephritis. • Aspirin induced acute tubulointerstitial nephritis • Chronic tubulointerstitial nephritis • Glomerulonephritis • Anaphylaxis • A 25-year-old woman presents with fatigue of 1 week's duration. She thinks that she has blood in her urine on two occasions after excessive exercise. Physical examination show mild muscle tenderness. Urinalysis is positive for 3+ blood. The BUN 12 mmol/l, Creatinine is 148 umol/l. What is the most likely cause diagnosis? - Postinfectiousglomerulonephritis - Myoglobinuria caused by rhabdomyolysis - IgA nephropathy - Wegener granulomatosis

6. Differentials of Hematuria • (-) dipstick, (-) RBCs → this is pseudohematuria caused by food (such as beets), dyes or medications (such as rifampin). • (+) dipstick, (-) RBCs → myoglobin (rhabdomyolysis). • (+) dipstick, (+) RBCs → true hematuria • (+) RBC casts → glomerulonephritis. • (-) RBC casts → lower urinary tract source

7. Questions • A patient has been admitted with severe burns. 3 days after her admission, her renal function starteed to deteriorate. Her blood pressure is normal and she is well filled on CVP line monitoring. What is the likely cause? • Acute tubular necrosis • Hypovolemia • Sepsis • Analgesia associated • Congestive cardiac failure • Which of the following suggests acute tubular necrosis as opposed to pre renal failure? • Urine osmolality <350 mOsm/kg and urine sodium >40 mmol/L • Urine osmolality >500 mOsm/kg and urine sodium <20 mmol/L • Hypotension. • Urine osmolality <350 mOsm/kg and urine sodium <40 mmol/L • Urine osmolality >350 mOsm/kg and urine sodium >40 mmol/L

8. Questions • A patient presents with acute renal failure secondary to rhabdomyolysis. Which other biochemical abnormalities may be seen? • Hyperkalemia and metabolic acidosis • Hypernatremia and respiratory acidosis • Hypokalemia and metabolic alkalosis • Hyperkalemia and metabolic alkalosis • Hypokalemia and metabolic acidosis • A 17-year-old man is referred to the nephrology unit for investigation. He reports having several episodes of visible hematuria. These typically occur within a 1 to 2 days of developing an upper respiratory tract infection. Urine dipstick shows RBCs. Blood tests show the following: Urea 4.1 mmol/l, Creatinine 72 μmol/l. What is the most likely diagnosis? • Chlamydia • Bladder cancer • IgA nephropathy • Rhinovirus-associated nephropathy • Post-streptococcal glomerulonephritis

9. Questions • Which one of the following types of glomerulonephritis is most characteristically associated with Goodpasture's syndrome? • Diffuse proliferative glomerulonephritis • Mesangiocapillaryglomerulonephritis • Membranous glomerulonephritis • Rapidly progressive glomerulonephritis • Focal segmental glomerulosclerosis • A patient with type 1 diabetes mellitus is reviewed in the nephrology outpatient clinic. He is known to have stage 1 diabetic nephropathy. Which of the following best describes his degree of renal involvement? • Latent phase • Hyperfiltration • End-stage renal failure • Overt nephropathy • Microalbuminuria

10. Diabetic Nephropathy

11. Questions • A 63-year-old woman presents for routine evaluation. She has had diabetes for the past 12 years with complications of neuropathy and retinopathy. You decide to screen her for renal complications of diabetes. Which of the following findings is not compatible with diabetic nephropathy? • Nephrotic range proteinuria • Hyperlipidemia • Hypertension • Red blood cell (RBC) casts in urine • High HbA1C level • A 55-year-old woman is seen in clinic, she has a 10 year history of type 2 diabetes treated with glibenclamide. Her BP is 148/93 with new onset proteinuria, her serum results show elevated lipid levels, HBA1C of 7.5% and FBS 7 mmol/L. Clinical examination show bilateral pitting edema. What is the most appropriate management? • Increase oral hypoglycemic dosage • Calcium channel blockers • Start insulin • Start ACE inhibitors • Start renal dialysis

12. Questions • A 18-year-old girl develops purpura on her lower limbs and buttocks associated with microscopic hematuria after upper respiratory tract infection. Her urea and electrolytes show mild renal impairment that is still present 4 weeks later, although she does not require any specific therapy. What is the most likely renal outcome? • Hypertension within 20 years • Persistent proteinuria • End stage renal failure • Full renal recovery • Frequent relapses • A 44-year-old man is referred to the renal team. He has a long history of chronic sinusitis and was investigated last year for hemoptysis but no cause was found. A number of recent urine dipstick tests has shown persistent microscopic hematuria. Urea 11.4 mmol/l, Creatinine 145 μmol/l, anti-GBM Negative, cANCA Positive, ANA Negative. What is the likely diagnosis? • Goodpasture disease • Kimmelstiel-Wilson nodules • Wegener's granulomatosis • Membranoproliferative GN • Membranous glomerulonephritis

13. Hypertension

14. Hypertension

15. Questions • A 62-year-old man is reviewed in the renal clinic. He has been referred as his creatinine level increased from 90 to 173 μmol/l after the introduction of ramipril. This had been started in an attempt to control his BP. An ultrasound abdomen is reported as follows: Both kidneys are small with the right measuring 5.8cm and the left 5.6cm. What is the most appropriate confirmatory investigation? • Captopril test • 24 hour urinary protein collection • Renal artery Doppler flow studies • CT angiography • MR angiography • You review a 62-year-old man who has recently been discharged from hospital following a MI. His echocardiogram report shows left ventricular ejection fraction is 48%. On examination his BP is 144 / 92 mmHg and his chest is clear. His current medications include aspirin, simvastatin and lisinopril. What is the most appropriate next step in terms of his medication? • Add calcium channel blocker • Add furosemide • Add bisoprolol (beta blocker) • Add isosorbidemononitrate • Make no changes

16. Questions • A 45-year-old woman with type 1 DM is reviewed in the clinic. Three months ago her blood tests show: K+ 4.5 mmol/l, Creatinine 116 μmol/l. At the time she was started on lisinopril. Lisinopril had been titrated up to treatment dose. Her current bloods are as follows: K+ 4.9 mmol/l, Creatinine 123 μmol/l. Of the following options, what is the most appropriate course of action? • Stop lisinopril and arrange investigations to exclude renal artery stenosis • Switch to a angiotensin 2 receptor blocker • Switch to a different ACE inhibitor • No action • Reduce dose of lisinopril • Each one of the following is associated with papillary necrosis, except: • Acute pyelonephritis • Tuberculosis • Chronic analgesia use • Syphilis • Sickle cell disease

17. Classification of Chronic Kidney Disease • Stage-I CKD: Kidney damage with normal or GFR ≥90 ml/min • Stage-II CKD: GFR 60-89 ml/min • Stage-III CKD: GFR 30-59 ml/min • Stage-IV CKD: GFR 15-29 ml/min • Stage-V CKD: GFR <15 ml/min

18. Questions • A 65-year-old man with a history of hypertension is reviewed. As part of routine blood tests to monitor his renal function whilst taking ramipril the following blood tests are received: Na+ 140 mmol/l, K+ 4.8 mmol/l, Urea 6.2 mmol/l, Creatinine 102 μmol/l, eGFR 98 ml/min • No chronic kidney disease • Chronic kidney disease stage 4 • Chronic kidney disease stage 3 • Chronic kidney disease stage 2 • Chronic kidney disease stage 1 • Painful ulcers developed on the thighs, abdomen and legs of a 47 years old obese woman with ESRD who was receiving dialysis. She has secondary hyperparathyroidism. What is your diagnosis? • Hypertensive ulcers. • Venous stasis ulcers. • Atheroemboli syndrome. • Mixed cryoglobulinemia. • Calciphylaxis.

19. Renal Transplantation • Acute kidney rejection can be: • Antibody mediated: • Hyper-acute rejection. • Vascular. • Cell-mediated: • Acute cellular rejection. • Borderline rejection. • Mild (grade I). • Moderate (grade II). • Severe (grade III). • Treatment of kidney rejection: • Acute humoral rejection: • Pulse steroids. • Plasmapheresis + IVIg. • Rituximab. • Acute cellular rejection: • Pulse steroids. • ATG or OKT3 (in resistant cases) • Recurrence of primary disease after renal transplantation: • High incidence: FSGS, IgA nephropathy and MPGN type-II

20. Renal Transplantation

21. Renal Transplantation • Post-renal transplantation complications: • Malignancy: • It is the most common cause of late mortality in these patients. • Risk factors include the following: • Age. • Donor-mediated malignancy (renal cell carcinoma). • Induction immunosuppression. • Cumulative steroid doses. • Genetic susceptibility. • Viral infections (EBV with Post-Transplant Lymphoproliferative Disease PTLD; HSV-8 with Kaposi sarcoma). Notice that most common tumor in post-renal transplantation cases are Kaposi sarcoma and PTLD. • Infection: • Patterns of infection: • 1st month: • Bacterial (wound, pneumonia and UTI). • Fungal. • CMV (transmitted). • Pneumocystisjiroveci (rare). • 1-6 months: • CMV (reactivated or transmitted). • HCV. • Opportunistic infections. • TB. • Bacterial (UTI). • Late: similar to general population.

22. Questions • A 75 years old male with type-2 diabetes has CKD. He has persistent proteinuria. His creatinine and eGFR have been static. He presents with three episodes of painless frank hematuria. There is no evidence of suprapubic tenderness or sepsis. There is no leukocytes or nitrates in urinalysis. A renal ultrasound shows no change. What is the next investigation? • Cystoscopy. • CT-KUB. • Urine culture. • Intravenous urography. • Renal biopsy. • A 65 years old male received kidney allograft 6 months back and he is on immunosuppression (prednisolone, tacrolimus and MMF). He developed painful vesicular rash over his face. What is the most likely diagnosis? • Herpes zooster.

23. Nephrotic Syndrome • Notice that nephrotic syndrome can be idiopathic or secondary to a systemic disease. • Clinical/lab features of nephrotic syndrome: • Heavy proteinuria (< 3.5 g/1.73 m2/day). • Hypoalbuminemia. • Edema. • hyperlipidemia. • Hypercoagulable state. • Patient may report frothy urine.

24. Questions • A 24 years old male who has a sister with adult polycystic kidney disease (ADPKD) asks if he could be screened for the disease. What is the most appropriate screening test? • PKD-1 gene testing. • CT-abdomen. • Urine microscopy. • Ultrasound of the abdomen. • IVU.

25. Good Luck!Wish You All The Best 