• Personal information

          

    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       

     

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    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى

     

    إقرأ المزيد

     

About Me

Tuesday, Aug 22nd

Last update10:09:06 AM

        

Kidney

Kidney

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Nephrology

 

Enumerate:

1. Pathological types of glomerulonephritis.

2. Clinical presentations of glomerulonephritis.

3. Causes of nephrotic syndrome.

4. Pre-renal causes of AKI.

5. Renal causes of AKI.

6. Causes of acute tubular necrosis.

7. Causes of AKI.

8. Manifestations of hyperkalemia.

9. Causes of CKD.

10. Cardiovascular manifestations of CKD.

11. Respiratory manifestations of CKD.

12. Gastrointestinal manifestations of CKD.

13. Neurological manifestations of CKD.

14. Musculoskeletal manifestations of CKD.

15. Skin manifestations of CKD.

16. Changes in blood chemistry in CKD.

17. Complications of dialysis.

18.  Complications of renal transplantation.

19. Causes of polyurea.

20. Causes of hematuria.

21. Causes of hyperkalemia.

22. Indications for dialysis in AKI.

23. Causes of metabolic acidosis.

24. Causes of acute deterioration of renal functions in CKD.

25. Causes of edema of the lower limbs.

26. Causes of nephritic syndrome.

27. Causes of metabolic alkalosis.

 


Outline:

1. Classification of Glomerulonephritis.

2. Diagnosis of nephritic syndrome.

3. Treatment of post-streptococcal glomerulonephritis.

4. Functional changes in nephrotic syndrome.

5. Diagnosis of nephrotic syndrome.

6. Investigations & treatment of nephrotic syndrome.

7. Complications of nephrotic syndrome.

8. Diabetic nephropathy.

9. Clinical picture & laboratory diagnosis of AKI.

10. Biochemical changes in AKI.

11. Clinical picture of CKD.

12. Investigations for CKD.

13. Treatment of CKD.

14. Etiology & predisposing factors of acute pyelonephritis.

15. Diagnosis of hypokalemia.

16. Diagnosis of hyperkalemia.

17. Differential diagnosis of polyurea.

18. The appropriate diet recommended for:

      - Oliguric phase of AKI.

      - CKD with creatinine 5 mg/dl.

      - Nephrotic syndrome in an adult with normal renal functions.

      - Acute post-streptococcal GN in a 16 years old child.

      - Recurrent oxalate nephrolithiasis.

19. Renal manifestations of lupus nephritis.

20. Management of  diffuse proliferative  lupus nephritis.

21. Causes and management of renal anemia

22. Management of AKI.

23. Stages & management of diabetic nephropathy.

24. Differential diagnosis of proteinuria.

25. Treatment of hypertension in CKD.

 

 

 


Case 1:

A male patient aged 55 years, known to be diabetic for 30 years, presented to the hospital complaining of swelling of both lower limbs of 4 weeks duration.

General examination revealed;

- Generalized edema including face & upper limbs, together with ascites.

- Pulse rate: 79 beats per minute.

- Temperature chart: normal.

- No organomegaly could be detected clinically.

1. What is your possible diagnosis?

2. How could you investigate this patient?

3. What are the lines of treatment of this patient?, treatment of diabetes not required

 

The edema decreased gradually with treatment, until it finally disappeared, and the patient was discharged for follow up in the outpatient clinic, and diuretics were withdrawn. Four years later, the patient came back with marked ill health, generalized bone aches, headache, blurring of vision, nocturia, polyurea, and parasthesia of both upper and lower limbs, together with vomiting and hiccups.

On examination:

- Blood pressure was 200/120.

- Respiratory rate was 30/m and deep.

- Marked pallor.

- Glove and stocking hyposthesia.

4. What is your diagnosis of the current problem?

5. How could you explain the following findings?

    - Abnormal breathing.

    - Glove and stocking hyposthesia.

    - High blood pressure.

    - Pallor.

    - Absence of edema in spite of withdrawal of diuretics.

    - Nocturia.                               - Bone aches.

6. What are the expected findings in?

    - Urine examination.

    - Ultra-sound of the kidneys.

7. How could you treat the following in the patient?

    - Bone aches.                                     - Anemia.

    - Hiccups.                                          - Vomiting.

8. Describe a suitable diet to this patient at the present stage.

Case 2:

A 16 years old boy used to develop one or two episodes of acute pharyngitis every winter for many years. Three weeks ago, developed pyrexia with a chill, sore throat and generalized bone aches. Examination of his throat shows severe congestion with multiple yellowish follicles over both tonsils. He was treated with a tetracycline and recovered in a week. Ten days later, he complained of mild headaches, and noticed a tinge reddening of the color of his urine. His mother noticed puffiness of his eyelids. Next morning, she brought him to the outpatient clinic. The attending physician observed that his temperature was  37.9 C, BP 150/100, pallor of the skin and mucous membranes and mild edema of lower limbs. A spot urine sample showed a smoky color. He ordered few investigations and started treatment immediately.

 

1. What is the most likely diagnosis?

2. Enumerate what you consider as the top 4 investigations that aught to be ordered in this setting , what would be the expected results, if your diagnosis was right?

3. What treatment would you prescribe in this condition?

4. What is the prognosis of this child? 

 

Case 3:

A 36 years old female presented with pallor, puffiness of eye lids, and edema of the lower limbs. Her BP was 180/100. Investigations revealed a 24 hours protein of 8 gm/dl, 2-3 RBCs in urine, serum creatinine of 1 mg/dl, her complement levels were normal. ANA and anti-DNA were negative.

 

1. What is the likely diagnosis?

2. What other investigations would you do?

    (Laboratory and procedure)

3. How would you treat her?

    (Details needed)

4. Enumerate secondary causes that can result in such a condition.

 


Case 4:

A 35 year old man presents to his GP complaining of a 2 weeks history of progressive swelling of his legs. He feels otherwise well and has had no significant previous medical illness. He smokes 20 cigarettes per day. He is taking no regular medications. On examination, there is marked pitting edema of both legs, extending up to the groin. His pulse is 72/m, regular, and his BP 140/90. His jugular venous pressure is not raised and her sounds are normal, with no added sounds. Examination of his respiratory, abdominal and neurological systems is normal.

Investigations revealed normal blood picture, sodium, potassium, creatinine, glucose, bilirubin and transaminases. Serum albumin was 2 gm/dl, cholesterol 350 mg/dl. Urine analysis revealed; proteins +++, 24 hours urinary protein    12.6 gm.

1. What is your diagnosis?

2. Mention 4 etiological factors for this diagnosis.

3. Mention 1 investigation to confirm underlying etiology.

4. How to treat this patient?

 

Case 5:

A 50 year old male presented with edema of the lower limbs. He is diabetic on oral hypoglycemic agents for 8 years. On examination his BP was 170/110 and there was peripheral neuritis reaching the mid leg. Fundus examination showed microaneurysms and soft exudates. His fasting blood sugar was 244mg/dl, his creatinine was 3 mg/dl and abdominal sonography revealed normal sized kidneys with grade one echogenicity.

1. What is the likely diagnosis?

2. What other investigations you would like to order?

3. How would you treat him?

 

Case 6:

A 20 year old female presented with joint pains, alopecia and edema of the lower limbs of few weeks duration. She was pale and hypertensive. Her serum creatinine was 1.9mg/dl.

1. What is the likely diagnosis?

2. What are the investigations you would ask for?

3. Describe the lines of therapy.

 


Case 7:

A male patient 15 years old presented with generalized edema. Urine analysis revealed the presence of heavy albuminuria.

1. What is the possible diagnosis?

2. How can you reach the diagnosis in such a case?

3. How can you treat this patient?

 

Case 8:

A 4 year-old boy,  presents with painless haematuria. The parents recall no preceding illness, trauma or urinary complaints. The boy complains only of headache. On examination a mild upper respiratory infection is found, some slight puffiness is found about the eyes. Blood pressure is 140/90.

1. Enumerate causes of hematuria.

 

Laboratory data reveals a mild anemia, slight decrease in level of serum albumin, elevated urea and elevated erythrocyte sedimentation rate.

2. What is the most likely diagnosis?

3. What are the findings of urine examination in this patient?

4. Comment on the lipid profile in this patient.

5. What type of anemia is here? What is its explanation?

6. What is the significance of the upper respiratory infection here?

7. What is the aetiology of this case?

8. What is the expected pathology in this case?

9. What is the diet regimen that must be followed in this case?

10. How would you treat this case?

 

Few days later, the patient developed edema of lower limbs, and he complained of severe dyspnea associated with expectoration of frothy sputum.

Examination revealed congestion of neck veins, bilateral pulmonary crepetations and marked edema of lower limbs.

11. What is the diagnosis of this new event? What is its pathogenesis?

12. How to manage this new event?

13. Enumerate other complications of the original condition.

14. Give an account on the diagnosis and treatment of one of them.

15. Are these complications common?

 


Case 9:

A 20 year old male complains of severe pain in the left loin & lower abdomen. Random urine sample revealed the following:

- Volume: 200 ml.                   - Proteins: trace.

- WBCs: 3-5/HPF.                             - RBCs: 20-25/HPF.

- Crystals: many calcium oxalates.

 

1. What are the 2 most probable causes?

2. How to manage this case?

 

Case 10:

A 40 year old male was operated upon to remove the gall bladder. One of the big vessels was injured and the patient got severe bleeding. The blood pressure of the patient dropped to 70/30 mm and intravenous fluids were infused till 4 units of blood could be given, but the blood pressure remained very low till the surgeons succeeded to stop the bleeding. After infusion of another 6 units of blood and large volume of plasma expanders the BP became 100/60 and remained as such for hours till it became 120/80. In the next 24 hours the patient passes 300 ml of urine.

1. How would you manage the patient?

 

In the next 24 hours the urine volume was 250 ml and the CVP became high.

Within 2 days, the patient had the following symptoms and signs:

- Mental dullness.

- Anorexia and nausea.

- Congested neck veins.

- Blood pressure: 160/100.

- Pulse: 50 beat/minute and regular.

- Dyspnea with deep respiration.

- Urineferous odour of breath.

- Urine output: 250 ml/day.

2. What is the pathogenesis of each of the previous S & S?

3. What are the abnormal findings in urine examination?

4. What are the biochemical changes in the blood?

5. How to correct potassium level?

6. How to correct the blood volume?

7. How to correct urea level?

8. How to correct the blood PH?

9. How to manage nausea in this patient?

10. What are the indications for dialysis?

 

MCQs Part I

 

Case 1:

A 60-year-old patient with long-standing diabetes has a creatinine of 3.6, which has been stable for several years. Which of the following antibiotics requires the most dosage modification in chronic renal failure?

 

(A) tetracycline

(B) gentamicin

(C) erythromycin

(D) nafcillin

(E) chloramphenicol

 

Case2:

A 57-year-old man is on maintenance hemodialysis for chronic renal failure. Which of the following metabolic derangements can be anticipated?

 

(A) hypercalcemia

(B) hypophosphatemia

(C) osteomalacia

(D) vitamin D excess

(E) hypoparathyroidism

Case 3:

An 8yr old child developed a throat infection which resolved without any treatment. About 10 days later the child presented with sudden onset of fever associated with decreased urine output, brown colored urine and peri-orbital edema.
This complication of the throat infection would most likely have been completely averted if, at the time of the initial throat infection

a) the girl had been instructed to drink plenty of water

b) the girl had been treated with penicillin

c) the girl had been treated with acyclovir

d) the girl had been treated with high dose corticosteroids

e) none of the above

 

 

Case 4:

Top of Form

A 50-year-old man has noted passing darker urine for the past week. On physical examination there are no abnormal findings. A urinalysis shows pH 5.5, specific gravity 1.013, 2+ blood, no protein, and no glucose. A urine cytology is performed and there are atypical uroepithelial cells seen. A urologist performs a cystoscopy, but no mucosal lesions are noted. He has a 60 pack year history of smoking cigarettes. Which of the following is the most likely diagnosis?

A Adenocarcinoma of prostate

B Urothelial carcinoma of renal pelvis

C Acute interstitial nephritis

D Nodular glomerulosclerosis

E Squamous cell carcinoma of penis

 

Case 5:

A 52-year-old previously healthy man has experienced episodes of discomfort with urination for 3 months. There are no remarkable findings on physical examination. Laboratory studies include a urinalysis that reveals sp. gr. 1.010, pH 7.5, no glucose, no protein, no ketones, and 1+ blood. Microscopic urine examination shows numerous RBCs, a few WBCs, and no casts. A urine culture is negative. A plain film radiograph of the pelvis shows a rounded, 1 cm radiopaque lesion in the region of the bladder. Which of the following laboratory test findings is most likely to be present in this man?

A Proteinuria

B Hypercalciuria

C Elevated transaminases in serum

D RBC casts in urine

E Hyperuricemia

Case 6:

A 35-year-old woman has experienced urinary frequency with dysuria for the past 4 days. On physical examination she has no flank pain or tenderness. A urinalysis reveals sp. gr. 1.014, pH 7.5, no glucose, no protein, no blood, nitrite positive, and many WBC's. She has a serum creatinine of 0.9 mg/dL. Which of the following is the most likely diagnosis?

A Lupus nephritis

B Urinary tract lithiasis

C Acute bacterial cystitis

D Malakoplakia

E Urothelial carcinoma

 

Case 7:

Top of Form

A 70-year-old man incurs blunt force trauma in a fall. On physical examination he has a contusion on his lower back. An abdominal CT scan shows 3 peripheral 1 to 2 cm cysts in his kidneys. The kidneys are normal in size. Laboratory studies show a serum urea nitrogen of 16 mg/dL and creatinine of 1.1 mg/dL. A urinalysis reveals no blood, ketones, protein, or glucose. Microscopic urinalysis reveals a few oxalate crystals. Which of the following is the most likely diagnosis?

A Dominant polycystic kidney disease

B Prostatic nodular hyperplasia

C Renal artery atherosclerosis

D Simple renal cysts in the cortex

E Recurrent urinary tract infection


Case 8:

A clinical study is performed with pediatric subjects who had minimal change disease. These patients are observed to have prominent periorbital edema. Laboratory test findings from serum and urine tests are analyzed. Which of the following laboratory test findings is most likely to be consistently present in these subjects?.

A Nitrite positive urinalysis specimen

B Proteinuria >3.5 gm/24 hours

C Hematuria with >10 RBC/hpf

D Lipiduria in association with hypercholesterolemia

E Renal tubular epithelial cells and casts

Case 9:

A 5-year-old boy is noted to have increased puffiness around his eyes for the past week, and he has been less active than normal. On physical examination he has periorbital edema. Vital signs include T 37 C, P 75/minute, RR 18/minute, and BP 140/90 mm Hg. A urinalysis reveals sp. gr. 1.010, pH 6.5, no glucose, 4+ protein, no blood, no casts, and no ketones. Microscopic urinalysis reveals oval fat bodies, but no WBC's or RBC's. He improves following a course of corticosteroid therapy. Which of the following renal lesions is most likely to have been present in this boy?

A Glomerular crescents

B Minimal Lesion Glomerulonephritis.

C Patchy tubular necrosis

D Hyperplastic arteriolosclerosis

E Mesangial immune complex deposition

Case 10:

A 50-year-old man is hospitalized for acute myocardial infarction. He has decreased cardiac output with hypotension requiring multiple pressor agents. His urine output drops over the next 3 days. His serum urea nitrogen increases to 59 mg/dL, with creatinine of 2.9 mg/dL. Urinalysis reveals no protein or glucose, a trace blood, and numerous hyaline casts. Five days later, he develops polyuria and his serum urea nitrogen declines. Which of the following pathologic findings in his kidneys is most likely to have caused his azotemia?

A Patchy tubular necrosis

B Fusion of podocyte foot processes

C Glomerular crescents

D Hyperplastic arteriolosclerosis

E Mesangial immune complex deposition

Case 11:

A clinical study is performed to determine the value of percutaneous renal biopsy. The medical records of subjects with renal diseases are analyzed to determine the circumstances in which the results of a renal biopsy facilitated determination of therapy that improved prognosis. In which of the following situations is a percutaneous needle biopsy of the kidney most useful?

A Fever with suspected acute pyelonephritis

B Prostatic hyperplasia with suspected hydronephrosis

C Premature neonate with suspected polycystic kidney disease

D Suspected renal cyst with abdominal pain

E Systemic lupus erythematosus and acute renal failure

Case 12:

A 55-year-old man complains of dull flank pain for the past month. On physical examination he has tenderness to percussion at the right costovertebral angle. Laboratory studies show microscopic hematuria but no proteinuria or glucosuria. A urine cytology shows no atypical cells. A CBC shows WBC count 7800/microliter, Hgb 21.1 g/dL, Hct 63.5%, MCV 94 fL, and platelet count 195,000/microliter. His serum urea nitrogen is 17 mg/dL and creatinine 1.2 mg/dL. Which of the following radiographic findings is most likely to be present in this man?

A Hydronephrosis on intravenous pyelogram

B Renal mass on abdominal CT scan

C Radiopaque ureteral calculus on an abdominal plain film

D Enlarged, multicystic kidneys on abdominal ultrasound

E Pelvic mass below the bladder on MR imaging

Case 13:

A 43-year-old man goes to his physician for a routine check of his health status. He is found to have a blood pressure of 150/95 mm Hg. His urinalysis shows pH 6.5, specific gravity 1.015, no glucose, blood, or protein, and no casts. His serum creatinine is 1.4 mg/dL. If he is not treated, which of the following conditions will most likely cause his death?

A Intracerebral hemorrhage (stroke)

B Aortic aneurysm rupture

C Congestive heart failure

D Chronic renal failure

E Intracranial aneurysm rupture

Case 14:

A 20-year-old previously healthy man has been feeling tired for the past 5 days. He goes to his physician when he passes dark-colored urine. On physical examination his blood pressure is 155/90 mm Hg. Laboratory studies show his serum creatinine is 4.4 mg/dL. A urinalysis reveals pH 6, specific gravity 1.011, 3+ blood, 1+ protein, no glucose, and no ketones. On urine microscopic examination there are numerous RBC casts. Which of the following pathologic findings on renal biopsy is most likely to be present in this man?

A Glomerular crescents

B Widened proximal tubules

C Polymorphonuclear infiltrates

D Lipiduria

E IgA deposited in glomerular capillaries

 

Case 15:

A 43-year-old man has had increasing malaise for the past 3 weeks. On physical examination he has a blood pressure of 150/95 mm Hg and 1+ pitting edema of the lower extremities to the knees. Dipstick urinalysis shows no glucose, blood, ketones, nitrite, or urobilinogen, and the microscopic urinalysis reveals no RBC/hpf and only 1 WBC/hpf. Additional laboratory studies show a 24 hour urine protein of 4.1 gm. His serum creatinine is 2.2 mg/dL with urea nitrogen of 40 mg/dL. His hepatitis B surface antigen is positive. Which of the following is the most likely diagnosis?

A Membranous glomerulonephritis

B Systemic lupus erythematosus

C Acute tubular necrosis

D Diabetic nephropathy

E Post-streptococcal glomerulonephritis

Case 16:

A 60-year-old woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. There is difficulty maintaining adequate blood pressure and tissue perfusion for 3 days. Her serum lactate becomes elevated. Her serum urea nitrogen and creatinine are noted to be increasing. Granular and hyaline casts are present on microscopic urinalysis. Which of the following renal lesions is most likely to be present in this situation?

A Chronic pyelonephritis

B Acute tubular necrosis

C Nodular glomerulosclerosis

D Renal vein thrombosis

E Minimal change disease

 

Case 17:

A 50-year-old man was diagnosed at age 15 with type 1 diabetes mellitus. His disease has been poorly controlled, as evidenced by elevated hemoglobin A1C levels. He develops a non-healing ulcer of his foot at age 35. At age 45, he has an increasing serum urea nitrogen and a urinalysis shows sp gr 1.012, pH 6.5, 1+ protein, no blood, 1+ glucose, negative leukocyte esterase, negative nitrite, and no ketones. Which of the following renal diseases is he most likely to have?

A Nodular glomerulosclerosis

B Hyperplastic arteriolosclerosis

C Papillary necrosis

D Crescentic glomerulonephritis

E Pyelonephritis


Case 18:

A 39-year-old woman is found to have a blood pressure of 160/105 mm Hg while at a free health screening clinic. She feels fine and has had no major medical problems in her life. An abdominal ultrasound reveals that the left kidney is smaller than the right, but that neither is cystic and no masses appear to be present. MR angiography reveals focal narrowing with thickening and beading of the left main renal artery. A urinalysis reveals no abnormal findings. She has an elevated plasma renin. Which of the following is the most likely diagnosis?

A Diabetes mellitus

B Antiphospholipid syndrome

C Renal Artery Fibromuscular dysplasia

D Thrombotic thrombocytopenic purpura

E Cholesterol emboli syndrome

 

Case 19:

Top of Form

A 40-year-old previously healthy man has the sudden onset of severe right flank pain that comes in waves all night long. When he is seen in the emergency room, after waiting for two hours, he is exhausted. On physical examination there are no abnormal findings. Urinalysis reveals no ketones, glucose, protein, nitrite, or urobilinogen, but blood is present. Urine microscopic examination shows many RBCs but few WBCs. The specific gravity is 1.015 and the pH is 5.5. Which of the following is the most likely diagnosis?

A Benign prostatic hyperplasia

B Membranous glomerulonephritis

C Ureteral calculus

D Renal angiomyolipoma

E Urothelial carcinoma of bladder


Case 20:

A 15-year-old girl has had increasing lethargy following a bout of the "flu" 3 weeks ago. On physical examination there are no abnormal findings. Her condition does not improve after 3 weeks on corticosteroid therapy, so a renal biopsy is performed. Microscopic examination shows segmental sclerosis of 3 of 10 glomeruli identified in the biopsy specimen. Immunofluorescence studies and electron microscopy do not show immune deposits. What is the most appropriate advice to give the girl's parents regarding her condition?

A She may require a renal transplant in 10 years

B She will probably improve with additional corticosteroid therapy

C She will likely develop a restrictive lung disease

D She has an underlying malignancy

E She will improve if she loses weight

 

Case 21:

A 55-year-old man has had dysuria for the past week. Over the past 2 days he has experienced shaking chills. On physical examination his temperature is 39.3 C.. A urinalysis shows sp gr 1.016, pH 6, 1+ glucose, 1+ blood, no ketones, and no protein. Urine microscopic examination shows numerous WBCs and WBC casts. His serum creatinine is 1.5 mg/dL and glucose 155 mg/dL with hemoglobin A1C 8.7%. A renal ultrasound scan shows a 0.3 cm free floating echodense object in the left renal pelvis. Which of the following complications has this man most likely developed?

A Acute tubular necrosis

B Aspergillus fungus ball

C Cystine calculus

D Hematoma

E Papillary necrosis


Case 22:

A 49-year-old woman has had increasing malaise for the past 6 months. On physical examination there are no abnormal findings except for diminished sensation to pinprick and light touch in her lower legs and feet. She is afebrile and normotensive. Laboratory studies show serum creatinine 4.5 mg/dL, urea nitrogen 42 mg/dL, glucose 130 mg/dL, and hemoglobin A1C 7.9%. A urinalysis shows 1+ glucose, 1+ protein, no blood, and no ketones. Urine microscopic examination shows 1 RBC/hpf and 1 WBC/hpf. Which of the following pathologic abnormalities is she most likely to have in her kidneys?

A Acute pyelonephritis

B Acute tubular necrosis

C Chronic glomerulonephritis

D Hydronephrosis

E Nodular glomerulosclerosis

 

Case 23:

A 49-year-old woman has been hospitalized for the past 10 days for treatment of bronchopneumonia. She has developed chills and fever over the past 2 days. On physical examination her temperature is 38.8 C and she has a diffuse erythematous skin rash. Laboratory studies show serum creatinine 2.2 mg/dL and glucose 73 mg/dL. A peripheral blood smear reveals eosinophilia. On urinalysis she has 2+ proteinuria but no blood, glucose, or ketones. Which of the following is the most likely diagnosis?

A Post-streptococcal glomerulonephritis

B Drug-induced interstitial nephritis

C IgA nephropathy

D Acute tubular necrosis

E Acute serum sickness


Case 24:

A clinical study is performed with subjects diagnosed with hypertension who underwent an extensive workup to determine possible treatable causes for the hypertension. It is observed that some causes for hypertension are surgically correctable, while other causes are amenable to pharmacologic therapy. Laboratory findings in the subjects are analyzed. Which of the following laboratory test findings is most likely to be present in subjects with hypertension treated by drugs, rather than by surgery?

A Hyperaldosteronemia

B Hyperreninemia

C Increased catecholamines

D Hypercalcemia

E Autoantibodies

 

Case 25:

A 30-year-old man has had increasing malaise with fever, abdominal pain, and weight loss of 3 kg over the past 3 weeks. On physical examination his blood pressure is 160/110 mm Hg. He has a stool positive for occult blood. A urinalysis reveals hematuria but no proteinuria or glucosuria. He has no serum anti-neutrophil cytoplasmic autoantibodies and his antinuclear antibody test is negative. Aneurysmal arterial dilations and occlusions are seen in the medium sized renal and mesenteric arteries with angiography. He improves with corticosteroid therapy. Which of the following is the most likely diagnosis

A Benign nephrosclerosis

B Fibromuscular dysplasia

C Nodular glomerulosclerosis

D Polyarteritis nodosa

E Systemic lupus erythematosus


Case 26:

Top of Form

A 30-year-old man has noted puffiness around his eyes and swelling of his feet for the past 2 weeks. On physical examination his blood pressure is 155/95 mm Hg. Urine microscopic examination reveals oval fat bodies. Which of the following conditions is he most likely to have?

A Ascending pyelonephritis

B Nephritic syndrome

C Nephrotic syndrome

D Obstructive uropathy

E Renal infarction

Case 27:

A 15-year-old child has been noted by his mother to be lethargic for 2 weeks. On physical examination he has periorbital edema. He is afebrile. Dipstick urinalysis reveals no glucose, ketones, or blood, but he has 4+ proteinuria present. Microscopic urinalysis reveals no casts, but oval fat bodies are seen. He is treated with corticosteroid therapy and his condition improves. Which of the following renal electron micrographic findings is most characteristic for this child's disease?

A Fusion of foot processes

B Subepithelial electron dense deposits

C Duplication of glomerular capillary basement membranes

D Irregular thickening of the glomerular basement membranes

E Mesangial cell proliferation


Case 28:

A 70-year-old female is admitted 12 hours after taking an overdose of aspirin.

Investigations revealed:

7.2 g/dL (14-18)

Serum sodium

72 fL (80-96)

Serum potassium

11.3 x 109 /L (4-11 x 109)

Serum brearbonate

480 x 109/L (150-400 x 109)

Serum urea

 

 

What is the most appropriate treatment of this patient?

A-  Haemodialysis                                          

B-   Haemofiltration

C-   Intravenous sodium bicarbonate.

D-  Peritoneal dialysis.

E-   Urine alkalinization.

Case 29:

A 59-year-old woman has had insulin dependent diabetes mellitus for over two decades. The degree of.control of her disease is characterized by the laboratory finding of a HbAlc of 10.1% (3.8-6.4%). She complains of repeated episodes of abdominal pain following meals. These.episodes have-become more frequent and last for longer periods over the last couple of months.

On physical examination, there are no abdominal masses or organomegaly and no tenderness to palpation.

Which of the following findings is most likely to be present?

A-  Acute pancreatitis

B-   Chronic renal failure

C-   Hepatic infarction

D-  Mesenteric artery occlusion                              

E-   Ruptured aortic aneurysm

 


Case 30:

A 26-year-old male with a three year history of type 1 diabetes presents with fever, vomiting and is dehydrated. Investigations revealed:-

 

148 mmol/L (137-144)

Sodium

3.3 mmol/L (3.5-4.9)

Potassium

24 mmol/L (2.5-7.5)

Urea

33 mmol/L (3.0-6.0)

Glucose

7.18(7.36-7.44) 

Blood pH

 

 

What would be the typical total body water deficit associated with his diabetic ketoacidosis?

A-              1 litre

B-   3 litres

C-   6 litres                                                              

D-  8 litres

E-   10 litres


 

MCQs Part I

 

Case 1:

Answer:  (B)

Many drugs require dosage modifications in chronic renal insufficiency. Bioavailability, distribution, action, and elimination of drugs all may be altered. Drugs that are nephrotoxic may be contraindicated or used only with extreme care in renal insufficiency. The aminoglycosides, vancomycin, ampicillin, most cephalosporins, methicillin, penicillin G, sulfonamides, and trimethoprim all should be given in reduced dosage to patients with chronic renal failure. The aminoglycosides and vancomycin

can be nephrotoxic and should be usedwith caution in renal insufficiency. The small group of antibiotics not needing dosage modification includes chloramphenicol, erythromycin, the isoxazolyl penicillins (nafcillin and oxacillin), and moxifloxacin.

 

Case2:

Answer: (C)

Chronic renal failure treated with hemodialysis results in predictable metabolic abnormalities.The kidneys fail to excrete phosphate, leading to hyperphosphatemia, and fail to synthesize1,25(OH)2D3. Vitamin D deficiency causes impaired intestinal calcium absorption. Phosphate retention, defective intestinal absorption, and skeletal resistance to parathyroidhormone (PTH) all result in hypocalcemia.

Hypocalcemia causes secondary hyperparathyroidism, and the excess PTH production worsens the hyperphosphatemia by increasing phosphorus release from bone. These derangements impair collagen synthesis and maturation, resulting in skeletal abnormalities collectively referred to as renal osteodystrophy. Osteomalacia, osteosclerosis, and osteitis fibrosa cystica may all be seen.

Case 3:

ANSWER: E

Bottom of Form

Treatment of established infection does not prevent the development of post-streptococcal glomerulonephritis, but may lessen its severity.
Early antimicrobial therapy in affected individuals and family members may prevent the spread of streptococcal infections.
Acute post-streptococcal glomerulonephritis though not very common nowadays is seen following a throat or skin infection by nephrogenic strains of group-A beta hemolytic streptococci.
This is an immunologically mediated disease. The latent period between the infection and onset of nephritis is compatible with the time required for building up of antibodies against the streptococcal products. Granular immune deposits are seen in the glomeruli on electron microscopy due to the deposition of the circulating immune complexes. These immune complexes cause a cellular reaction consisting of neutrophils and monocytes in the glomerular basement membrane. This ultimately leads to injury and dysfunction of the basement membrane.The injury to the basement membrane is responsible for the decreased urine output due to a decreased glomerular filtration rate and also hematuria manifested by the brown colored urine. Mild proteinuria ( <1gm/day) also occurs which is responsible for the periorbital edema.

 

Case 4:

Top of Form

 (B) CORRECT.

The lack of findings in the bladder, but the presence of atypical cells, suggests that the lesion is located higher.

The surface epithelium of the renal collecting tubules, calyces, pelvis, ureter, bladder & urethra is called "urothelium" or ‘transitional epithelium’.

Urothelial (transitional cell) carcinomas of the upper urinary tract & bladder tend to be multifocal. This phenomenon is termed "field cancerization".

Other tumors in the upper urinary tract & bladder are squamous cell carcinoma and adenocarcinoma.


Case 5:

(B) CORRECT.

The findings suggest a bladder calculus. Most stones are composed of calcium with oxalate or phosphate. The calcium content makes them radiopaque, unlike pure uric acid stones that are radiolucent and which are not very common.

Case 6:

(C) CORRECT.

These are features of acute inflammation. There are no casts, because the infection involves the bladder, though such an infection could ascend to produce pyelonephritis. Urinary tract infections are more common in women because of the shorter urethra.

 

Case 7:

Top of Form

Bottom of Form (D) CORRECT.

Simple renal cysts typically do not interfere with renal function. A few small cysts can be found in many older persons and are inconsequential. They will appear as incidental findings in radiographic studies.

Case 8:

(B) CORRECT.

This is the definition of nephrotic syndrome. A single urine specimen will not suffice for the definition of nephrotic syndrome (though it could be extrapolated, given the daunting task of 24 hour urine collection in children).

Case 9:

(B) CORRECT.

This is minimal change disease, the most common cause for nephrotic syndrome in children, and fusion of podocyte foot processes is the only pathologic finding present (on electron microscopy). Most patients respond to corticosteroid therapy.

Case 10:

(A) CORRECT.

He has findings of ischemic acute tubular necrosis from heart failure with hypotension. A clue is the >20:1 ratio of urea nitrogen to creatinine, which occurs early in the course, from prerenal azotemia. As the disease progresses, the ratio begins to approach 10:1, typical for renal diseases.

(The BUN/plasma creatinine ratio is 10-15:1 in ATN, but may be greater than 20:1 in pre-renal disease due to ↑↑ in the passive reabsorption of urea).

ATN may also be produced by toxins such as ethylene glycol in antifreeze.

Case 11:

(E) CORRECT.

Therapy may depend upon determination of the severity and nature of the renal disease with SLE.

·  Class I (minimal mesangial lupus nephritis)

    Normal urine and creatinine.

·  Class II (mesangial proliferative lupus nephritis)

    Microscopic hematuria and/or proteinuria.

·  Class III (focal lupus nephritis)

    Hematuria, proteinuria, nephrotic syndrome and hypertension.

    Creatinine may increase.

·  Class IV (diffuse lupus nephritis)

    Hematuria, proteinuria, nephrotic syndrome and hypertension.

    Creatinine is increased.

·  Class V (membranous lupus nephritis)

    Nephrotic syndrome. Creatinine is usually normal

·  Class VI (advanced sclerosing lupus nephritis)

    Progressive renal dysfunction with proteinuria.

Case 12:

(B) CORRECT.

The polycythemia suggests a paraneoplastic syndrome, and a renal cell carcinoma is a likely candidate for the primary lesion. The flank pain and hematuria can be explained by a renal cell carcinoma.

Case 13:

(C) CORRECT.

Hypertension leads to cardiac enlargement, then dilation, and eventual failure. This is the most common outcome with untreated hypertension.

Case 14:

(A) CORRECT.

Crescents are characteristic for a rapidly progressive glomerulonephritis; they form when there is leakage of fibrinogen into Bowman's space, with proliferation of epithelial cells to form the crescent.

Case 15:

(A) CORRECT.

Membranous GN is the most common cause for nephrotic syndrome in adults. Some cases are associated with underlying infections or malignancies, but in most cases the cause is unknown.

Case 16:

(B) CORRECT.

Ischemia, typically in hypotensive hospitalized patients, is the most frequent antecedent to ATN, and MI's are common.

Case 17:

(A) CORRECT.

This is a typical complication of long-standing diabetes mellitus. Microalbuminuria may preceed development of other abnormalities.

Renal Pathology Society classification of diabetic nephropathy:

  • Class I: Isolated GBM thickening.
  • Class II: Mesangial expansion.
  • Class III: Nodular glomerulosclerosis.
  • Class IV: Advanced diabetic sclerosis.

 

Case 18:

(C) CORRECT.

  • Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic disorder that leads to arterial stenosis, aneurysm or dissection. It is more common among women. It occurs at any age.
  • The most often involved arteries are the renal (60 %) and internal carotid arteries (30-60%).
  • The cause is unknown.
  • The most common manifestations are hypertension, headache, dizziness, tinnitus, TIAs, and stroke.
  • It should be suspected in patients with severe or resistant hypertension and an increase in serum creatinine after ACEI or ARB, onset of hypertension before the age of 35 years, and with epigastric bruit.
  • DD: atherosclerotic vascular disease and vasculitis.
  • Duplex ultrasound is performed, if it is inconclusive digital subtraction arteriography is done.
  • It is a surgically treatable cause for hypertension. The abnormal segment of artery can be treated with angioplasty or removed and replaced with a graft.

 

Case 19:

Top of Form

(C) CORRECT.

These acute symptoms are typical for a calculus that is being passed.

Case 20:

(A) CORRECT.

The findings point to focal segmental glomerulosclerosis (FSGS), which leads to chronic renal failure in half of cases. The lack of resolution with corticosteroid therapy and the progression to chronic renal failure is what sets FSGS apart from minimal change disease.

Case 21:

(E) CORRECT.

Papillary necrosis is a renal complication of diabetes mellitus, as in this case. Papillary necrosis may also be seen with analgesic abuse nephropathy, with sickle cell anemia, and with a severe acute pyelonephritis.

Case 22:

(E) CORRECT.

The classic lesion with diabetes mellitus is nodular glomerulosclerosis, which gradually reduces renal function. Diffuse glomerulosclerosis may also be present.

Case 23:

(B) CORRECT.

These findings are typical for a drug-induced acute interstitial nephritis. The eosinophilia is seen with allergic phenomena (as in a drug allergy).

Diagnosis:

  • Non-specific symptoms: nausea, vomiting, or malaise.
  • Allergic manifestations: rash, fever, & eosinophilia.
  • Acute rise in the plasma creatinine concentration.
  • Urine: protein, WBCs, RBCs, and white casts. 
  • Signs of Fanconi syndrome & renal tubular acidosis, may be present.
  • Renal biopsy:
    • In uncertainty of diagnosis.
    • Advanced renal failure.
    • Lack of recovery following cessation of drug therapy.

Treatment:

  • Discontinuation of the suspected drug:  if renal functions improve, no further evaluation or therapy is required.
  • Early use of corticosteroids may improve prognosis.

 

Case 24:

(E) CORRECT.

Immunologic diseases of the kidney often produce glomerulonephritis, and renal damage often leads to hypertension.

Case 25:

(D) CORRECT.

Classic polyarteritis nodosa often affects multiple organs, not just the kidney. The classic form of polyarteritis affects medium to small sized arteries.

 

Case 26:Top of Form

Bottom of Form

(C) CORRECT.

Oval fat bodies appear with pronounced proteinuria and lipiduria.

Case 27:

(A) CORRECT.

This is the typical (and only) pathologic finding for minimal change disease, the most common cause for nephrotic syndrome in children, but it can be seen at older ages, too.

Case 28:

A is correct.

This patient is at major risk of aspirin toxicity as reflected by the excessive aspirin concentration and appears to have developed acute renal failure -is acidotic with an elevated potassium. Bicarbonate is recommended as a supportive therapy but in this patient, Haemodialysis is the treatment of choice. The latter is advised when the plasma-salicylate concentration is greater than 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis.

Case 29:

D is correct.

Diabetes- especially Type 2 diabetes- is associated with macrovascular disease. Smoking is a further risk factor for macrovascular atherosclerosis. After a meal splanchnic blood flow is increased. If the mesenteric artery is occluded the lack of blood flow to the bowel will produce ischaemic type pain.

 

Case 30:

C is correct.

The typical fluid- deficit associated with DKA is approximately 6 liters. The initial half of this amount is derived-from intracellular fluid and precedes signs of dehydration, while the other half is from extracellular fluid and is responsible for clinical signs of dehydration., Appropriate fluid replacement requires 1 liter of Normal saline over the first 1/2 hour, then 1 liter over the next hour, then 1 liter over the next two hours followed by 1 liter every 4 hours depending on the degree of dehydration.


MCQs Part II

 

1) All are recognized causes of chronic renal failure (CRF) except:

A.    Snake bite

B.     Malignant hypertension

C.     Diabetes mellitus

D.    Obstructive uropathy

E.     Analgesic abuse

 

2) All are true in acute renal failure (ARF) except

A.    ­Urea

B.     ­H+ concentration

C.        ­ Ca++

D.    ­ K+

E.     ↓ Na+

 

3) Broad casts are found in:

A.    Acute glomerulonephritis

B.     Urinary tract infection

C.     Analgesic nephropathy

D.    Chronic renal failure (CRF)

E.     Obstructive uropathy

 

4) Which is not a criteria for diagnosis of nephrotic syndrome:

A.    Hypertension

B.     Massive proteinuria

C.     Hyperlipidaemia

D.    Anasarca

E.     Hypoalbuminemia

 

5) Oliguria is:

A.   < 50 mL urine/24 hrs

B.   < 100 mL urine/24 hrs

C.   < 200 mL urine/24 hrs

D.   < 400 mL urine/24 hrs

E.    < 600 mL urine/24 hrs

 


6) Fatty cast is often diagnostic of:

A.    Nephrotic syndrome

B.     Acute glomerulonephritis

C.     End-stage renal disease

D.    Papillary necrosis

E.     Hyperlipidaemia

 

7) Which is not a neuromuscular complication of uraemia:

A.    Encephalopathy

B.     Myelopathy

C.     Neuropathy

D.    Myopathy

E.     Myoclonus

 

8) 'Complete' anuria is found in:

A.    Diffuse cortical necrosis

B.     Acute gastroenteritis

C.     Acute renal failure

D.    Chronic glomerulonephritis

E.     Acute interstitial nephritis

 

9) Which is not a recognized cause of microalbuminuria:

A.    Nephrotic syndrome

B.     Diabetes mellitus with early renal involvement

C.     Congestive cardiac failure

D.    Strenuous physical exercise

E.     Fever

 

10) Which of the following does not produce red urine:

A.    Haemoglobinuria

B.     Myoglobinuria

C.     Microscopic haematuria

D.    Acute intermittent porphyria

E.     Beet route intake

 

11) Polyuria is produced by all of the following except:

A.    Diabetes insipidus

B.     Congestive cardiac failure

C.     Hypercalcaemic nephropathy

D.    Chronic renal failure

E.     High protein tube feeding

 

12) Which metal is not responsible for development of nephrotic syndrome:

A.    Gold

B.     Iron

C.     Mercury

D.    Lead

E.     Chromium

 

13) Commonest renal lesion in diabetic nephropathy is:

A.    Diffuse glomerulosclerosis

B.     Chronic interstitial nephritis

C.     Arterionephrosclerosis

D.    Nodular glomerulosclerosis

E.     Papillary necrosis

 

14) Absolute indication for dialysis:

A.    Serum K+ level > 6 mEq/L

B.     Serum urea level > 200 mg/dL

C.     Serum creatinine level > 4 mg/dL

D.    Clinical evidence of pericarditis

E.     HCO3 level < 10 mEq/dL

 

15) Serum urea and creatinine remain normal in:

A.    Hepato-renal syndrome

B.     Haemolytic-uraemic syndrome

C.     Hydronephrosis

D.    Acute renal failure

E.     Lipoid nephrosis

 

16) Blood level of all rises in ARF except:

A.    Uric acid

B.     K+

C.     Na+

D.    Creatinine

E.     Phosphate

 

17) Prognosis of which of the following is excellent:

A.    Acute glomerulonephritis

B.     Interstitial nephritis

C.     Chronic nephritis

D.    Nephrotic syndrome

E.     Diabetic nephropathy

 

18) Recognized feature of minimal change glomerular disease is:

A.    Haematuria

B.     Hypertension

C.     Absence of oedema

D.    Response to corticosteroid

E.     Decreased complement

 

Answer key :

1.     A

2.     C

3.     D

4.     A

5.     D

6.     A

7.     B

8.     A

9.     A

10.                        C

11.                        B

12.                        B

13.                        A

14.                        D

15.                        C

16.                        C

17.                        A

18.                        D

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