nephrology

14/04/2025

rhabdomyolysis

as skeletal muscles are dying, they release → (3)

common scenarios and hints (5)

it is a common side effect of _______ (drug)

myoglobulin, K, creatine kinase

trapped hours under heavy object, fall → long time lying down, marathon runner, old with frequent falls with AKI, IVDU found not moving, severe crush injury ± reddish brown hematuria (false positive as redness is myoglobulin), hypotension, AKI, very high creatine kinase

statin

myoglobulin is _______ and can lead to ________. initial step → _______.

ECG must be performed to detect ________ (findings?). initial step → _______.

nephrotoxic…AKI…IV fluid

hyperkalemia (tall tented T wave… CaCl/ Ca gluconate (to protect heart)

main complication of rhabdomyolysis → _______ and ________

initial management → ______ (to avoid ____)

initial DX for management → _______

if _______ , initial line → give ______/________

best specific initial test for rhabdomyolysis → ________ (shows _______)

to confirm → _________ (indicates ________)

other lines of TX → ________ and _________

AKI…hyperkalemia

IV fluids…AKI

ecg

hyperkalemia…CaCl/Ca gluconate

urine analysis…red-brown / tea colour (false hematuria)

creatine phosphokinase…muscle necrosis

Sodium bicarbonate…dialysis

most appropriate management →

likely cause of his renal failure →

best investigation to perform →

to confirm →

likely diagnosis →

causing med that needs to be stopped →

rhabdomyolysis

simvastatin

creatine kinase

goodpasture syndrome is ________________ + _____________

expressed as __________ and ____________ + impaired KFT

initial DX →

most accurate DX →

chest x-ray shows →

acute rapid progressive glomerulonephritis + pulmonary alveolar hemorrhage

hematuria + hemoptysis (lung involvement)

anti glomerular basement membrane antibodies

kidney/lung biopsy (cresentic glomerulonephritis)

patchy interstitial infiltration (intra pulmonary bleeding)

goodpasture syndrome → +DX

alport syndrome →

alpha antitrypsin →

churg strauss → +DX

wegener’s granulomatosis → +DX

hemolytic uremic syndrome →

hematuria + hemoptysis (anti GBM antibodies)

hematuria + hemoptysis + can’t see + can’t hear

hemoptysis + jaundice (liver)

eosinophilia + asthma (p-ANCA)

hematuria + upper respiratory syndrome (c-ANCA)

hematuria + diarrhea that turns bloody

“itching after hot shower” +

• pale, peripheral edema, skin pigmentation, lethargy → (itching due to _____, lethargy due to ________)

• red skin, flushed (due to high ___) ± splenomegaly ± burning fingers and toes ± gout →

• linear tracks on skin (burrows) →

• yellow skin →

chronic renal failure…uremia…low erythropoietin/anemia

polycythemia rubra vera…high Hb

eczema

liver

normal Na level → _______

hyponatremia can occur after inappropriate _________ such as by _______. this is a _________ cause.

in sepsis either _______ and ______ is allowed (these won’t cause ________)

135-145 mmol/l

IV fluid therapy…dextrose 5%…iatrogenic

ringer lactate…NS (0.5% NaCl)…dilutional hyponatremia

likely cause →

iatrogenic

massive hemorrhage + hypotensive shock + high creatinine → _________

kidneys needs to remain _________ to avoid it.

prolonged _______ → low _______ to kidneys → dying ________ = _______ = _______ → ______

acute tubular necrosis

hydrated

ischemia…perfusion…tubules…necrosis…acute tubular necrosis → AKI

allergy (eg drug intake followed by rash/fever) + hematuria + high creatinine →

acute interstitial nephritis

25-alpha-hydroxylation of vit D occurs in →

1-alpha-hydroxylation of vit D occurs in →

25-hydroxyvitamin D is formed in _______ → enzyme called ______ in _______ converts to active form which is _______.

hence, vitamin D deficiency is due to ______________.

liver

kidney

liver…1-alpha-hydroxylase…kidney…1,25-dihydroxyvitamin D

chronic renal failure

hypertension + hx of repeated UTIs →

repeated UTI → _________ → chronic pyelonephritis → __________

loin/back pain + UTI features →

NB! repeated UTI but SUDDEN loin/back pain/fever/rigors ± urinalysis shows blood, nitrites, leucocyte esterase → (why not the other one?)

chronic pyelonephritis

renal scarring…HTN

acute pyelonephritis

acute pyelonephritis (chronic has no active infection such as fever)

acute pyelonephritis

pyelonephritis = _______________

RF → (4)

suspect if (4 main) ± (3 in urinalysis)

inflammation of the pelvis of the kidney

stones, pregnancy, VUR, DM

lower UTI features | fever | loin//back pain

± hematuria, nitrites, leucocyte esterase

dysuria, frequency, urgency ± abdominal pain → (+TX)

above + loin/back pain + fever → (+TX)

DX → _______ (to look for ____, ____, ____, ____)

DX → ________ (then start immediately ________!!) (_______ specimen for adults and old children, ________ in young children)

lower UTI || TX - trimethoprim, nitrofurantoin

ascending UTI || TX - co-amoxiclav/ciprofloxacin

urinalysis → blood, nitrate, leucocyte esterase, protein

urine culture and sensitivity…empirical antibiotics

midstream…clean catch/ catheter/ suprapubic aspiration

most common cause of UTI →

TX for non pregnant women, men and patients with indwelling catheters → __________/ ___________

TX for children → 1st line ________, 2nd line __________

TX for pregnant who dont require admission → __________

!! if patient is admitted, these AB are given _____

e.coli (gram negative)

ciprofloxacin 500mg BID 7d / co-amoxiclav 625 mg TID 14d

co-amoxiclav…cefixime

cefalexin 500mg BID 10-14d

IV

small kidneys + HTN → ________/ _______

drug that is CI in ______ → ________

bilateral renal artery stenosis / chronic pyelonephritis

bilateral renal artery stenosis…ACEi

mild proteinuria on urine dipstick (up to +1) + gymrat →

if no other symptoms →

if still high →

NB! never refer a patient with _______ to renal clinic! always investigate further first.

normal

repeat test

24h urine specimen test / PCR

isolated proteinuria

triad of nephrotic syndrome

children peak incidence age ___ to ___ (80% due to MCG)

features of minimal change glomerulonephritis (3)

definitive DX → (+ findings)

proteinuria >3g/24h, hypoalbuminemia <30g/l, edema

2-5 YO

nephrotic syndrome, normotensive, selective proteinuria (mid size protein such as albumin and transferrin can leak through glomeruli)

renal biopsy - fusion of podocytes

_________ always presents as nephrotic syndrome (75% children, 25% adults).

good prognosis with TX ______.

other features (2) due to (2) + (1)

foamy urine indicates →

fluid retention indicates →

minimal change disease

high dose oral steroids

hyperlipidemia, hypercoagulable state (due to loss of antithrombin III), liability of infection (due to loss of Ig)

proteinuria

edema

diagnosis →

most appropriate investigation →

another valid answer →

most definitive diagnostic test →

likely diagnosis →

minimal change disease

prolonged vomit and diarrhea can lead to __________ and __________.

most common cause of AKI is ________

AKI → ________ → kidneys unable to excrete K, creatinine, urea → ________, ________, _______.

hypokalemia…dehydration

dehydration “hypovolemia”

decreased eGFR…hyperkalemia, high urea serum, high creatinine

to reduce risk of “contrast induced nephropathy” in CT scan with contrast

→

→

→ ________ (drug) needs to be stopped

drink plenty of water

IV fluid NS (0.9% NaCl)

metformin (nephron harmful)

blood gas norm - abnormality

pH ____ to _____ (> is alkalemia, < is acidemia)

PaCo₂ ____ to _____ kPa (< is respiratory alkalosis, > is acidosis)

bicarbonate level _____ to _____mmol/l (< is metabolic acidosis, > is alkalosis)

base level _____ to _____mmol/l (< is metabolic acidosis, > is alkalosis)

*profuse diarrhea also leads to loss of ________ → ________

7.35-7.45

4.7-6

22-26

-2 to +2

hypovolemia “dehydration” → AKI

his blood gas interpretation →

renal stones management

< 0.5cm →

0.5cm-2cm → (2)

> 2cm →

1 functioning kidney + any size stone + dilatation of pelvicalyceal system (PCS) ± anuria, fever

indicates →

initial management is to → (to save remaining kidney)

done by →

2 functioning kidneys, develops AKI, fever, hydronephrosis, stone

indicates →

management →

obstructive uropathy

percutaneous nephrostomy

decompressing the PCS

percutaneous nephrostomy vs percutaneous nephrolithotomy

HTN + CKD + GFR>30 + ACR>30, TX → (2)

if GFR<30 / ACR<30, avoid →

(2) can be used as long as ACR ≥ ____, ACR ≥ ____ (if HTN), ACR ≥ ____ (if DM)

SGLT-2 provides ____, _____, ____ protection

SGLT-2 examples → flozin → ____, _____, _____

percutaneous nephrostomy - stoma catheter to the PCS for decompression (drain fluid)

percutaneous nephrolithotomy - remove stone via scope (if >2cm)

ACEi /ARB

ACEi /ARB

ACEi /ARB…70…30…3

renal…cardio…diabetic

cana, dapa, empa + gliflozin

most common cause of nephrotic syndrome in

• children

• adults (white/caucasian/unspecified) →

• adults (african/black/american/hispanic) →

minimal change glomerulonephritis

membranous GN

focal segmental GN

membranous glomerulonephritis

presentation (3)

cause (4)

prognosis (1/3 for each) → ______, _______, ______

proteinuria, nephrotic syndrome, CKD

idiopathic, infection, rheumatoid drugs, malignancy

remission, partial remission, end stage renal failure

suspect CKD if (4)

reason for hypocalcemia → deficiency of _______ → low vit D and Ca

hypocalcemia SX (4)

anemia + hypocalcemia + hyperphosphatemia + small kidneys (US < 9mm)

1-alpha hydroxylase

tingling, numbness, paresthesia, involuntary spasms/cramps

patient presents with CKD and DM

loss of sensation in fingers and muscle cramps

labs : hyperkalemia, hypocalcemia, hyperphosphatemia, anemia

likely reason for his symptoms →

other valid answers (2)

autosomal dominant polycystic kidney disease (ADPKD) - 50% by fam hx

________ + ________ + _______ → ______PKD

it is associated with ___________

DX (3)

hematuria + HTN + loin/flank pain → adultPKD

intracranial aneurysm

US of kidney, ureter, bladder

hemolytic uremic syndrome (HUS) triad

children eat contaminated food → _______ → produce ________ → profuse _______ → turns ______ → (after 2-14d) → ________ “acute renal failure” (________, _______, high _____ and ______)

TX (3), if severe (1), NEVER give (1) because _____________

hemolytic anemia || uremia (acute renal failure) : low urea and creatinine || thrombocytopenia (low platelet)

e.coli 0157…verotoxin…diarrhea…bloody…uremia…(hematuria, proteinuria, high urea and creatinine)

IV fluids, blood transfusion, dialysis || plasma exchange || antibiotics (dead e.coli produce more toxin)

hemolytic uremic syndrome (HUS) triad + fever + neurological manifestations →

TTP - thrombotic thrombocytopenic purpura

hematuria that develops after a hx of URTI (_______/________) or gastroenteritis is due to

• (2) disease

• time of exacerbation, main presentation, organisms, TX, ± gender, DX and findings

causes of small kidneys (4) and large kidneys (2)

chronic pyelonephritis || chronic glomerulonephritis || hypertensive renal disease || bilateral renal artery stenosis

ADPKD || obstructive neuropathy (stone/ enlarged prostate → hydronephrosis → large)

simple lower UTI (dysuria,frequency) is treated by

→

→

uncomplicated upper UTI (acute pyelonephritis)

→

→

→ (if pregnant/outpatient)

best management →

likely case of →

indications of hemodialysis (5)

persistently high K ≥ 6.5 (refractory hyperkalemia)

severe metabolic acidosis

fluid overloaded with anuria/non-effective diuretics

uremic pericarditis, pulmonary edema

uremic encephalopathys

most appropriate investigation →

ACEi / statins / BB / diuretics

ACEi (reno protective, delay progress of CKD)

AKI / addison’s/ renal tubular acidosis

MCUG / renal USS / DMSA / urine mcs / ct scan

renal USS

reflux nephropathy (______ → ______ → ______ → ______)

reflux involved

occurs mainly in?

cause

DX initial (2), gold standard, for parenchymal damage(cortical scars)

TX initial (1), failed/parenchymal damage(1)

urine goes back from bladder to ureters and kidneys (vesico-ureteric reflux) → dilated pelvicalyceal system → repeated UTIs → progressive renal failure

young children

congenital abnormality of the insertion of ureters into urinary bladder (can be seen on US)

renal US, urinalysis, urine culture || micturating cystourethrogram || technetium scan (DMSA)

low dose trimethoprim (AB) || surgery/utreters re-implantation

hypertensive neuropathy / bph / prostate car / chronic pyelonephritis / vur

hypertensive neuropathy

diagnosis →

hypertensive renal disease → small and scarred kidneys → renal impairment

HTN + hx of repeated UTIs

think of →

chronic pyelonephritis

repeated UTI → renal scarring → chronic pyelonephritis → HTN

membranous GN / minimal change GN / post strep GN / IgA nephropathy

minimal change GN always presents as nephrotic syndrome

likely reason for hypocalcemia is →

1,25-dihydroxyvitamin D3 deficiency

TFT / x-ray / blood glucose / urinalysis / LFT

urinalysis

abdominal US / blood cultures / serum creatinine phosphokinase / echo / TFT

serum creatinine phosphokinase

bilaterally small kidneys + HTN

possible diagnosis (2)

bilateral renal artery stenosis

hypertensive renal disease

female presents with dysuria, loin pain and rigors

likely →

initial investigation →

then →

acute pyelonephritis

urinalysis

urine culture

likely diagnosis →

most appropriate investigation →

most definitive diagnostic test →

likely cause of renal failure → (+why)

a case of →

myoglobulin (reno toxic)

rhabdomyolysis

D.A.M.N. drugs that need to be stopped if patient presents with diarrhea/vomiting (risk of dehydration and AKI) until symptoms resolve

causes of AKI (6)

rhabdomyolysis

HUS

dehydration : diarrhea/ vomit

sepsis

following major surgery

DAMN drugs

DM + microalbuminuria, start on ________ (even if normotensive)

because DM can lead to _________

ACEi (enalapril, lisinopril)

diabetic nephropathy

BPH / hypertensive nephropathy / prostate car / chronic pyelonephritis / vur

hypertensive nephropathy

initial TX for hypocalcemia (eg tingling, low serum Ca)

calcium gluconate infusion

most likely diagnosis →

most appropriate management →

most likely diagnosis →

most appropriate management →

most likely diagnosis →

common complication of CKD is anemia (eg extreme fatigue, sleepiness, pallor). “due to impaired ________ and ________)

in patients with CKD + anemia but with

• normal serum ferritin and iron, give →

• low serum ferritin/iron →

iron absorption…erythropoietin

diabetic nephropathy/membranous nephropathy

normal albumin creatine ratio (ACR) is < ____

microalbuminuria (proteinuria) ____ to _____

macroalbuminuria (albumin is a protein) > ___

30

30-300

300

when should GP refer patient to a nephrologist (4)

initial step is →

the anatomical structures affected in nephrotic syndrome are

diagnosis →

management if

normal bp, low proteinuria (<50 uPCR) →

high bp / high proteinuria (>50 uPCR) →

high proteinuria (>1g/d) or (<50uPCR) →