Mowafy Medical Symphony Nephrology revision

Nephrology problem solving

CASE 210 :

A female patient 50 yrs old, known to have long standing hypertension on irregular
treatment, presented with history of generalized fatigue over the last 6 months. Over the
last 2 months, she complained of nausea with occasional vomiting and she reported to
have weight loss and some itching. On examination, her BP was 170/110 mmHg, she was
found to be pale with some scratch marks over the LL. Her skin was dry and cardiac
examination revealed a systolic murmur.

Investigations showed serum Creatinine 9 mg/dl, BUN 100 mg/di, serum Na 135mmol/L,
K 5.8mmol/L, Ca 7.5 mg/dl, P 6.5mg/dl, Hb 8gm/dl, WBC 4.7 x 103/mm3, Platelets count
190 x 103 /mm3

1. What is the most likely diagnosis?

2. What further investigation would you like to perform?

3. How can you manage her anemia?

4. Discuss treatment strategies for this patient?1. What is the most likely diagnosis?

2. What is the most appropriate investigation to reach the diagnosis? Explain why.

3. What are the indications of surgery?

Answers :

1. The most likely diagnosis is : End stage chronic renal failure.

Data with : The patient presents with typical symptoms of end stage renal failure :
nausea, weight loss, fatigue and pruritus. The elevated urea & Cr confirm renal
failure. Anemia & skin manifestations indicate CRF.
Mowafy Medical Symphony Nephrology revision

2. Ultrasonography : either showing shrunken kidneys increased echogenicity or obvious

causes of renal failure such as a polycystic kidney discase. Asymmetrically sized kidneys
suggest reflux nephropathy or renovascular disease.

3. Management of anemia :

o Complete blood picture with RBC indices, reticulocytic count and iron study
(serum Fe, TIBC and ferritin) are done to investigate the type of anemia:
- If normochromic normocytic (due to erythropoietin deficiency) : erythropoietin
injection is usually needed.
- If inadequate iron stores, iron should be replaced by oral iron, however, if iron
absorption is not adequate, iron can be given through the IM route (Fe
dextrane) or the IV route which is the preferred route on dialysis.

4. Treatment :

 Renal replacement therapy (hemodialysis HD or perotineal dialysis PD) or

transplantation (with life long immunosuppression) are indicated.

 Problems uncontrolled by dialysis : HEPA or HIBA 😊😊

o Hypertension.
o Endocrinal & gonadal dysfunction.
o Infections.
o Bone disease : active vit D
o Anemia : controlled by erythropoietin
Mowafy Medical Symphony Nephrology revision

CASE 12
A 70 year old male, living alone developed an attack of diarrhea that persisted for 3 days
before coming to the hospital. He complained of reduced urine output and marked
weakness and reported that he was too weak even to bring himself a glass of water. He
has no past history of medical importance.
On examination his BP was 90/60, he had dry mucous membranes and skin turgor
showed evident dehydration.
Laboratory work revealed serum Creatinine 6 mg/di, urea 200 mg/d, Hb 12gm/dl. Urine
analysis was unremarkable
1. What is the most likely diagnosis?
2. How would you confirm the diagnosis?
3. What other tests are needed?
4. What is the first line of management to be done in this patient?

Answers :
1. The patient has : prerenal acute kidney injury/acute tubular necrosis (AKI/ATN). The
latter develops with prolongation of the prerenal condition.

2. Urine analysis : to differentiate between prerenal & ATN :

Pre-renal Renal

Urine Na (mEq/L) < 20 > 40

FENa < 1% > 2%

Urea/creatinine > 20 < 10

Urine osmolality (mOsm/kg) > 500 < 350

- Renal tubular epithelial cells and brownish pigmented cellular casts in ATN.
Mowafy Medical Symphony Nephrology revision

3. Other tests :

o Tests to exclude other causes of acute kidney injury AKI, abdominal

ultrasonography (to exclude post renal causes, especially prostatic

enlargement).

o Active urine sediment may point to an intrinsic renal cause.

o Tests for serum Na, K, Ca, P, uric acid and blood gases are needed for further

management.

4. First line of management :

o IV saline, preferably under CVP guidance.

o Urinary catheter : to assess urine volume & to exclude post-renal cause.

o Central venous catheter : to assess the blood volume.

o Immediate IV saline

o In the presence of hyperkalemia, first line will be IV infusion of Ca

gluconate, glucose- insulin and sodium bicarbonate.

Mowafy Medical Symphony Nephrology revision

CASE 212
A 37 year old male presented with lower limb edema and puffiness of the eye
lids. He has no previous history of DM or HTN. Examination reveals BP 140/80,
edema was restricted to the ankles. Chest, heart and abdominal examination
was unremarkable.
Lab tests revealed urine albumin +++, WBC 5-10 cell/mm3, RBC 20-30 cell/mm3,
serum Creatinine 1.5mg/dl, cholesterol 319mg/dl, TG 225mg/dl, HDL 48, LDL
240mg/dl, Hb 12gm/dl. Hepatitis markers were negative so as ANA and anti
DNA. C3 and C4 were not consumed. Renal biopsy was done.
1. What is the likely diagnosis?
2. What is the most likely underlying etiology?
3. Discuss possible measures to reduce proteinuria.
4. Discuss possible pathologic findings.

Answer :
1. The most likely diagnosis is :
o Nephrotic syndrome however 24 hours urinary protein and serum albumin
are needed to confirm diagnosis.
o Data with : The patient presented with proteinuria, edema and
hypercholesterolemia
2. The most likely etiology :
Probably the case is primary (idiopathic ) nephrotic syndrome: WHY?
- Hepatitis markers are negative, so as ANA and anti DNA, this exclude
hepatitis and collagen diseases. ANCA is also needed to exclude vasculitis
which usually has a more stormy presentation.
Mowafy Medical Symphony Nephrology revision

- ASOT and CRP can be done for diagnosis of post streptococcal GN which is
more of nephritic presentation and has reduced C3.
- The patient has no history of DM and this can be confirmed by lab test.
3. Proteinuria reduction will necessitate :
 Reduction of BP to less than 120/70
 Use of ACE inhibitors or angiotensin receptor blockers (ARBs) with or
without non dihydropyridine calcium channel blocker.
 Immunosuppression treatment of the primary nephrotic syndrome
depending on pathologic type.
4. Possible pathological finding are : (proteinuria + hematuria)
o Membrano-proliferative glomerulonephritis, focal sclerosis GN, or
mesangioproliferative GN (IgA nephropathy).
o Hematuria is not a common occurrence with membranous or minimal
change GN.
Mowafy Medical Symphony Nephrology revision

CASE 214
A 19 year-old male was involved in a road traffic accident while diving his
motorbike. He suffered a penetrating wound of his left knee joint. There was no
clinical suggestion of trauma to his kidneys or lower urinary tract, and he
continued to pass urine normally.
Routine urine analysis was unremarkable.
Within 3 days, the left knee joint became swollen, painful and inflamed The
patient was febrile. Pus was aspirated from the knee which grew a penicillin
resistant staphylococcus pyogenes and parenteral methicillin therapy was
commenced. The response to treatment was rapid but, after few days, he
developed a diffuse skin rash, fever and he became oliguric, serum creatinine,
which was 0.7 mg/dl on admission had risen to 5mg/dl.
There was no fluid depletion.
Examination of his fluid balance and blood pressure charts were unremarkable.
The urine contained blood and protein but no myoglobin. Serum potassium was
4.9mm/l, full blood count showed an eosinophilia 10% of a total WBC count of
12.9 x 103/, abdominal sonography demonstrated a normal sized kidneys, with
no evidence of urinary tract obstruction.
1. What is the most likely diagnosis?
2. How should the patient be managed?
Mowafy Medical Symphony Nephrology revision

Answer
1. Most likely diagnosis : Methicillin-induced interstitial nephritis.
2. Management :
o Renal biopsy is indicated to confirm the diagnosis.
o Stop the methicillin.
o If no improvement, then steroids are given at a dose of 1 mg/kg/day.
o If no response occurs in 2 weeks, addition of cyclophosphamide is
considered.
o TTT of ARF : e.g. dialysis may be needed
Mowafy Medical Symphony Nephrology revision

CASE 216
A 35 year old man was noted to be hypertensive but no other abnormality was
revealed. His father had died at the age of 56 from cerebrovascular accident. 2
years later, his blood pressure having been controlled, he experienced several
episodes of painless hematuria unrelated to trauma or infection. There was no
proteinuria.
Examination revealed fullness in both flanks. Over the next 15 years his renal
function deteriorated at a steady rate. The patient recently entered the phase
of terminal renal failure and is currently being integrated into the dialysis and
transplantation program.
1. What is the most probable diagnosis?
2. What anatomical abnormality may have been responsible for the
cerebrovascular accident (CVA) ?
3. What investigation is needed to prove the condition?
4. What are the implications of this disease for his children?

Answer
1. The most likely diagnosis is : Autosomal dominant polycystic kidney (ADPKD)

2. Hemorrhagic cerebrovascular accident (CVA) could have been associated with

an increased incidence of berry aneurysms of the Circle of Willis which is
reported in adult polycystic disease.
Mowafy Medical Symphony Nephrology revision

3. Ultrasonography : It usually identifies the presence of variable sized cysts in

both kidneys and is usually sufficient. Excretory or retrograde urography typically
shows large kidneys with elongated pelvises and flat calyces indented by cysts.
CT and MRI may also be useful.

4. The genetic importance of this condition is that the offspring of the affected
parent will have a 50 % chance of being affected.
These children should have their BP checked and later be screened by
ultrasound. In their early 20s, ultrasound examination usually indicates
involvement or not. By age 30, 90% of ADPKD patients will have cysts detected by
ultrasound.
Mowafy Medical Symphony Nephrology revision

CASE 221
A 45 old male working as executive secretary born and living in Banha city.
He's married, fertile and has no special habits of medical importance. He's
presenting with pyrexia, repeated vomiting and diarrhea. Clinical examination
showed: normal mental functions, toxic pale facies, temperature 38.1°c, B.P.
155/95 mmHg, R.R. 24/minute, diffuse mild tenderness in all abdominal
quadrants with increased intensity of intestinal sounds. Laboratory
investigations revealed: serum creatinine 2.4 mg/dl, eGFR 34 ml/minute, serum
urea 97 mg/dl, serum uric acid 8 mg/dl, serum bicarbonate 11 mmol/L, urine
protein +++, 24 hour urine protein 1.95 gm/dl, hemoglobin concentration is 10.4
g/d and hematocrit value 31%
1. What is the diagnosis? What are the other investigations needed to evaluate
kidneys in this patient?
2. Do you think this patient deserves other therapeutic interventions?
3. Which anti- hypertensive drug do you prefer in this patient?
4. What are the other medications that should be prescribed?
5. What are the targets for your treatment?
Answer
1. The diagnosis is : Chronic kidney disease associated with gastro enteritis.
- Data with : being hypertensive, proteinuria with impaired kidney functions.
associated with attack of gastro enteritis as manifested by fever, vomiting,
diarrhea and tender abdomen.
- Investigations needed to evaluate his kidneys are :
Abdominal U/S (to show: kidney size and echogenicity), doppler of renal arteries
(to show evidence of renal artery stenosis).
Mowafy Medical Symphony Nephrology revision

2. Do you think this patient deserves other therapeutic interventions?

- Yes, since the patient has vomiting and diarrhea that induced some dehydration
& metabolic acidosis, so the patient is in need of fluid replacement to correct
dehydration and oral sodium bicarbonate to keep serum bicarbonate level at 22
mEq/L. Levofloxacin 250 mg daily for GE.

3. Which anti- hypertensive drug do you prefer in this patient?

RAS antagonist as the patient has proteinuria and CKD, RAS blockers decrease
urine protein excretion rate.
But is not indicated if the patient has dehydration. ACE inhibitors and ARBs can
cause further decrease in kidney function in case of dehydration.
4. What are the other medications that should be prescribed?
Oral calcium carbonate to supply calcium and as phosphate binder to be given
immediately before meals, Active vitamin D, S.C. Erythropoietin & iron IV.

5. Targets of treatment:
o B.P. 130/80 mmHg
o Serum Bicarbonate 22 mmol/L
o Serum phosphorus <4.5 mg/dl
o Serum PTH within normal range
o Serum ferritin not exceeding 800 ng/ml, transferrin saturation not
exceeding 40%.
o Hemoglobin concentration 11-12 gm/dl, hematocrit value 33-36%