NEPHROLOGY

URINE
1. Perform dipstick urinalysis whenever you suspect renal disease.
2. Perform ACR or PCR.

Box-1 . Interpretation of ACR.

Interpretation of raised urine ACR

Urine ACR reference range: Less than 3.0

mg/mmol

Urine ACR 3.0 - 30.0 mg/mmol: Moderately

Important.
To detect and identify proteinuria, use urine ACR in preference to protein:creatinine
ratio (PCR), because it has greater sensitivity than PCR for low levels of proteinuria.
For quantification and monitoring of high levels of proteinuria (ACR 70 mg/mmol or
more), PCR can be used as an alternative. ACR is the recommended method for
people with diabetes. Microalbuminuria: Ultra-sensitive dipsticks are now available
to measure microalbuminuria (albumin excretion 30300mg/24h). Causes: DM,
increased BP, minimal change GN.
PCR (protein:creatinine ratio) rather than ACR should be requested in pregnancy
and where non-albumin proteinuria is suspected.

3. List few reasons for increased ACR/PCR.

Box-2. Interpretation of PCR

Interpretation of PCR
Adult reference range: Less than 15 mg/mmol
Paediatric reference range (<18 years of age): Less than 20 mg/mmol
In pregnancy a PCR result of more than 30 mg/mmol indicates
significant proteinuria

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 4. Haematuria The technical terms have been changed. Now it is called
VISIBLE or NON- VISIBLE.
5. NVH is further sub divided to sNVH with LUTS & aNVH.
6. Dipstick fresh urine is more sensitive than MSU.

Important
Patients with one episode of VH , one of sNVH or persistent aNVH require
further assessment.

7. List cases of Haematuria.

8. Imaging: AXR is no longer used for primary assessment of stones, CTKUB is

first choice investigation .NB: Not all women with recurrent UTI + Haematuria
need cystoscopy, but have a good reason not to (Reynards rule)

URINARY TRACT INECTION

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) COHCS p174
9. Definitions:

Bacteriuria:

UTI:

Lower UTI

Upper UTI:

10. Classification

11. Risk factors

12. Organisms

13. Acute pyelonephritis:

14. Symptoms

15. Cystitis

16. Prostatitis

17. Signs

18. Tests

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 19. Causes of Sterile pyruia.

20. Blood tests.

21. Imaging

22. Prevention

URINARY TRACT INECTION- MANAGEMENT

Drink water- Urinate often.

Antibiotics for UTI.

Listen and make a quick notes.

ACUTE KIDNEY INJURY (AKI): DIAGNOSIS & MANAGEMENT

23. KDIGO staging system for AKI

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AKI is defined as any of the following
Increase in SCr by 0.3mg/dl (26.5mol/l) within 48 hours or
Increase in SCr to 1.5 times baseline, which is known or presumed to
have occurred within the prior 7 days; or
Urine volume <0.5ml/kg/h for 6 hours.

Table-1

Stag eGFR Description Qualifier

e (ml/min/1.73 m2 )

1 90 Kidney damage, normal or Kidney damage (presence of structural abnorm

increased GFR and/or persistent haematuria, proteinuria or
microalbuminuria) for 3 months

2 60-89 Kidney damage, mildly

reduced GFR

3A 45-59 Moderately reduced GFR GFR < 60 ml/min for 3 months kidney da
other evidence of kidney
damage
3B 30-44

4 15-29 Severely reduced GFR

other evidence of kidney
damage

5 < 15 Established kidney failure

Stages of chronic kidney disease

Table 2|Staging of AKI

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 Stage Serum creatinine Urine output

1 1.51.9 times baseline OR 0.3mg/dl Less than 0.5ml/kg/h for 6

(26.5mmol/l) increase 12 hours

2 2.02.9 times baseline <0.5ml/kg/h for 12 hours

3 3.0 times baseline OR Increase in serum <0.3ml/kg/h for 24 hours

creatinine to 4.0mg/dl (353.6mmol/l) OR OR Anuria for 12 hours
Initiation of renal replacement therapy OR, In
patients <18 years, decrease in eGFR to
<35ml/min per 1.73 m2

24. Key priorities of implementation.

1. Alports syndrome

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Explanation:

Membranous nephropathy can be idiopathic or secondary to all of the options above except Alports
syndrome. It leads to nephrotic syndrome and is due to deposition on immune complexes in the
subepithelial space.

2.

Bartters syndrome is the most likely diagnosis. It is a combination of juxtaglomerular hyperplasia, hyperaldosteronism and
hypokalaemic, hypochloraemic alkalosis often with hypercalciuria. It is autosomal recessive. There is reduced sodium and chloride
absorption and excessive aldosterone production resulting in the biochemical abnormalities. It can lead to renal stones due to the
hypercalciuria. Type 1 and Type 4 RTA leads to metabolic acidosis. Gitelmans syndrome is similar but presents later and is more
common. There is also hypocalciuria and as opposed to hypercalciuria and hypomagnesaemia. Prolonged QT syndrome can be
seen in Gitelmans syndrome. Liddles syndrome is not associated with high aldosterone although does lead to hypokalaemic,
hypochloraemic alkalosis but no hypercalciuria.

3.The history of numerous UTI and evidence of renal scarring is highly indicative of
vesicoureteric reflux leading to reflux nephropathy.
4- SEE THE NOTES.

5.Polycystic Kidney Disease

This patient is likely to have polycystic kidney disease. It is an autosomal dominant
condition. They can presents cutely as in this case if there is haemorrhage into a
cyst. Chronic loin pain can occur due to the increasing size of the kidney.
Hypertension and symptoms of uraemia can also be the presenting complaint. Now
often it is picked up due to screening if relatives have been affected. Intracranial
aneurysms can be present in about 10% of patients and can lead to intracranial
haemorrhage and death. Hepatic cysts are also common. In medullary sponge
kidney there is not normally a family history and in tuberous sclerosis there is
typically neurological and dermatological manifestations.
A 35 year old male has had loin pain for several months however has never sought
medical help. He now presents with severe loin pain and haemturia. He is found to
be hypertensive and his bloods reveal renal

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6.Painless haematuria is bladder cancer until proven otherwise. The majority are
transitional cell carcinomas. In the developing world the majority are due to
squamous cell carcinoma, due to infection, predominantly with schistosomiasis. Risk
factors include smoking, aromatic amines in dyes, paints, solvents and rubber and
textiles. Cyclophosphamide is thought to be a risk. Patient typical present with
painless haematuria. Renal cell carcinoma can present with loin, pain, abdominal
mass, pyrexia and hypertension. Aspirin is an unlikely cause. There is no other
symptoms suggestive of UTI or renal stones. Cystoscopy is useful for visualisation
and biopsy and therefore diagnosis.

A 28 year old female presents to her GP with joint pain , fever, a butterfly rash and
fatigue. She has marked peripheral oedema. She is found to be hypertensive, in
acute renal failure, low albumin levels and proteinuria. A renal biopsy is performed
and reveals focal glomerulonephritis with subendothelial and mesangial immune
deposits. What is the most likely diagnosis?

Your answer was Lupus nephritis class II which is incorrect

Lupus nephritis Class III correct answer

Lupus nephritis class I
Lupus nephritis class II
Membranous glomeurlonephritis
IgA nephropathy
Explanation:

This patient presents with features of SLE. Lupus nephritis can lead to hypertension,
proteinuria, nephrotic syndrome and renal failure. There is immune complex
deposition and complement activation and can lead to various findings on renal
biopsy. In class I there is minimal change with some mesangial immune deposits
and mild proteinuria. In Class II there is mesangial hypercellularity and mesangial

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immune deposits and presents with mild renal disease. In class III there is focal
lupus nephritis with renal biopsy findings as described. There is normally active SLE
and moderate proteinuria.

A 12 year old boy who has recently been diagnosed with a sensorineural hearing
loss presents with haematuria. He has recently had a cold. He is wearing glasses
and his mother states the optician said he an abnormality of the lens of his eye.
From the following which is the most likely diagnosis?

Your answer was Alport's syndrome which is correct

Alport's syndrome correct answer

Bergers syndrome
Haemolytic Uraemic Syndrome
Bartter's Syndrome
Minimal change disease
Explanation:

Alports syndrome comprises of haematuria, progressive renal failure , sensorineural

hearing loss and ocular abnormalities including perimacular flecks and corneal
ulceration. Anterior lenticonus where there is an abnormal conical or spherical
forward projection of the lens is pathognomonic. Similar to Bergers syndrome there
can be frank haematuria following an URTI. There is persistent microscopic
haematuria. The hearing loss begins late childhood or early adolescence. In alports
syndrome there is a defect of the type IV collagen of the glomerular basement
membrane which results in accumulation of Type V and VI collagen which leads to
basement membrane thickening, impairment of selectivity and glomerulosclerosis
and interstitial fibrosis.

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Which of the following is due to a defect in type IV collagen in the glomerular
basement membrane?
Your answer was Bergers Syndrome which is incorrect
Alport's Syndrome correct answer
Bergers Syndrome
Bartters syndrome
Goodpastures syndrome
Liddles syndrome
Explanation:

A patient is found to have cystine renal stones. What is the most likely cause of
this?

Your answer was Cystinuria which is correct

Cystinuria correct answer

Cystinosis
Furosemide abuse
Poor water intake
Calciuria
Explanation:

Cystinuria is whereby the glomerulus fails to reabsorb cystine, ornithine, lysine and
arginine. It is an autosomal recessive disorder which leads to kidney stone, pain,
haematuria, obstruction and sometimes renal failure. The renal stones are often
multiple or staghorn. It is important to encourage high fluid intake, over 3 litres per
day, dietary restrictions and urinary alkalinisation with potassium citrate may be
useful. IF these measures fail then captopril or penicillamine (reduces cystine
excretion) may be utilised. Cystinosis is a lysosomal disorder and a common cause
of Fanconi syndrome.

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In Fanconis syndrome there is a type 2 renal tubular acidosis along with
aminoaciduria, glycosuria and phosphaturia. Which of the following is also a
presenting feature of fanconis syndrome?

Your answer was Osteomalacia which is correct

Osteomalacia correct answer

Anaemia
Thrombocytopenia
Mental retardation
Fatigue
Explanation:

Due to the loss of excessive calcium and phosphate and a defect in the
hydroxylation of 25 hydroxyvitamin D. Osteomalacia is a common presenting
feature in adults.

6.Retroperitoneal fibrosis is rare. It is characterised by fibro inflammatory tissue

around the aorta and iliac arteries, into the retroperitoneum and surrounding other
structures such as the ureters. It is thought to be an autoimmune process to
insoluble lipid leaking from atherosclerotic plaques. This can lead to an obstructive
uropathy as seen here. In the majority there is no clear underlying cause found
however t has been associated with aortic aneurysm, renal tract trauma, infection,
retroperitoneal malignancy, post irradiation and chemotherapy and with certain
drugs such as methysergide, beta blockers, methyldopa and amphetamines. It has
also been associated with certain autoimmune disease and vasculitis such as PBC,
Rheumatoid arthritis, SLE and polyarteritis nodosa. Lymphomas, sarcoma ,
pancreatic carcinomas and other malignancies can also lead to similar appearances
to it on ultrasound and these are therefore differentials. However in this case the
previous radiation therapy is a clue and MRI can be utilised to assess further the
degree of fibrosis. A biopsy may be required if the other differentials cannot be
excluded. Intravenous urography is useful in assessing the degree of ureteric
obstruction. Removal of the offending agent, steroids, immunosuppressants and
ureterolysis and ureteric stent placement for obstruction have all been utilised in
the management.

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7. Cystinuria is whereby the glomerulus fails to reabsorb cystine, ornithine, lysine
and arginine. It is an autosomal recessive disorder which leads to kidney stone,
pain, haematuria, obstruction and sometimes renal failure. The renal stones are
often multiple or staghorn. It is important to encourage high fluid intake, over 3
litres per day, dietary restrictions and urinary alkalinisation with potassium citrate
may be useful. IF these measures fail then captopril or penicillamine (reduces
cystine excretion) may be utilised. Cystinosis is a lysosomal disorder and a common
cause of Fanconi syndrome.
8. Painless haematuria is bladder cancer until proven otherwise. The majority are
transitional cell carcinomas. In the developing world the majority are due to
squamous cell carcinoma, due to chronic infection, predominantly with
schistosomiasis. Risk factors include smoking, aromatic amines in dyes, paints,
solvents and rubber and textiles. Cyclophosphamide is thought to be a risk. Patient
typical present with painless haematuria. Renal cell carcinoma can present with loin,
pain, abdominal mass, pyrexia and hypertension. Aspirin is an unlikely cause. There
is no other symptoms suggestive of UTI or renal stones. Cystoscopy is useful for
visualisation and biopsy and therefore diagnosis.
9. In hyperkalaemia of over 6.5 mmol/L and with associated ECG changes then 10%
calcium gluconate should be given. This is cardioprotective although does not lower
the potassium. Insulin dextrose and salbutamol nebulisers should be utilised for the
treatment of hyperkalaemia as both drive potassium into cells. Calcium resonium is
not useful in the acute setting. Sodium bicarbonate would be to correct metabolic
acidosis and therefore improve hyperkalaemia however this should only be used by
specialists. Depending on he cause of renal failure, this should be treated e.g. if pre
renal then IV fluids. Dialysis may be required ultimately.

10. Erythropoietin is produced by the renal peritubular cells in the cortex. EPO
improves red cell survival and promotes development of precursor cells. It is useful
in the management of anaemia secondary to chronic renal failure. It can lead to
hypertension, hyperviscosity and thus increased risk of thrombosis and rarely lead
to encephalopathy.

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