Lange Renal Reading

Question 1

Hyaline casts

Answer 1

Concentrated urine, febrile disease, after strenuous exercise, in the course of
diuretic therapy (not indicative of renal disease)

Question 2

Red cell casts

Answer 2

Glomerulonephritis

Question 3

White cell

casts

Answer 3

Pyelonephritis, interstitial nephritis (indicative of infection or inflammation)

Question 4

Coarse,

granular casts

Answer 4

Nonspecific; can represent acute tubular necrosis

Question 5

Conditions elevating creatinine

Answer 5

Ketoacidosis, cephalothin, cefoxitin, flucytosine - Noncreatinine chromogen

Other drugs: aspirin, cimetidine, probenecid,
trimethoprim - Inhibition of tubular creatinine secretion

Question 6

Conditions decreasing creatinine

Answer 6

Advanced age - Physiologic decrease in muscle mass
Cachexia - Pathologic decrease in muscle mass
Liver disease - Decreased hepatic creatine synthesis and
cachexia

Question 7

Conditions affecting BUN independently of GFR.

Increased BUN

Answer 7

Reduced effective circulating blood volume (prerenal azotemia)
Catabolic states (gastrointestinal bleeding, corticosteroid use)
Highprotein
diets
Tetracycline

Question 8

Conditions affecting BUN independently of GFR.

decreased BUN

Answer 8

Liver disease
Malnutrition
Sickle cell anemia
SIADH

Question 9

Etiology

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 9

Prerenal Azotemia - Poor renal perfusion

Postrenal Azotemia - Obstruction of the urinary tract

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) - Ischemia,
nephrotoxins

Acute Glomerulonephritis - Immune complexmediated, pauciimmune, antiGBM
related

Acute Interstitial Nephritis - Allergic reaction; drug reaction; infection,
collagen vascular disease

Question 10

Serum
BUN:Cr
ratio

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 10

Prerenal Azotemia - > 20:1

Postrenal Azotemia - > 20:1

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) - 20:1

Acute Interstitial Nephritis -

Question 11

UNa (meq/L)

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 11

Prerenal Azotemia - > 20:1

Postrenal Azotemia - variable

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) - > 20:1

Acute Glomerulonephritis -

Question 12

FE (%)

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 12

Prerenal Azotemia -

Question 13

Urine
osmolality
(mosm/kg)

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 13

Prerenal Azotemia - >500

Postrenal Azotemia -

Question 14

Urinary
sediment

Prerenal Azotemia -

Postrenal Azotemia -

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) -

Acute Glomerulonephritis -

Acute Interstitial Nephritis -

Answer 14

Prerenal Azotemia - Benign or hyaline casts

Postrenal Azotemia - Normal or red cells, white cells, or crystals

Intrinsic Renal Disease
Acute Tubular Necrosis Oliguric or Polyuric) - Granular muddy brown) casts, renal tubular casts

Acute Glomerulonephritis - Red cells, dysmorphic red cells and red cell casts

Acute Interstitial Nephritis - White cells, white cell casts, with or without eosinophils

Question 15

Stages of chronic kidney disease 1

Answer 15

Kidney damage with normal or ↑↑ GFR
≥ 90
Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk reduction.

Question 16

Stages of chronic kidney disease 2

Answer 16

Kidney damagewith mildly ↓ GFR
60–89
Estimating progression.

Question 17

Stages of chronic kidney disease 3

Answer 17

Moderately ↓GFR
30–59
Evaluating and treating complications.

Question 18

Stages of chronic kidney disease 4

Answer 18

Severely ↓ GFR
15–29
Preparation for kidney replacement therapy.

Question 19

Stages of chronic kidney disease 5

Answer 19

Endstage-renal disease (ESRD)

Question 20

Primary glomerular diseases

Answer 20

Focal and segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
IgA nephropathy
Membranous nephropathy
Alport syndrome (hereditary nephritis)

Question 21

Secondary glomerular diseases

Answer 21

Diabetic nephropathy
Amyloidosis
Postinfectious glomerulonephritis
HIVassociated
nephropathy
Collagenvascular
diseases (eg, SLE)
HCVassociated
membranoproliferative glomerulonephritis

Question 22

Tubulointerstitial nephritis causes

Answer 22

Drug hypersensitivity
Heavy metals
Analgesic nephropathy
Reflux/chronic pyelonephritis
Sickle cell nephropathy
Idiopathic

Question 23

Cystic diseases

Answer 23

Polycystic kidney disease

Medullary cystic disease

Question 24

Obstructive nephropathies

Answer 24

Prostatic disease
Nephrolithiasis
Retroperitoneal fibrosis/tumor
Congenital

Question 25

Vascular diseases

Answer 25

Hypertensive nephrosclerosis | Renal artery stenosis

Question 26

Symptoms and signs of uremia. General

Answer 26

Symptoms -Fatigue, weakness Signs - Sallowappearing, chronically ill

Question 27

Symptoms and signs of uremia. | skin

Answer 27

Symptoms -Pruritus, easy bruisability Signs - Pallor, ecchymoses, excoriations, edema, xerosis

Question 28

Symptoms and signs of uremia. ent

Answer 28

Symptoms -Metallic taste in mouth, epistaxis Signs - Urinous breath

Question 29

Symptoms and signs of uremia. eye

Answer 29

Symptoms - Signs - Pale conjunctiva

Question 30

Symptoms and signs of uremia. pulmonary

Answer 30

Symptoms -Shortness of breath Signs - Rales, pleural effusion

Question 31

Symptoms and signs of uremia. cardiovascular

Answer 31

Symptoms - Dyspnea on exertion, retrosternal pain on inspiration (pericarditis) Signs - Hypertension, cardiomegaly, friction rub

Question 32

Symptoms and signs of uremia. gastrointestinal

Answer 32

Symptoms - Anorexia, nausea, vomiting, hiccups Signs -

Question 33

Symptoms and signs of uremia. gentiourinary

Answer 33

Symptoms - Nocturia, erectile dysfunction Signs - Isosthenuria

Question 34

Symptoms and signs of uremia. neuromuscular

Answer 34

Symptoms - Restless legs, numbness and cramps in legs Signs -

Question 35

Symptoms and signs of uremia. neurologic

Answer 35

Symptoms - Generalized irritability and inability to concentrate, decreased libido Signs - Stupor, asterixis, myoclonus, peripheral neuropathy

Question 36

Reversible causes of kidney injury. infection

Answer 36

Urine culture and sensitivity tests

Question 37

Reversible causes of kidney injury. obstruction

Answer 37

Bladder catheterization, then renal | ultrasound

Question 38

Reversible causes of kidney injury. Extracellular fluid volume depletion or significant hypotension relative to baseline

Answer 38

Blood pressure and pulse, including | orthostatic pulse

Question 39

Reversible causes of kidney injury. Hypokalemia, hypercalcemia, and hyperuricemia (usually > 15 mg/dL)

Answer 39

Serum electrolytes, calcium, | phosphate, uric acid

Question 40

Reversible causes of kidney injury.nephrotoxic agents

Answer 40

Drug history

Question 41

Reversible causes of kidney injury. severe/urgent hypertension

Answer 41

Blood pressure, chest radiograph

Question 42

Reversible causes of kidney injury. heart failure

Answer 42

Physical examination, chest | radiograph

Question 43

Postinfectious glomerulonephritis

Answer 43

Children: abrupt onset of nephritic syndrome and acute kidney injury but can present anywhere in nephritic spectrum ``` Streptococci, other bacterial infections (eg, staphylococci, endocarditis, shunt infections) ``` Rising ASO titers, low complement levels

Question 44

``` IgA nephropathy (Berger disease) and HenochSchönlein purpura, systemic IgA vasculitis ```

Answer 44

Classically: gross hematuria with per respiratory tract infection; can present anywhere in nephritic spectrum; HenochSchönlein purpura with vasculitic rash and gastrointestinal hemorrhage Abnormal IgA glycosylation in both primary (familial predisposition) and secondary disease (associated with cirrhosis, HIV, celiac disease) HenochSchönlein purpura in children after an inciting infection No serologic tests helpful; complement levels are

Question 45

``` Pauciimmune (granulomatosis with polyangiitis, ChurgStrauss, polyarteritis, idiopathic crescentic glomerulonephritis) ```

Answer 45

``` Classically as crescentic or RPGN, but can present anywhere in nephritic spectrum; may have respiratory tract/sinus symptoms in granulomatosis with polyangiitis ``` See Figure 22–5 ``` ANCAs: MPO or PR3 titers high; complement levels normal ```

Question 46

``` Antiglomerular basement membrane glomerulonephritis; Goodpasture syndrome ```

Answer 46

``` Classically as crescentic or RPGN, but can present anywhere in nephritic spectrum; with pulmonary hemorrhage in Goodpasture syndrome ``` May develop as a result of respiratory irritant exposure (chemicals or tobacco use) ``` AntiGBM antibody titers high; complement levels normal ```

Question 47

Cryoglobulinassociated | glomerulonephritis

Answer 47

Often acute nephritic syndrome; often with systemic vasculitis including rash and arthritis ``` Most commonly associated with chronic hepatitis C; may occur with other chronic infections or some connective tissue diseases ``` ``` Cryoglobulins positive; rheumatoid factor may be elevated; complement levels low ```

Question 48

Idiopathic MPGN

Answer 48

Classically presents with acute nephritic syndrome, but can see nephrotic syndrome features in addition Most patients are

Question 49

Hepatitis C | infection

Answer 49

Anywhere in nephritic spectrum ``` Can cause MPGN pattern of injury or cryoglobulinemic glomerulonephritis; membranous nephropathy pattern of injury uncommon ``` ``` Low complement levels; positive hepatitis C serology; rheumatoid factor may be elevated ```

Question 50

Systemic lupus | erythematosus

Answer 50

Anywhere in nephritic spectrum, depending on pattern/severity of injury ``` Treatment depends on clinical course andInternational Society of Nephrology and Renal Pathology Society (ISN/RPS) classification on biopsy ``` ``` High ANA and antidoublestranded DNA titers; low complement levels ```

Question 51

Minimal change disease (nil disease; lipoid nephrosis)

Answer 51

Child with sudden onset of full nephrotic syndrome Children: associated with allergy or viral infection Adults: associated with Hodgkin disease, NSAIDs

Question 52

Membranous | nephropathy

Answer 52

``` Anywhere in nephrotic spectrum, but nephrotic syndrome not uncommon; particular predisposition to hypercoagulable state ``` Primary (idiopathic) may be associated ``` with antibodies to PLA R Associated with nonHodgkin lymphoma, carcinoma (gastrointestinal, renal, bronchogenic, thyroid), gold therapy, penicillamine, SLE, chronic hepatitis B or C infection ```

Question 53

Focal and segmental | glomerulosclerosis

Answer 53

Anywhere in nephrotic spectrum; children with congenital disease have nephrotic syndrome Children: congenital disease with podocyte gene mutation, or in spectrum of disease with minimal change disease Adults: Associated with heroin abuse, HIV infection, reflux nephropathy, obesity, pamidronate, podocyte protein mutations, APOL1 mutations in blacks

Question 54

Amyloidosis

Answer 54

Anywhere in nephrotic spectrum AL: plasma cell dyscrasia with Ig light chain overproduction and deposition; check SPEP and UPEP AA: serum amyloid protein A overproduction and deposition in response to chronic inflammatory disease (rheumatoid arthritis, inflammatory bowel disease, chronic infection)

Question 55

Diabetic nephropathy

Answer 55

High GFR (hyperfiltration) → microalbuminuria → frank proteinuria → decline in GFR Diabetes diagnosis precedes diagnosis of nephropathy by years

Question 56

HIVassociated | nephropathy

Answer 56

Heavy proteinuria, often nephrotic syndrome, progresses to ESRD relatively quickly Usually seen in antiviral treatmentnaïve patients (rare in HAART era), predilection for those of African descent (APOL1 mutations)

Question 57

Membranoproliferative | glomerulonephropathy

Answer 57

``` Can present with nephrotic syndrome, but usually with nephritic features as well (glomerular hematuria) See Table 22–8 ```

Question 58

Causes of acute tubulointerstitial nephritis Drug reactions Antibiotics

Answer 58

``` Betalactam antibiotics: methicillin, penicillin, ampicillin, cephalosporins Ciprofloxacin Erythromycin Sulfonamides Tetracycline Vancomycin Trimethoprimsulfamethoxazole Ethambutol Rifampin ```

Question 59

Causes of acute tubulointerstitial nephritis Drug reactions NSAIDS

Answer 59

NSAIDS

Question 60

Causes of acute tubulointerstitial nephritis Drug reactions Diuretics

Answer 60

Thiazides | Furosemide

Question 61

Causes of acute tubulointerstitial nephritis Drug reactions Misc

Answer 61

Allopurinol Cimetidine Phenytoin

Question 62

Causes of acute tubulointerstitial nephritis Systemic infections bacteria

Answer 62

Streptococcus Corynebacterium diphtheriae Legionella

Question 63

Causes of acute tubulointerstitial nephritis Systemic infections Viruses

Answer 63

Epstein barr

Question 64

Causes of acute tubulointerstitial nephritis Systemic infections Others

Answer 64

Mycoplasma Rickettsia rickettsii Leptospira icterohaemorrhagiae Toxoplasma

Question 65

Causes of acute tubulointerstitial nephritis | idiopathic

Answer 65

idiopathic

Question 66

``` Causes of acute tubulointerstitial nephritis Tubulointerstitial nephritisuveitis (TIN–U) ```

Answer 66

``` Tubulointerstitial nephritisuveitis (TIN–U) ```

Question 67

Simple renal cysts

Answer 67

``` Prevalence - common inheritance- none age at onset- ... kidney size - normal cyst location - cortex and medulla hematuria - occasional hypertension - none associated complication - none kidney failure - never ```

Question 68

acquired renal cysts

Answer 68

``` Prevalence - dialysis pts inheritance-none age at onset-... kidney size - small cyst location - cortex and medulla hematuria - occasional hypertension - variable associated complication - adenocarcinoma in cysts kidney failure - always ```

Question 69

autosomal dominant polycystic kidney disease

Answer 69

``` Prevalence - 1:1000 inheritance- autosomal dominant age at onset- 20-40 kidney size - large cyst location - cortex and medulla hematuria - common hypertension - common associated complication - urinary tract infections, renal calculi, cerebral aneurysms 10-10%, hepatic cysts 40-60% kidney failure - frequently ```

Question 70

medullary sponge kidney

Answer 70

``` Prevalence - 1:5000 inheritance-none age at onset-40-60 kidney size - normal cyst location - collecting ducts hematuria - rare hypertension - none associated complication - renal calculi, uti kidney failure - never ```

Question 71

medullary cystic kidney

Answer 71

``` Prevalence - rare inheritance-autosomal dominant age at onset- adulthood kidney size - small cyst location - corticomedullary junction hematuria - rare hypertension - none associated complication - polyuria, salt wasting kidney failure - always ```