USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD

Premier Review
USMLE Step 3 Video Review Course

Nephrology
Part 1 of 3

N .D. Agrawal, MD

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USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD
Urine Cast:
Tam Horsefall proteins are secreted by thick ascending loop and make Hyaline cast, it is a normal finding
Muddy brown granular cast- ATN
RBC cast, dysmorphic RBC- Glomerulonephritis
WBC, Granular cast- Interstitial nephritis, Acute Pyelonephritis
Oval or round fat droplets (In polarized light have maltese cross appearance)- Proteinuria

Waxy cast or Broad cast- Chronic kidney disease

Acute Renal Failure
Pre-Renal
Intra-Renal
Post Renal or Obstructive Uropathy
Post Renal
Elderly: mostly secondary to Prostate enlargement in male

Pelvic tumor, Ca cervix in female

Young adults- stone
Children- urethral valve, urethral stenosis, stenosis of vesico-ureteral junction
Post void residual>200ml- highly suspicious
Test of choice- Renal ultrasound- dilated bladder, ureter, calyceal system (hydronephrosis)
Ultrasound ve no obstruction
Ultrasound +ve look for the cause
If no obvious cause- do IVP, Retrograde pylography, Lasix renogram
Treatment: Lower tract obstruction- Foleys catheter
Upper tract obstruction- Ureteral stent or percutaneous nephrostomy
Once obstruction is relieved massive diuresis can occur- T/t- IVF 75cc/hr

BUN/Creatinine
Urine sodium
FENa

Pre-Renal
>20:1
<10
<1

Renal
<20:1
>20
>1

Pre-Renal
Secondary to poor renal perfusion
Causes:
Dehydration
Peripheral vasodilatation eg. Sepsis
Low cardiac output
GI bleeding
Excess diuresis
T/t: IVF
Intra-Renal
Acute tubular necrosis (ATN)
Muddy Brown Cast
FENa >1%
Urine Na >20
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USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD
Causes:
Ischemia- Dehydration, GI bleed-usually patients are oliguric
Toxin- Aminoglycoside, Ampho B, Radiocontrast, Myoglobinuria secondary to Rhabdomyolysis
Aminoglycoside and radio contrast cause non oliguric ARF
Contrast nephropathy typically begins immediately after the study, renal function starts recovering after 3-5
days
Aminoglycoside nephrotoxicity begins at least after 5 days of treatment
Prevention of contrast nephropathy Hydration, normal saline 75cc/hr 8-12 hr before and after the study.
Acetylcystein-600mg BID for 2 days in high risk patient eg. Pt. with diabetes, CHF, CRI
Rhabdomyolysis causing ARF
Cause:
Prolonged immobilization- Comatose patient or after prolonged surgery in one position e.g. elderly hip
fracture reduction.
Crush injury
Seizure
Patient struggling against restraints
Cocaine or other drug induced agitation
Extreme exertion
Neuroleptic Malignant syndrome
Labs: CPK, urine- blood+++, but microscopy- No RBC
Treatment: IVF, IV Sodium bicarbonate to alkalinize urine to solubilize myoglobin
Mannitol or forced diuresis
Tumor Lysis syndrome
Secondary to chemotherapy for malignancy, usually Burkitts lymphoma, Leukemia
ARF, hyperkalemia, Hyperphosphatemia, hypocalcemia, Uric acid
Treatment; Hemodialysis
Prevention: Allopurinol prior to chemotherapy, IVF+ sod.Bicarb to alkalinize urine which increases
solubility of uric acid
Acute interstitial nephritis
ARF + Fever + rash + arthralgia + Peripheral blood eosinophilia
Urine- WBC cast +ve, eosinophil +ve (Wrights stain)
Cause: Penicillin, Sulfonamide, NSAID (Including COX-2 inhibitors), Rifampin, Allopurinol, Indinavir, 5aminosalicylates, Proton Pump Inhibitors
Treatment: stop drug +Prednisone (can be prescribed)
Note: In NSAID induced acute interstitial nephritis typical features-Fever, rash, eosinophilia, eosinophiluria are
usually absent. Features like ARF, Increased WBC in urine, WBC cast and h/o use of NSAID should be there.
Papillary necrosis
Causes
Analgesic abuse
Diabetes
Sickle cell anemia
Obstructive uropathy
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USMLE Step 3 Video Review Course

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Nephrology
N. D. Agrawal, MD
Labs: CT abdomen without contrast is study of choice
IVP-Ring shadow at papillary tip
Indication of hemodialysis
Hyperkalemia, metabolic acidosis (refractory to medical treatment)
Symptoms of uremia: abdominal pain, nausea, vomiting, anorexia, Asterixis, seizure, uremic pericarditis
Volume overload-Refractory to diuretics
Athero-embolic renal disease (Cholesterol emboli)
Another cause of ARF
Usually elderly patient with severe atherosclerosis went for angioplasty or angiography or vascular surgeryabout 3-4 weeks before (mostly subacute presentation)
ARF +cyanosis or gangrene in the toes, although peripheral pulses are intact + livedo reticularis
Lab finding hypocomplementemia, eosinophilia, urine eosinophil
If diagnosis in doubt- biopsy of skin lesion or kidney.
Treatment-supportive, no role of anticoagulation
Clot emboli causing Acute Renal Failure
Patient with history of A. Fibrillation comes with c/o acute onset of flank pain, nausea, vomiting and acute renal
failure
Confirm with Radioisotope Renogram (Study of choice) or Doppler ultrasound of renal arteries
Treatment: Heparin followed by coumadin
Glomerulonephritis
C/F: Hematuria, proteinuria, hypertension
Causes:
IgA nephropathy
Post - streptococcal GN
Wegener's granulomatosis
Good Pasture syndrome
Endocarditis

Lupus Nephritis
IgA nephropathy
History of upper respiratory tract infection, 1-2 days before presentation + Hematuria
Usually history of recurrent Hematuria following URI or exertion (after playing with children)
U/A- RBC + RBC cast or dysmorphic RBC + Protein
Other labs: in 50% Serum IgA increased, so normal IgA does not rule the diagnosis.
Normal complement level
To confirm renal biopsy
Treatment:
ACE inhibitor+ARB (Angiotensin II receptor blocker)
Fish Oil (Add if there is continued gradual deterioration despite ACE inhibitor/ARB)
Prednisone (Add if progressively active disease despite ACE inhibitor/ARB/Fish oil or severe disease to
begin with, like Nephrotic syndrome/ markedly proliferative disease on biopsy)

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USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD
Post - streptococcal GN
History of URI 7-10 days before the presentation + Hematuria
Labs:
U/A- RBC + RBC cast or dysmorphic RBC + Protein
ASO titer
Low serum complement
Treatment:
Supportive
Almost 100% children will recover.
<5% adults will develop chronic renal failure
Wegener's granulomatosis
History of upper respiratory tract involvement (sinusitis or persistent rhinorrhea or bloody nasal discharge)
+ Lower respiratory tract symptoms (cough, shortness of breath, hemoptysis)
Chest X-ray- diffuse opacity or alveolar opacity or nodular lesion with cavity.
+ Hematuria, proteinuria
+ renal failure
+ cANCA +ve
U/A- RBC, RBC cast or dysmorphic RBC
Confirm with biopsy of nasopharyngeal lesion ( preferable)
If there is no nasopharyngeal lesiondo renal biopsy( shows crescentic necrotizing GN)
Treatment: Corticosteroid + Cyclophosphamide
Good Pasture syndrome
History of hemoptysis + Hematuria , proteinuria + renal failure
+anti-GBM antibody +ve
U/A- RBC, RBC cast or dysmorphic RBC
Treatment: Plasmapheresis +prednisone + Cyclophosphamide
Endocarditis
Presents with fever, peripheral signs of arterial emboli due to endocarditis.
C/O- flank pain, Hematuria
Labs: U/A- RBC, RBC cast
Hypocomplementemia
Renal failure
Lupus Nephritis:
Six types
Type I- Minimal mesangial
Type II- Mesangial proliferative
Type III- Focal proliferative
Type IV- Diffuse proliferative
Type V- Membranous
Type VI- Advance sclerosis
Prognosis is worst in Type IV.
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USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD
Treatment:
Type I & II- No specific treatment, Just treat lupus
Type III If < 40% glomeruli involved, only Prednisone.
> 40% involved- Treat like Type IV.
Type IV Intravenous pulse Cyclophosphamide- Monthly X 6 dose.
Intravenous pulse Methylprednisone 1gm daily X 3 dose then monthly X 6 dose
Type V Non nephrotic proteinuria- only Prednisone
Nephrotic Proteinuria- Cyclosporine oral + Oral prednisone
Patients on Cyclophosphamide, should get:
Trimethoprim- Sulfamethoxazole Prophylaxis for PCP
IV hydration and MESNA- During infusion to prevent hemorrhagic cystitis and bladder cancer
Leuprolide (in women of child bearing age)- To prevent ovarian failure.
Patient on long term high dose steroid should get:
H2 Blocker or Proton Pump inhibitor- To prevent gastritis
Calcium and Vitamin D or Biphosphonate To prevent osteoporosis
Nystatin (Swish and swallow )- To prevent oropharyngeal candidiasis.
Nephrotic syndrome
C/F: Proteinuria >3.5gm/24h, Edema, Hypoalbuminemia, Hyperlipidemia
These pt. also have hypercoagulable state secondary to loss of anti-thrombin III in urine
Causes:
Renal:
Minimal Change Disease
Membranous Nephropathy
Focal segmental glomerular sclerosis
Systemic disease:
Systemic lupus Erythematosus
Diabetes
Amyloidosis
Minimal Change Disease
Most common cause of Nephrotic syndrome in children
Causes: Mostly idiopathic, Hodgkins disease, NSAID
Renal biopsy: on electron microscopy- fusion of epithelial foot processes are characteristic finding
Renal biopsy is a must in adults to diagnose minimal change disease but in children due to very high
prevalence empiric trial of corticosteroid is recommended and biopsy is done only in resistant cases
Treatment: Prednisone Relapse Again Prednisone
Frequent relapses: Cyclophosphamide
Membranous nephropathy
Most common cause of Nephrotic syndrome in adults
Causes: Idiopathic, Carcinoma, Hepatitis B, Hepatitis C, Systemic lupus erythematosus, Drugs-Gold,
Penicillamine, Captopril
Treatment: Prednisone
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USMLE Step 3 Video Review Course

Part 1 of 3
Nephrology
N. D. Agrawal, MD
Focal Segmental Glomerular Sclerosis
Most common cause of Nephrotic syndrome in blacks, obese patients, IVDA, heroin abuse, HIV
Treatment: Prednisone
Mild proteinuria: May be Functional or Orthostatic
24 hour urine < 150mg / 24 hour is normal
Functional proteinuria: due to fever, stress, congestive heart failure or any other acute illness. If patient was
acutely sick at the time of urine collection, repeat the test after the acute event is over.
Orthostatic proteinuria: proteinuria at upright position, usually history of athlete with proteinuria. Take
morning spot sample of urine for protein and Creatinine or split urine collection of 16 hour (day time) and 8
hour (night)
CCS:
Patient with significant bilateral leg edema, facial swelling, may have anasarca
If has anasarca or crackels in lung field admit the patient and use IV furosemide otherwise manage as
outpatient with oral furosemide.
Labs: CBC, CHEM 8, PT/PTT, Liver function test, Lipid profile, Urine analysis, chest x-ray, EKG 12 lead
Order: Furosemide (oral if sending home, IV if admitting the patient)
Result: Urine analysis: Protein 3+, low albumin, increased cholesterol
Order: 24 hour urine for protein and creatinine, ANA, C3, C4, Hepatitis B Surface antigen, Hepatitis B
Surface antibody, Hepatitis C antibody, HIV, Renal ultrasound, start simvastatin, oral
Follow up results: Nephrotic range proteinuria
Order: Kidney biopsy
Result: Membranous Nephropathy
Order: PPD, Age appropriate cancer screening
Follow up results: Everything is normal:
Order: Prednisone, oral, continuous; Pantoprazole, oral; Nystatin, swish and swallow; Calcium, oral;
vitamin D, oral.

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