09.26.08: Course Introduction

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RENAL SEQUENCE 9/26 - 10/13

2008

Fall 2008

Case 1: Tragic Misdiagnosis

25 y.o. female presents complaining of fatigue and mild joint pain. Routine urinalysis with a dipstick shows proteinuria and microscopic hematuria. Diagnosed as cystitis and treated with an antibiotic. 6 months later patient returns with hypertension and edema. Blood tests: Creatinine 10 mg/dl (normal 0.8 - 1.3), BUN 130 mg/dl (normal 10-20), and, on urinalysis, RBC casts. Admitted to hospital and started on dialysis.

Case 1: Tragic Misdiagnosis

25 y.o. female presents complaining of fatigue and mild joint pain. Routine urinalysis with a dipstick showed proteinuria and microscopic hematuria. Diagnosed as cystitis and treated with an antibiotic. 6 months later patient returns with hypertension and edema. Blood tests: Creatinine 10 mg/dl (normal 0.8 - 1.3), BUN 130 mg/dl (normal 10-20), and, on urinalysis, RBC casts. Admitted to hospital and started on dialysis. Dx: SLE with diffuse proliferative glomerulonephritis

Case 2: Problems After a Diagnostic Study

75 yo female (45 kg) complaining of intermittent chest pains is admitted to the hospital for cardiac catheterization. Creatinine is 1.7 mg/dl. Following the study, patient is noted to have decreased urine output, and over the next three days her creatinine progressively increases to 5.5.

Case 2: Problems After a Diagnostic Study

75 yo female (45 kg) complaining of intermittent chest pains is admitted to the hospital for catheterization. Creatinine is 1.7 mg/dl. Following the study, patient is noted to have decreased urine output, and over the next three days her creatinine progressively increases to 5.5. Dx: Contrast-induced acute renal failure in a patient at increased risk because of reduced renal function. Renal function declines with age and at 45 kg she has relatively small muscle mass, lowering creatinine production. The creatinine of 1.7, therefore, represents not a minimally elevated value, but, rather one indicative of substantially decreased baseline glomerular filtration.

Case 3: Life Threatening Hyperkalemia

A 35 y.o. female with 20 year history of Type I diabetes and hypertension is hospitalized for treatment of a cellulitis. Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The intern starts enalapril (angiotensin converting enzyme inhibitor) and atenolol (beta-blocker). Three days later, BP is well-controlled at 115/70, but morning chemistries return with a K+ is 6.8 and EKG shows peaked T waves and widening of the QRS complex. Urgent treatment for hyperkalemia is started.

Case 3: Life Threatening Hyperkalemia

A 35 y.o. female with 20 year history of Type I diabetes and hypertension is hospitalized for treatment of a cellulitis. Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The intern starts enalapril (angiotensin converting enzyme inhibitor) and atenolol (beta-blocker). Three days later, BP is well-controlled at 115/70, but morning chemistries return with a K+ is 6.8 and EKG shows peaked T waves and widening of the QRS complex. Urgent treatment for hyperkalemia is started. Dx: Hyperkalemia secondary to inhibition of aldosterone production by angiotensin converting enzyme inhibitor and shift of potassium out of cells by beta-blocker in the setting of preexisting decrease of kidney clearance function and lack of insulin.

Case 4: A missed treatment opportunity

A 77 y.o. man has a renal scan for assessment of hypertension and a small area of increased tracer uptake is seen in the left upper pole, so he is referred for a CT scan, which shows a small undulation less than 1 cm. in size in the upper left kidney. Repeat CT scan in 6-12 months is recommended but not done. Three years later a repeat CT done to evaluate possible diverticulitis shows a 1.7 cm heterogenously enhancing mass in the posterior left upper kidney and a noncalcified subpleural nodule in the right middle lobe. What is going on?

Case 4: A missed treatment opportunity

A 77 y.o. man has a renal scan for assessment of hypertension and a small area of increased tracer uptake is seen in the left upper pole, so he is referred for a CT scan, which shows a small undulation less than 1 cm. in size in the upper left kidney. Repeat CT scan in 6-12 months is recommended but not done. Three years later a repeat CT done to evaluate possible diverticulitis shows a 1.7 cm heterogenously enhancing mass in the posterior left upper kidney and a noncalcified subpleural nodule in the right middle lobe. What is going on? Dx: The initial lesion was a renal cell carcinoma (hypernephroma), which grew and metastasized to lung in the subsequent three years, changing a completely curable lesion into one with a much poorer prognosis.

12:00 - 1:00 p.m. Mon. 10/6 Tues. 10/7 Wed. 10/8 Thurs. 10/9 This is a patient contact activity, so please dress appropriately and bring a white coat.

DIALYSIS UNIT VISIT SIGNUP: DATE: ________________ 1. ____________________ 2. ____________________ 3. ____________________ 4. ____________________ 5. ____________________ 6. ____________________ 7._____________________ 8. ____________________

•  Syllabus - Power Point format used throughout.

•  Web site - CTools M2 page has all Power Point material from the syllabus as Acrobat PDF files and will have updates and additions.



•  Introduction to Pathology, Urinalysis labs, and Electrolyte problems are web-based teaching exercises available via CTools.



•  Introduction to Pathology, Urinalysis labs, and Electrolyte problems are web-based teaching exercises available via CTools.

•  Grading Quiz – 10/3-10/5 - Fluid and electrolytes only - 30% Attending and submission of answers to small group problem sets on 10/10 - 5% Laboratory practical - 10/10–10/13 - 10% Written final - 10/10–10/13 - 55%

Course Texts (not required) !Renal Physiology, 3rd edition by Bruce M. Koeppen and Bruce A. Stanton, Mosby, 2007

Course Texts (not required) !Renal Physiology, 3rd edition by Bruce M. Koeppen and Bruce A. Stanton, Mosby, 2001 Renal Pathophysiology, The Essentials, 2nd Edition Rennke and Denker, J.B. Lippincott and Co. 2006

Image of the recommended book for the course: Renal

Pathophysiology, The Essentials, 2nd Edition

Rennke and Denker, J.B. Lippincott and Co. 2006

removed

Course Texts (not required) !Renal Physiology, 3rd edition by Bruce M. Koeppen and Bruce A. Stanton, Mosby, 2001 Renal Pathophysiology, The Essentials, 2nd Edition Rennke and Denker, J.B. Lippincott and Co. 2006 Robbins 7th edition Primer on Kidney Diseases, 4rd Edition, National Kidney Foundation, 2005

Kidney Functions !1. Maintenance of body composition - Volume, osmolarity, electrolyte content, and acidity of all body fluids. 2. Excretion and degradation of metabolic end products (e.g. urea), foreign substances (drugs), and hormones (insulin). 3. Production and secretion of enzymes and hormones. - Renin - Erythropoietin - 1,25-Dihydoxyvitamin D3 - Prostanoids

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1. Renal pyramid 2. Interlobar artery

3. Renal artery 4. Renal vein

5. Renal hylum 6. Renal pelvis

7. Ureter 8. Minor calyx

9. Renal capsule

10. Inferior renal capsule

11. Superior renal capsule

12. Interlobar vein 13. Nephron

14. Minor calyx 15. Major calyx

16. Renal papilla 17. Renal column

Piotr Michael Jaworski (Wikipedia)

Gray’s Anatomy

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Faber, Kupin, Krishna, and Narins

Fig 2-3

Image illustrating the

changes of epithelium along the

nephron removed

Regents of University of Michigan

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Image illustrating similarities

between the epithelial cells of the distal tubule

and collecting duct removed

Figure above showing an epithelial cell of Distal Tubule (similar to collecting tubule

epithelial cell)

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Image illustrating the difference between principal cells and

intercalated cells in the collecting duct

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Collecting Duct Source Undetermined

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Patrick Glanz (Wikipedia)

Yassiin Mrabet (Wikipedia)

Newslighter (Flickr)

Image illustrating a

kidney surgical procedure removed

Slide 31: Source Undetermined; Source Undetermined Slide 32: Source Undetermined Slide 33: Source Undetermined Slide 34: Source Undetermined Slide 35: Piotr Michael Jaworski (Wikipedia) http://en.wikipedia.org/wiki/File:KidneyStructures_PioM.svg (Wikipedia), GNU FDL 1.2

http://www.gnu.org/copyleft/fdl.html Slide 36: Gray’s Anatomy Slide 37: Source Undetermined Slide 38: Source Undetermined Slide 39: Faber, Kupin, Krishna, and Narins Slide 41: Regents of University of Michigan, CC: BY-SA-3.0 http://creativecommons.org/licenses/by-sa/3.0/ Slide 42: Source Undetermined; Source Undetermined Slide 43: Source Undetermined Slide 44: Source Undetermined Slide 45: Source Undetermined Slide 46: Source Undetermined Slide 47: Source Undetermined; Source Undetermined Slide 48: Source Undetermined; Source Undetermined; Source Undetermined Slide 49: Source Undetermined; Source Undetermined Slide 50:Yassiin Mrabet (Wikipedia) http://en.wikipedia.org/wiki/File:Hemodialysis-en.svg CC: BY http://creativecommons.org/licenses/by/3.0/ ; Patrick Glanz (Wikipedia) http://en.wikipedia.org/wiki/File:Hemodialysismachine.jpg CC: BY-SA-3.0

http://creativecommons.org/licenses/by-sa/3.0/ Slide 51: Newslighter (Flickr) http://www.flickr.com/photos/newslighter/523392/, CC: BY 2.0 http://creativecommons.org/licenses/by/2.0/deed.en !!! !!!!!!!!!!!!!!!!!!!!!!

!!!!!!!

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09.26.08: Course Introduction