nephrotoxicity and acid base balance

TOP 10 NEPHRO SLIDES IN TOP 10 NEPHRO SLIDES IN EACH BOARD EXAM EVERY EACH BOARD EXAM EVERY

YEARYEAR

BOARD EXAM SLIDESBOARD EXAM SLIDES

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

WHAT IS THIS ?WHAT IS THIS ?

COMMONEST NEPHRO CASES COMMONEST NEPHRO CASES IN BOARD EXAM – TRICKS AND IN BOARD EXAM – TRICKS AND CLUESCLUES• MOST OF THE CASES CONTAIN ONE MOST OF THE CASES CONTAIN ONE

SINGLE OUTSTANDING CLUE THAT SINGLE OUTSTANDING CLUE THAT CAN GIVE YOU THE DIAGNOSIS --- CAN GIVE YOU THE DIAGNOSIS ---

• LOOK FOR THAT CLUELOOK FOR THAT CLUE

• THIS IS THE M-KASAP TYPE OF THIS IS THE M-KASAP TYPE OF QUESTIONSQUESTIONS

CASE-1CASE-1

• 72 OLD MALE DIABETIC ON INSULINE 72 OLD MALE DIABETIC ON INSULINE HAD CHEST PAIN AND WENT FOR HAD CHEST PAIN AND WENT FOR CARDIAC CATH .AFTER SECOND DAY CARDIAC CATH .AFTER SECOND DAY HIS CREATININE WENT UP TO 300 HIS CREATININE WENT UP TO 300 FROM BASE LINE BEFORE CATH 90.FROM BASE LINE BEFORE CATH 90.

• HIS LABS SHOW;HIS LABS SHOW;• CBC; WBC 4500,HB 11.5,PLAT 200 CBC; WBC 4500,HB 11.5,PLAT 200

THOUSANDSTHOUSANDS

BUN 23, CR 300,NA 138,K 5.8BUN 23, CR 300,NA 138,K 5.8LDH 400,AST 60,ALT 40LDH 400,AST 60,ALT 40

UA +BLOOD,UA +BLOOD,+PROTIEN,TOTAL 24 HRS +PROTIEN,TOTAL 24 HRS

COLLECTION 1GMCOLLECTION 1GMC 3 LOW,C 4 LOW,ESR 90C 3 LOW,C 4 LOW,ESR 90

THE MOST LIKELY DX IS :THE MOST LIKELY DX IS :

• A. CHOLESTEROL EMBOLISATIONA. CHOLESTEROL EMBOLISATION

• B. CONTRAST NEPHROPATHYB. CONTRAST NEPHROPATHY

• C. SLE-DIFFUSE PROLIF GNC. SLE-DIFFUSE PROLIF GN

• D. SLE-FOCAL PROLIF GND. SLE-FOCAL PROLIF GN

• E. RENAL ARTERY STENOSIS WITH E. RENAL ARTERY STENOSIS WITH ISHEMIA INDUSED BY ANGIOGRAMISHEMIA INDUSED BY ANGIOGRAM

CORRECT ANSWER IS ACORRECT ANSWER IS A

• CHOLESTEROL EMBOLISATATIONCHOLESTEROL EMBOLISATATION

• ONE OF THE MOST AND TOP ONE OF THE MOST AND TOP QUESTIONS IN ARAB-SAUDI-QUESTIONS IN ARAB-SAUDI-AMERICAN BOARD EXAMSAMERICAN BOARD EXAMS

• SIMPLY EXAMINERS THEY LOVE IT !!!SIMPLY EXAMINERS THEY LOVE IT !!!

I TOLD U LOOK FOR THE I TOLD U LOOK FOR THE CLUE!!CLUE!!WHERE IS THE CLUE HERE ?WHERE IS THE CLUE HERE ?• THE CLUE IS THE TIME OF INCREASE THE CLUE IS THE TIME OF INCREASE

IN CR WHICH IS AFTER 48 HRSIN CR WHICH IS AFTER 48 HRS

• CONTRAST GIVE U INCREASE CR CONTRAST GIVE U INCREASE CR WITHIN FIRST 24 HRS OF THE ANGIO WITHIN FIRST 24 HRS OF THE ANGIO BUT CE THE RISE IS AFTER 48 HRSBUT CE THE RISE IS AFTER 48 HRS

• OTHER CLUES LOW OTHER CLUES LOW COMPLEMENTS,AND HIGH ESRCOMPLEMENTS,AND HIGH ESR

CE-CASECE-CASE

• ESINOPHILLIAESINOPHILLIA

• DIGITAL INFARCTSDIGITAL INFARCTS

• LIVEDO RETICULARISLIVEDO RETICULARIS

• RETINAL EMBOLI AND HEMORRHAGESRETINAL EMBOLI AND HEMORRHAGES

• RISK INCREASED BY HEPARINERISK INCREASED BY HEPARINE

• AS CTDAS CTD

• PROGNOSIS GRAVE ( NO SINGLE CASE HAS PROGNOSIS GRAVE ( NO SINGLE CASE HAS BEEN RECOVEREDBEEN RECOVERED

Cr timingCr timing

• Cr increase in contrast within first 24 hrsCr increase in contrast within first 24 hrs

• Cr increase in embolisation after 24-72 hrsCr increase in embolisation after 24-72 hrs

• Cr increase in gentamycine after 7-10 dysCr increase in gentamycine after 7-10 dys

CASE-2CASE-2

• 65 OLD MALE DIABETIC FOR 15 YRS 65 OLD MALE DIABETIC FOR 15 YRS ON INSULINE PRESENTED WITH ON INSULINE PRESENTED WITH INCREASE CR FOR THE LAST 6 INCREASE CR FOR THE LAST 6 MONTHS ,HAS HX OF IHD 1 YEAR MONTHS ,HAS HX OF IHD 1 YEAR AGO,PRESENTED WITH PULMONARY AGO,PRESENTED WITH PULMONARY EDEMA,HIS DRUG HX INCLUDE AMLOR EDEMA,HIS DRUG HX INCLUDE AMLOR 10 MG,ISORDIL,CLONIDINE,AND 10 MG,ISORDIL,CLONIDINE,AND ZESTRIL 20 MG,AND RECENTLTY ZESTRIL 20 MG,AND RECENTLTY START TAKING NSAID . HIS V/S IN ER;START TAKING NSAID . HIS V/S IN ER;

HR 110 REGULAR,BP HR 110 REGULAR,BP 185/95,T 37185/95,T 37

CBC; WBC 5000,HB11,PLAT CBC; WBC 5000,HB11,PLAT 180,000180,000

CR 300 AND 2 MONTHS AGO CR 300 AND 2 MONTHS AGO WAS 150,BUN 27,NA 136,K WAS 150,BUN 27,NA 136,K

2.8,HCO3 202.8,HCO3 20LFT NORMALLFT NORMAL

UA ++ PROTIEN,RBS 5-10 UA ++ PROTIEN,RBS 5-10 ECHO ; EF 55 %ECHO ; EF 55 %

THE MOST LIKELY CAUSE OF THE MOST LIKELY CAUSE OF HIS RENAL DETORIATION IS;HIS RENAL DETORIATION IS;

• A. HYPERTENSIVE A. HYPERTENSIVE GLOMERULOSCELEROSISGLOMERULOSCELEROSIS

• B.NSAID NEPHROPATHYB.NSAID NEPHROPATHY

• C.RASC.RAS

• D.ACE INHIBITORD.ACE INHIBITOR

• E. B AND DE. B AND D

RAS-VERY COMMON QUESTION RAS-VERY COMMON QUESTION IN BOARD EXAMS-THE CLUEIN BOARD EXAMS-THE CLUE

• PATIENT ON 3 DRUGS ( RESISTANT PATIENT ON 3 DRUGS ( RESISTANT HYPERTENTION )HYPERTENTION )

• DIABETIC AND IHD(ATHEROSCELEROSISDIABETIC AND IHD(ATHEROSCELEROSIS• ACE CAN CAUSE RENAL DETORIATIONACE CAN CAUSE RENAL DETORIATION• FLASH PUL EDEMA IN A PATIENT WITH FLASH PUL EDEMA IN A PATIENT WITH

NORMAL HEART (NORMAL EF ) AND NORMAL HEART (NORMAL EF ) AND HYPERTENSIVE IS ALMOST ALWAYS HYPERTENSIVE IS ALMOST ALWAYS DIAGNOSTIC OF RASDIAGNOSTIC OF RAS

• MOST IMPORTANT IS HYPOKALEMIAMOST IMPORTANT IS HYPOKALEMIA

NSAID CAUSE HYPERKALEMIANSAID CAUSE HYPERKALEMIAREMEMBER THAT !!!!!!!REMEMBER THAT !!!!!!!ACE INHIBITOR CAUSE ACE INHIBITOR CAUSE HYPERKALEMIA-ALSO HYPERKALEMIA-ALSO

REMEMBER THAT.REMEMBER THAT.

RAS-GOLDEN POINTS IN RAS-GOLDEN POINTS IN BOARD EXAMS-IF U KNOW IT U BOARD EXAMS-IF U KNOW IT U WILL NOT MISS THE ANSWER:WILL NOT MISS THE ANSWER:• FIRST RULE IS THE CLASSIC SETTING;FIRST RULE IS THE CLASSIC SETTING;• ELDERLY,ATHEROSCELEROTIC,IHD,PVD,OELDERLY,ATHEROSCELEROTIC,IHD,PVD,O

N THREE OR MORE ANTIHYPERTENSIVESN THREE OR MORE ANTIHYPERTENSIVES• ACE CAUSE DETORIA OF RENAL FUNCTIOACE CAUSE DETORIA OF RENAL FUNCTIO• HYPOKALEMIA,HIGH BP,ABD BRUITEHYPOKALEMIA,HIGH BP,ABD BRUITE• IN YOUNG FEMALES ABOVE SIGNS ARE IN YOUNG FEMALES ABOVE SIGNS ARE

ABSENT EXCEPT BRUITE AND HIGH BP ABSENT EXCEPT BRUITE AND HIGH BP AND THE CAUSE IS FMDAND THE CAUSE IS FMD

All the follwing are true of All the follwing are true of preclampcia EXCEPT :preclampcia EXCEPT :

• A. high uric acidA. high uric acid

• B. high CrB. high Cr

• C. no urine RBC castsC. no urine RBC casts

• D. high urine calciumD. high urine calcium

• E. high urine protienE. high urine protien

36 yrs female known case of 36 yrs female known case of SLE want to become pregnant, SLE want to become pregnant, what would u advice her ?what would u advice her ?• A. the single most important is Cr level A. the single most important is Cr level

at the time of conceptionat the time of conception

• B.the single most important is disease B.the single most important is disease activity level at conceptionactivity level at conception

• C.the single most imprtant is C.the single most imprtant is protienureaprotienurea

• D.A AND BD.A AND B

• E.B AND CE.B AND C

What is the single most What is the single most important labs finding to important labs finding to diffrenciate between diffrenciate between preeclamcia and SLE during preeclamcia and SLE during pregnancy?pregnancy?

25 OLD MALE COCCAINE 25 OLD MALE COCCAINE ABUSER PRESENTED TO ER ABUSER PRESENTED TO ER WITH :WITH :• VOMITING,HYPERTENTION,AND FEVER VOMITING,HYPERTENTION,AND FEVER

WITH DECREASE URINE OUTPUTWITH DECREASE URINE OUTPUT

• O/E BP 170 / 98 T 38 O/E BP 170 / 98 T 38

• CVS S1,S2 NORMAL WITH ESMCVS S1,S2 NORMAL WITH ESM

• LUNGS CLEAR,ABD NO LUNGS CLEAR,ABD NO ORGANOMEGALYORGANOMEGALY

• HX OF CHANGE OF URINE COLOURHX OF CHANGE OF URINE COLOUR

LABSLABS

• CBC WBC 7,PLAT 230,Hb 10.6CBC WBC 7,PLAT 230,Hb 10.6

• LFT NORMALLFT NORMAL

• Cr 600 AND ONE MONTH AGO WAS 78Cr 600 AND ONE MONTH AGO WAS 78

• Na 137, K 6.8,Ca 1.2,Ph 1.9Na 137, K 6.8,Ca 1.2,Ph 1.9

• Uric Acid 600Uric Acid 600

• UA POSITIVE FOR BLOOD +++ ON UA POSITIVE FOR BLOOD +++ ON DIPSTICK,PROT +,RBC 1-5DIPSTICK,PROT +,RBC 1-5

THE MOST LIKELY DX:THE MOST LIKELY DX:

• A. RHABDOMYOLYSISA. RHABDOMYOLYSIS

• B. SBEB. SBE

• C.TUMOR LYSIS SYNDROMEC.TUMOR LYSIS SYNDROME

• D.POST INF GND.POST INF GN

• E.POLYARTERITIS NODOSAE.POLYARTERITIS NODOSA

RHABDOMYOLYSIS-THINS IN RHABDOMYOLYSIS-THINS IN EXAM TO REMEMBEREXAM TO REMEMBER

• THE COMMONEST CAUSE IS TRUMA-THE COMMONEST CAUSE IS TRUMA-SOLDIER SYNDROMESOLDIER SYNDROME

• THE COMMONEST DRUG IS COCCAINETHE COMMONEST DRUG IS COCCAINE

• OTHER DRUGS HMG-COENZ-RED-OTHER DRUGS HMG-COENZ-RED-INHIBITORS AS STATINSINHIBITORS AS STATINS

• THE SINGLE MOST IMPORTANT STEP THE SINGLE MOST IMPORTANT STEP IN MANAG IS IVF AND IVF AND IVFIN MANAG IS IVF AND IVF AND IVF

COMMONEST MCQ IN EXAMS-COMMONEST MCQ IN EXAMS-GNGN

• 54 YRS MALE PRESENTED WITH 54 YRS MALE PRESENTED WITH WEAKNESS,DIAZINESS, FOR 4 MONTHSWEAKNESS,DIAZINESS, FOR 4 MONTHS

• CBS HB 8GM,WBC 5,PLAT 230CBS HB 8GM,WBC 5,PLAT 230

• LFT Na 137,K 6,Ca 2.6,LFT Na 137,K 6,Ca 2.6,

• U/A DIPSTICK PROTIEN +,BLOOD –U/A DIPSTICK PROTIEN +,BLOOD –

• MICROSCOPY NO RBC CASTSMICROSCOPY NO RBC CASTS

• TOTAL 24 HRS PROTIEN 8 GMTOTAL 24 HRS PROTIEN 8 GM

RENAL BX;RENAL BX;

THE MOST LIKELY DX IS ;THE MOST LIKELY DX IS ;

• A.AMYLOIDOSISA.AMYLOIDOSIS

• B.MYELOMA KIDNEYB.MYELOMA KIDNEY

• C.MEMRANOUS GNC.MEMRANOUS GN

• D.FSGSD.FSGS

• E.MINIMAL CHANGE DISEASEE.MINIMAL CHANGE DISEASE

MYELOMA KIDNEY-EXAM MYELOMA KIDNEY-EXAM FAVOURITE FAVOURITE

• THE MOST IMPORTANT CLUE IN EXAM THE MOST IMPORTANT CLUE IN EXAM IS DIPSTICK URINE NEGATIVE FOR IS DIPSTICK URINE NEGATIVE FOR PROTIEN OR MILD + POSITIVE BUT PROTIEN OR MILD + POSITIVE BUT THE 24 HRS URINE COLLECTION FOR THE 24 HRS URINE COLLECTION FOR PROTIEN IS MORE THAN 3 GM. WHY ?PROTIEN IS MORE THAN 3 GM. WHY ?

• LARGE KIDNEY. WHAT OTHER LARGE KIDNEY. WHAT OTHER CAUSES OF LARGE KIDNEY ????CAUSES OF LARGE KIDNEY ????

TWO TYPES OF MYELOMA TWO TYPES OF MYELOMA KIDNEYKIDNEY

• A. TUBULAR WITH LIGHT CHAIN A. TUBULAR WITH LIGHT CHAIN DEPOSITION AND GIVE U FRACTURED DEPOSITION AND GIVE U FRACTURED CAST DIAGNOSTIC OF MM.THIS TYPE CAST DIAGNOSTIC OF MM.THIS TYPE HAS GOOD PROGNOSISHAS GOOD PROGNOSIS

• B.LDD-CHARACTERISED BY NODULAR B.LDD-CHARACTERISED BY NODULAR SCELEROSIS AND POOR PROGNOSISSCELEROSIS AND POOR PROGNOSIS

MEMBRANOUS GN-EXAM MEMBRANOUS GN-EXAM POINTSPOINTS

• THE COMMONEST CAUSE OF RENAL THE COMMONEST CAUSE OF RENAL VIEN THROMBOSISVIEN THROMBOSIS

• THE COMMONEST CAUSE OF THE COMMONEST CAUSE OF NEPHROTIC SYNDROME IN ADULTSNEPHROTIC SYNDROME IN ADULTS

• COMPLEMENTS NORMAL,NO RBC COMPLEMENTS NORMAL,NO RBC CASTSCASTS

• ASSOCCIATED WITH MALIGNANCY ASSOCCIATED WITH MALIGNANCY COLONCOLON

MGNMGN

• IDIOPATHICIDIOPATHIC• SECONDARY TO DRUGS SECONDARY TO DRUGS

( ACE,GOLD,PENCILLAMINE )( ACE,GOLD,PENCILLAMINE )• INFECTIONS(MALARIA,HEP B)INFECTIONS(MALARIA,HEP B)• TREATMENT( ACE,PONTICELLI TREATMENT( ACE,PONTICELLI

PROTOCOL=CHLORAMPUCIL PROTOCOL=CHLORAMPUCIL ALTERNATING WITH STEROIDS OR ALTERNATING WITH STEROIDS OR IMMURANIMMURAN

PROGNOSIS-THE 25 % DISEASEPROGNOSIS-THE 25 % DISEASE

• 25 % COMPLETE RECOVERY25 % COMPLETE RECOVERY

• 25 % PARTIAL RECOVERY25 % PARTIAL RECOVERY

• 25 % ESRD25 % ESRD

• 25 % RELAPSE ON AND OFF25 % RELAPSE ON AND OFF

FSGS-EXAM QUESTIONSFSGS-EXAM QUESTIONS

• THE COMMONEST QUESTIONS IS CAUSES THE COMMONEST QUESTIONS IS CAUSES • OR A CASE WHICH TELL U THE CAUSEOR A CASE WHICH TELL U THE CAUSE• OBESE PATIENT WITH PROTIENUREA IS OBESE PATIENT WITH PROTIENUREA IS

FSGSFSGS• A PATIENT WITH HIV THE COOMNEST A PATIENT WITH HIV THE COOMNEST

RENAL BX FINDING IS COOLAPSING FSGSRENAL BX FINDING IS COOLAPSING FSGS• A PATIENT ON HEROINE OR DRUG A PATIENT ON HEROINE OR DRUG

ABUSER IS FSGSABUSER IS FSGS

FSGSFSGS

• A PATIENT WITH SINGLE KIDNEY AND A PATIENT WITH SINGLE KIDNEY AND PROTIENUREA IS FSGSPROTIENUREA IS FSGS

• A PATIENT WITH REFLUX HAS FSGSA PATIENT WITH REFLUX HAS FSGS

• STEROIDS CAN INDUSE REMISSION IN STEROIDS CAN INDUSE REMISSION IN 40 % OF CASES40 % OF CASES

• IT IS THE HIGHEST AND FASTEST IT IS THE HIGHEST AND FASTEST RECURRENCE OF RENAL TX WITH RECURRENCE OF RENAL TX WITH MPGNMPGN

MCD-EXAM QUESTIOSMCD-EXAM QUESTIOS

• NSAID IS THE ONLY DRUG KNOWN NSAID IS THE ONLY DRUG KNOWN TO CAUSE MCDTO CAUSE MCD

• ALL MALIGNANCY ASSOCIATED WITH ALL MALIGNANCY ASSOCIATED WITH MEMBRANOUS GN EXCEPT ONE MEMBRANOUS GN EXCEPT ONE MLIGNANCY ASSOCIATED WITH MCD MLIGNANCY ASSOCIATED WITH MCD DO U KNOW WHAT IT IS ????????????DO U KNOW WHAT IT IS ????????????

MCD-EXAM POINTSMCD-EXAM POINTS

• IN A PATIENT WITH MCD WHO IS NOT IN A PATIENT WITH MCD WHO IS NOT RESPONDING TO ADEQUATE COURSE OF RESPONDING TO ADEQUATE COURSE OF STEROIDS THE MOST LIKELY CAUSE IS STEROIDS THE MOST LIKELY CAUSE IS FSGS SO DO RENAL BXFSGS SO DO RENAL BX

• THE MOST IMPORTANT POINTS ABOUT THE MOST IMPORTANT POINTS ABOUT MCD IS THISMCD IS THIS

• IN CHILDREN A COURSE OF 8 WEEKS IN CHILDREN A COURSE OF 8 WEEKS STEROIDS IS ADEQUATE TO INDUSE STEROIDS IS ADEQUATE TO INDUSE REMISSIONREMISSION

BUT IN ADULTS THE STORY IS BUT IN ADULTS THE STORY IS DIFFERENTDIFFERENT

• IN ADULTS DO NOT LABEL THE PATIENT IN ADULTS DO NOT LABEL THE PATIENT AS STEROIDS RESISTANT UNLESS U AS STEROIDS RESISTANT UNLESS U GIVE 12 WEEKS OF STEROIDS GIVE 12 WEEKS OF STEROIDS

• REMEMBER AT LEAST 12 WEEKSREMEMBER AT LEAST 12 WEEKS

• DO U KNOW THE DIFFERENCE BETWEEN DO U KNOW THE DIFFERENCE BETWEEN STEROIDS DEPENDENT AND STEROIDS STEROIDS DEPENDENT AND STEROIDS RESISTANT AND STEROIDS RELAPSERRESISTANT AND STEROIDS RELAPSER

MPGN-EXAM POINTSMPGN-EXAM POINTS

• THE HIGHEST RECURRENCE OF THE HIGHEST RECURRENCE OF DISEASE IN TX ( 80 % )DISEASE IN TX ( 80 % )

• THE COMMONEST CAUSE OF MPGN IN THE COMMONEST CAUSE OF MPGN IN THE WORLD NOW IS THE WORLD NOW IS ……………………………………………………

• CRYOGLOBULINEMIA IS IMPORTANT CRYOGLOBULINEMIA IS IMPORTANT CAUSECAUSE

FREQUENT AND COMMON FREQUENT AND COMMON BOARD EXAM QUESTION IS BOARD EXAM QUESTION IS THIS ONETHIS ONE• 54 YRS MALE PRESENTED WITH 54 YRS MALE PRESENTED WITH

HEAVY PROTIENUREA OF 7GMHEAVY PROTIENUREA OF 7GM

• HIS LFT IS ABNORMALAHIS LFT IS ABNORMALA

• THE RENAL BIOBSY WILL THE RENAL BIOBSY WILL SHOW…………………………….SHOW…………………………….

RPGN-THE MOST FREQUNT RPGN-THE MOST FREQUNT QUESTION COMES IN EXAMSQUESTION COMES IN EXAMS

• IT IS A MEDICAL EMERGENCYIT IS A MEDICAL EMERGENCY

• IN FACT IT IS THE ONLY GN THAT IS IN FACT IT IS THE ONLY GN THAT IS EMERGENCYEMERGENCY

• IT CAN KILL THE KIDNEY IN 72 HRS IF IT CAN KILL THE KIDNEY IN 72 HRS IF U DID NOT ACTU DID NOT ACT

• U START RX EVEN BEFORE THE BX U START RX EVEN BEFORE THE BX RESULTRESULT

CAUSES;CAUSES;

• WEGNERSWEGNERS

• PANPAN

• CHURG-STRAUSSCHURG-STRAUSS

• ANTI-GBMANTI-GBM

THE MOST IMPORTANT AND THE MOST IMPORTANT AND MOST THAT COMES IN THE MOST THAT COMES IN THE EXAM IS THIS QUESTION:EXAM IS THIS QUESTION:• 36 OLD MALE PRESENTED WITH HX OF 36 OLD MALE PRESENTED WITH HX OF

URTI AND SUDDEN DECREASE IN URTI AND SUDDEN DECREASE IN URINE OUTPUT AND RISING Cr .HIS Cr URINE OUTPUT AND RISING Cr .HIS Cr 2WEEKS AGO WAS 80 NOW IT IS 4902WEEKS AGO WAS 80 NOW IT IS 490

• CXR SHOWED LUNG INFILTRATECXR SHOWED LUNG INFILTRATE• U/A SHOWED RBC 10-20,RBC CASTSU/A SHOWED RBC 10-20,RBC CASTS• THE BEST FIRST STEP OF TREATMENT THE BEST FIRST STEP OF TREATMENT

IN THIS PATIENT IS :IN THIS PATIENT IS :

RPGN CASE;RPGN CASE;

• A. START PULSE STEROIDS,DO BX IF RPGN A. START PULSE STEROIDS,DO BX IF RPGN ADD CYCLOPHOSPHAMIDEADD CYCLOPHOSPHAMIDE

• B. DO BX THEN START CYCLOPHOSPHAMIDEB. DO BX THEN START CYCLOPHOSPHAMIDE

• C. START PULSE STEROIDS AND C. START PULSE STEROIDS AND CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE

• D. START PLASMAPHRESIS AND STEROIDSD. START PLASMAPHRESIS AND STEROIDS

• E. START PLASMAPHRESIS AND E. START PLASMAPHRESIS AND CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE

P-ANCAP-ANCA

• WEGNERSWEGNERS

• MICROSCOPIC POLYANGIOPATHYMICROSCOPIC POLYANGIOPATHY

• CHURG-STRAUSSCHURG-STRAUSS

• IDIOPATHIC RPGN IN THE ELDERLYIDIOPATHIC RPGN IN THE ELDERLY

REVERSAL OF RENAL REVERSAL OF RENAL FUNCTION IN ANTI-GBM FUNCTION IN ANTI-GBM DISEASE(GODPASTUER)DISEASE(GODPASTUER)• IF Cr LESS THAN 550IF Cr LESS THAN 550

• IF PATIENT NOT YET STARTED ON IF PATIENT NOT YET STARTED ON DIALYSISDIALYSIS

• IF PLASMAPHRESIS STARTED EARLYIF PLASMAPHRESIS STARTED EARLY

BEST RX FOR GODPASTUREBEST RX FOR GODPASTURE

• PLASMAPHRESISPLASMAPHRESIS

• PULSE IV STEROIDSPULSE IV STEROIDS

BEST RX FOR WEGNERSBEST RX FOR WEGNERS

• PULSE IV STEROIDSPULSE IV STEROIDS

• CYCLOPHOSCYCLOPHOS

• PLASMAPHRESISPLASMAPHRESIS

C-ANCA-ONLY WEGNERSC-ANCA-ONLY WEGNERS

THE MOST IMPORTANT SLIDE THE MOST IMPORTANT SLIDE IN GLOMERULONEPHRITISIN GLOMERULONEPHRITIS

• ANY CASE IN THE EXAM MENTION UA ANY CASE IN THE EXAM MENTION UA CONTAIN RBC-CASTCONTAIN RBC-CAST

• THERE ARE ONLY 5 DDX IN MEDICINETHERE ARE ONLY 5 DDX IN MEDICINE

• DO U KNOW WHAT ARE THEY ??????? DO U KNOW WHAT ARE THEY ??????? ????

CAUSES OF RBC-CAST THIS IS CAUSES OF RBC-CAST THIS IS CALLED ACTIVE URINE CALLED ACTIVE URINE SEDIMENTSEDIMENT• 1. MPGN1. MPGN

• 2.IGA NEPHROPATHY2.IGA NEPHROPATHY

• 3.POST-INFECTIOUS GN AS POST-3.POST-INFECTIOUS GN AS POST-STREPTOCOCCAL GNSTREPTOCOCCAL GN

• 4.SLE4.SLE

• 5.RPGN5.RPGN

WHAT IS THE SINGLE MOST WHAT IS THE SINGLE MOST IMPORTANT TEST TO IMPORTANT TEST TO

DIFFRENTIATE BETWEENDIFFRENTIATE BETWEEN

PRERENAL AND POSTRENAL PRERENAL AND POSTRENAL AZOTEMIA ( ATN ) ??AZOTEMIA ( ATN ) ??

IT IS FENAIT IS FENA

22 yrs male found comatose 22 yrs male found comatose and his friends mention that he and his friends mention that he had problems with his wife and had problems with his wife and attempted suicide and his labs;attempted suicide and his labs;Na 140,k 5,cl 95,CO2 Na 140,k 5,cl 95,CO2 10,GLUCOSE 7,PLASMA OSMOL 10,GLUCOSE 7,PLASMA OSMOL 325,BUN 13325,BUN 13

PH 7.1,PCO2 24,PO2 85PH 7.1,PCO2 24,PO2 85

• WHAT ACID BASE DISTURBANCE ?WHAT ACID BASE DISTURBANCE ?

• IS IT SIMPLE OR MIXED ?IS IT SIMPLE OR MIXED ?

• WHAT IS THE DX ?WHAT IS THE DX ?

Expected PCO2 = 1.5 X HCO3 + 8 ( + OR – 2 )

• MA WITH HIGH AG

• EXP PCO2 IS 21 – 25

• MA POISONING

5-DAYS LATER HIS ABG :

• PH 7.2

• HCO3 16

• PCO2 45

• WHAT ACID BASE IS THIS ?

EXP PCO2=1.5 X 16 + 8=32

• BUT PCO2 IS 45 SO THIS IS MIXED MA + RESP ACIDOSIS