Clinical Topics Conference:Chapter 16, Kidney

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  1. Rapidly progressive renal failure in a 40 year-old male
  2. Proteinuria in 25 year-old female
  3. Hematuria and elevated serum creatinine in a 15 year-old female
  4. Hematuria and flank pain in a 60 year-old male

Clinical vignette 1

This 40 year old man with no known renal disease developed a fever and malaise. He saw a physician who ordered a CBC and routine blood chemistries. The patient was found to have an elevated white count, normal liver enzymes and normal BUN and serum creatinine. He was given oral penicillin which he was told to take for 2 weeks. He began to feel better but after 9 days he developed a tired felling, a head ache and cloudy urine. He went back to the physician. His urine contained white blood cells red blood cells, granular casts and 1+ protein by dip stick. His white count was elevated and his serum creatinine was 2.0 mg/dl.

Discussion topics

  1. List at least 3 diseases which need to be investigated and indicate how a diagnosis should be made. ?

  2. A renal biopsy was done; describe at least 3 different diseases which might have been present. ?

  3. What is the treatment and prognosis for each of the above? What would indicate a bad prognosis?

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    Clinical vignette 2

    A 25 year old female noted a recent weight gain and edema of her extremities and face. She was seen by a physician who noted 4+ proteinuria by dip stick and oval fat bodies by microscopic examination of the urine. Her CBC values were within normal limits.

    Discussion topics

    1. What would you expect this patients serum albumin level to be? serum cholesterol to be? What serology tests would you draw and what might they show you? ?

    2. What disease entities should be considered as likely. How can you differentiate them. What non-renal or systemic diseases might be associated??

    3. If a biopsy is done what would it show for each of the above entities??

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    Clinical vignette 3

    A 15 year-old female who had had malaise and low grade fevers for several months recently sought medical attention when she noted an erythematous rash on sun exposed skin and red urine. Her WBC was slightly elevated and her urine contained numerous red cells, leukocytes and red cell casts. A 24 hour urine collection contained 2 gms of protein. Her serum creatinine was 1.2 mg./dl. and her creatinine clearance was 75 ml./min. After additional blood tests a procedure was done.

    Discussion topics

    1. What systemic disease does this patient probably have? Name at least one other possible disease or condition.

    2. What blood tests are you going to do to further work up this patient and what are the most likely results?

    3. How can you determine the type and severity of this patient's renal disease?

    4. Describe the most likely appearance of the renal biopsy you just did and tell why you feel it should appear this way ?

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    Clinical vignette 4

    This 60 year-old male noted a recent sudden onset of unilateral flank pain and red urine. In the emergency room, he was noted to have red cells, too numerous to count, and a few white cells and granular casts in his urine. The urine was 2+ for protein by urine dipstick. His WBC as slightly elevated.

    Discussion topics

    1. Name at least 3 possible diagnoses; overlapping diagnoses are permitted.

    2. What additional tests should be done to work this patient up and what would they show?

    3. If tissue is taken, what might it show ?

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