GU/Patient Problem Solving Seminar 1: Glomerulonephritis, Stones & UTS's

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Case 1

A 7 year old male is brought to your office by his mother who informs you that her son's urine is clear but that he has some puffiness around his eyes.

  1. What is the simplest screening test for renal causes of edema in this patient?
    • Urinalysis - non-invasive; sensitive; specific; inexpensive
  2. What is the best test to measure the patient's kidney function and what would you expect it to be in this case?
    • Gockcroft estimate - clearance = (140-age) * IBW / serum creatinine
    • Serum creatinine
    • 24 hour urine for creatinine test (difficult with a young child; produces an overestimate)
    • GFR study would be the gold standard
  3. What is the most likely cause and how would you manage it ?
    • Nephrotic syndrome caused by minimal change disease
    • Can be managed with corticosteroids for a few weeks before proceeding with a biopsy

Case 2

A 65 year old male complains of recent onset symmetrical swelling in his lower extremities, fatigue and shortness of breath. Creatinine is 180 μmol/l, urinalysis shows protein and blood and microscopy shows red cell casts. Ultrasound shows normal sized kidneys.

  1. Pathologically, what type of renal disease is this likely to be?
    • Proliferative disease has blood in the urine and abnormal kidney function (the case here)
    • Non-proliferative: nephrotic
  2. What is the differential diagnosis here?
  3. What additional history and physical signs would you look for?
  4. What noninvasive and invasive tests would you arrange?
    • Autoantibody (ANA; C/P-ANCA; Anti-GBM)
    • Invasive tests include renal biopsy
  5. What treatments might you institute?
    • Steroids should be considered, as well as other immunosuppressants (cyclophosphamide)

Case 3

A 40 year old male presents to your office complaining of weight gain and symmetrical pitting edema. He denies orthopnea and paroxysmal nocturnal dypnea (PND) and has no stigmata of liver disease. His urinalysis reveals occasional RBC's, with no cellular casts and >3 g/L protein.

  1. What general type of glomerular pathology is this patient likely to have?
    • Non-proliferative (Minimal Change Disease; Membranous Nephropathy; Focal segmental Glomerulosclerosis; Membranoproliferative Glomerulonephritis)
  2. What simple non-invasive investigations would you order?
    • Serum creatinine
    • Renal ultrasound
    • Quantify the 24 hour urine
    • protein elecrophoresis and immunofixation - test for multiple myeloma
  3. How do you make a specific diagnosis in this patient?
    • Renal biopsy
  4. What is the differential diagnosis of this patient?
    • Primary GNs and all nonproliferative GNs
  5. What would be your management?
    • No salt
    • Use an ACE Inhibitor so that the GFR would be reduced

Case 4

A 55-year-old male with a 4-year history of type II diabetes mellitus controlled on diet is referred because of detection of 3+ proteinuria on dipstick. He has a 10 year history of hypertension and a 5 year history of stable angina managed with beta blockers. On examination, he is obese, blood pressure is 150/95, his retina show mild hypertensive changes and ECG shows LV hypertrophy. His creatinine is 190 μmol/L (up from 120 4 years previously). A 24-hour urine shows 5 grams of protein and the 24-hour urinary creatinine clearance is 40 ml/min. Glycated hemoglobin is 7.5% (normal <6%).

  1. What is the renal diagnosis here and what investigations would you suggest to confirm it?
    • Diabetic nephropathy
  2. What is the significance of the absence of diabetic retinopathy?
    • generally, the two go together, though not always
  3. What is the renal prognosis?
    • Not good at this pace
    • Eventually, he will hit dialysis
    • On the bright side, he would more likely die of heart disease before dying of renal failure
  4. How would you manage his renal disease?
  5. What other management suggestions have you?

Case 5

A 30 year old type 1 diabetic is referred for renal evaluation. He has diabetes x 6 years, is on twice daily insulin and is somewhat casual about glycemic control. He weighs 90 kgs , BP is 125/85 and he has background retinopathy. Serum creatinine is 40 μmol/l, glycated hemoglobin is 8.5% (normal < 6%); 24 hour urine contains 60 mgs of albumin (normal < 30 mgs);120 mgs of protein (normal < 150 mgs);and 14 mmol of creatinine (normal 8-18 mmol)

  1. What is the renal diagnosis here and what investigations are indicated?
    • Early diabetic nephropathy and microalbuminurea
  2. Why is his serum creatinine so low and how could you prove your explanation?
    • The low serum creatinine is due to the hyperfiltration that is going on
  3. How would you manage this case?
    • Improve the lifestyle and add medications such as ACEI or ARBs
  4. How would you monitor the response to your management?
    • Urinalysis; protein; creatinine

Case 6

A 40-year-old man has had three renal stones in three years, which passed spontaneously. Exam is normal. A flat-plate shows two small calcifications in the left kidney. The stones are composed of calcium oxalate and the patient is found to be hypercalciuric.

  1. What is the most likely composition of the stones?
  2. What investigations would you recommend and discuss the rationale?
  3. Which general treatment measures would you introduce?
    • Add more calcium to the diet so that there would be more available calcium to bind with the oxalate and dump it in the bowel
  4. What other treatment might be considered?

Case 7

A 4 year old female has a history of enuresis and episodes of fevers, chills and flank pain. She presents with dysuria and frequency. Routine urinalysis reveals 15-10 WBC's, 5-7 RBC's, 2 WBC casts/hpf and many bacteria.

  1. How would you make the diagnosis in this patient?
    • E. coli accounts for approximately 80 % of UTIs in children
    • Try to get a culture from the child
  2. How would you treat this patient?
    • Antibiotics
  3. Would you investigate this patient further?
    • It is not normal for little girls or boys to have any urinary tract infections
    • Potential sexual abuse
    • Structural or anatomical problems
  4. What is the long-term management?
  5. What is the long-term prognosis?

Case 8

A 24-year-old woman presents with frequency and dysuria.

  1. What is the most likely diagnosis?
    • UTI
  2. What is the most likely organism?
    • E Coli
  3. What investigation is necessary?
    • Not really necessary; perhaps culture it
  4. What is the treatment?
    • Antibiotics

Case 9

A 65-year-old man presents with fever, chills, flank pain and dysuria.

  1. What is the likely diagnosis?
  2. What determines whether the patient requires admission?
  3. What constitutes a "complicated" urinary tract infection, and what are the differences with respect to the management?
  4. Describe the investigation and management of uncomplicated and complicated pyelonephritis.